CNA253 AT2: Orthopedic Nursing Report on Mrs. Gwen Boren's Fall Case

This report presents a comprehensive analysis of Mrs. Gwen Boren's fall case, admitted to an orthopedic unit after a fall from a nursing home. The report meticulously interprets assessment findings, identifying normal and abnormal data, and links these findings to underlying physiology, specifically addressing the fracture of the left lateral malleolus, confusion, and a small hypodense area in the left cerebrum. It applies the clinical reasoning cycle to relate and infer the patient's condition, predicting potential health problems and developing three nursing diagnoses: high risk of falls, disorientation, and motor skill deficits. Two priority diagnoses are then addressed with specific goals, actions, and evaluations, focusing on maintaining patient safety and reorientation. The report emphasizes the importance of multidisciplinary approaches, fall prevention protocols, and patient education. The document includes a reference list and relevant clinical data such as neurological observations and medication records.

Student number:
CNA253 AT2 Scenario: Mrs Gwen Boren
Interpret:
In the following table, list the data that you consider to be normal/abnormal (not included in word count)
Normal (Subjective & Objective) Abnormal (Subjective & Objective)
Respiratory rate
Oxygen Saturation
BP
Heart Rate
Temperature
Eye, Motor, and Verbal Response
Backslab colour, warmth, Pulse
Lower limb movement
Blood loss
Lower limb swelling
Lower limb sensation
Confusion
small hypo dense area of tissue in left cerebrum
a fracture of the left lateral malleolus
Relate & Infer (550 words):
Unwanted falls is characterized by the event that causes an individual to come to rest inadvertently on the floor and having an inability to be stable in due
time. The patient named, Gwen Boren, female reviewed on 18-Feb-2020 was admitted to orthopaedic unit from the nursing home after an unwanted fall. The
clinical reasoning cycle stage namely, process the information which involves steps such as relate and infer, in other words to analyse the information in
order to understand the signs and symptoms of the patient while comparing the normal as well as abnormal data obtained though the clinical assessment of
falls. Considering relate, the patterns and relationships were recognised in the patient i.e., the patient was confused when found and furthermore the patient
pain score of left limb is 3 out of 10 which is comfortable for the patient, a fracture of the left lateral malleolus, swelling and moderate sensation in the lower
limb, and small hypo dense area of tissue in left cerebrum which is abnormal but reasonable due to CVA effect (Leat et al., 2017). Furthermore, the concern
right now is the small hypo dense area of tissue in left cerebrum and the confusion. The most related factor recognized in the present case is the weakness in
the muscle hence resulting in loss of balance as well as disoriented self-ability of the patient (Anderson, Dolansky, Damato and Jones, 2014).
Infer- My opinion in the present case scenario is to keep the patient under further observation considering all the standard policies of unwanted falls
prevention in elderly. It should be with respect to the pathophysiology of the affected part of the patient’s brain which suggests that the presence or absence
of a small diffused hypodense area in the left cerebrum related with the white matter as identified though the baseline CT scan (i.e., computed tomography) of
the affected area is found to be associated with the occurrence of consequent stroke. It should also be related with the possibility of high risk of fall due to the
confused state of the patient (Karaoğlan, 2017). Several evidence states that as the fall has occurred within the nursing care, it is related with high risk of falls
among patients due to several reasons such as the risk factors including both intrinsic and extrinsic factors such as age, gender, loss of balance and utilizing
medications, and weak policies (Karaoğlan, 2017). Furthermore, NICE guidelines suggested that specific inpatients must be considered as being at high risk
of falling in nursing care (NICE, 2014). It consists of the patients of age 65 and above is at a higher risk of falls due to any condition such as dementia and
stroke. Considering such type of patients, the outlooks of the inpatient environment of nursing care can affect the risk of unwanted falls (NICE, 2014).
Furthermore, unwanted falls might result in a sentinel event that poses a threat to the patient’s life while breaking the nursing care standards. In case a patient

fall in a nursing care it makes the nurse to fill a form related to patient safety network hence alerting the quality management to get the nursing care alarmed
about the situation which might also result in terminating of staff (Morello et al., 2015). In the present case scenario, the unwanted fall might result in further
damage such as brain injury or in extreme cases stroke hence, delaying the process of healing.
Predict (150 words):
The analysis of the information obtained and the symptoms and risk related factor in Gwen Boren suggests that the major health problem is small hypo dense
area of tissue in left cerebrum, confusion, and unwanted fall. It tends to increase further risk of stroke in patients and the patient is required to be able to
manage her daily activities. Furthermore, taking consideration about the age of the patient and her health, regular family and nursing care is required for the
patient (Najafpour, Godarzi, Arab and Yaseri, 2019). Moreover, community support is highly important for managing her in the nursing care. Another health
problem which can affect the well being of Gwen Boren is that even though she depicts normal vital signs but, she had a a fracture of the left lateral
malleolus. Therefore, nursing support is required in this part for providing relief to her. Considering the present condition of the patient as well as the CVA
effect recognised in the report, nursing diagnosis is formulated (Najafpour, Godarzi, Arab and Yaseri, 2019).
Develop, Articulate and Prioritise Nursing Diagnoses – at least 3 (not included in word count)
Diagnosis 1: high risk of fall associated with imbalance and mobility
Diagnosis 2: disorientation associated with confusion
Diagnosis 3: motor skills
Goals, Actions and Evaluation 2 highest priority diagnoses only (550 words)
Diagnosis 1 Goal/Desired outcome/s Related actions Rationale Evaluate outcomes
DO NOT REWRITE
DIAGNOSIS
Maintaining safety and
orientation for safe
discharge of the patient
with no falls
The nurse should take
relevant actions for the
formulation of
interventions which will
help in addressing all the
health issues considering
the completion of goals
proposed.
The initial intervention is
for maintaining safety
through the application of
nursing care protocols
associated with unwanted
falls. The protocol
Considering the patient in the case
and the unwanted fall risk is high
and might cause disorientation of
time as well as place. The basic
idea behind the intervention is to
place the patient near the nursing
care for further observation,
staying with the patient and
accompanying her in her daily
activities (Najafpour, Godarzi,
Arab and Yaseri, 2019).
The desired goal is met as
the patient is being
discharged without any
further cases of unwanted
falls as the patient have
depicted no vital signs hence
is capable of reorientation of
self about the present time as
well as the place without any
external force. Further
outcomes are consent to see
a physiotherapist, being
more open about her other
issues and to resume her

includes assessment of
unwanted falls, high risk
fall intervention as well as
care provided post fall.
Secondly, another action is
utilizing the help of
multidisciplinary team
approach for ensuring the
patient to regain the
movement with the help of
occupational as well as
physiotherapy.
former life.
Diagnosis 2 Goal/Desired outcome/s Related actions Rationale Evaluate outcomes
DO NOT REWRITE
DIAGNOSIS
Reorientation of the
patient whenever she felt
confused regarding the
time and place
The desired actions to be
carried out in case of
altered cognition i.e.,
confused state of the
patient, the intervention of
developing a reorientation
of the patient while
educating her on the
pathophysiology of the
confused state of mind and
its significance in terms of
unwanted falls is relevant.
She also needs counselling
for her confused state of
mind.
A good form of communication
should be utilized for informing
the next responsible individual
associated with the patient
considering the high score of
unwanted fall while its
documentation is important.
Furthermore, the patient and her
next responsible person should be
educated about the exercises as
explained by the physiotherapist
for allowing maximum regaining
mobility by self which in turn will
reduce the chance of unwanted
falls (Morello et al., 2015).
The patient has been
educated about the
maintenance of safety at the
nursing care by the removal
of any type of cluster in her
room and to make sure that
she should take the non-
slippery pathway more often
to avoid any further
unwanted falls. Gwen Boren
is on the right track of the
recovery on the basis of the
medication provided to her
(Morello et al., 2015).
Reference list:
Anderson, C., Dolansky, M., Damato, E. and Jones, K., 2014. Predictors of Serious Fall Injury in Hospitalized Patients. Clinical Nursing Research, 24(3),
pp.269-283.
Karaoğlan, M., 2017. One-year Risk of Stroke after Transient Ischemic Attack or Minor Stroke. Turkish Journal Of Neurology, 23(3), pp.144-145.
Leat, S., Zecevic, A., Keeling, A., Hileeto, D., Labreche, T. and Brymer, C., 2017. Prevalence of vision loss among hospital in-patients; a risk factor for
falls?. Ophthalmic and Physiological Optics, 38(1), pp.106-114.
Morello, R., Barker, A., Watts, J., Haines, T., Zavarsek, S., Hill, K., Brand, C., Sherrington, C., Wolfe, R., Bohensky, M. and Stoelwinder, J., 2015. The extra
resource burden of in‐hospital falls: a cost of falls study. Medical Journal of Australia, 203(9), pp.367-367.

Najafpour, Z., Godarzi, Z., Arab, M. and Yaseri, M., 2019. Risk Factors for Falls in Hospital In-Patients: A Prospective Nested Case Control
Study. International Journal of Health Policy and Management, 8(5), pp.300-306.
NICE, 2014. Older Patients At High Risk Of Hospital Falls. [online] NICE. Available at: <https://www.nice.org.uk/news/article/older-patients-at-high-risk-
of-hospital-falls> [Accessed 18 March 2020].