Assignment task:
Mrs Lucy is an 86 year old woman who presents to the Emergency Department at 0300 hours following a trip and fall at home as she was ambulating to the toilet. She has a history of hypertension, atrial fibrillation and is taking regular warfarin. Her BP is 102/50mmHg, HR: 110 beats/min and RR: 22 breaths/minute, Temperature 38.8. She is complaining of pain in her left wrist and left ankle. There is obvious swelling to her left ankle, and she is unable to weight bear. Mrs Lucy is the carer for her husband who is aged 89 and has dementia. On arrival her GCS was 15/15, however, it is now 0500 and her GCS has decreased to 14/15 as she appears to be disorientated to her location and is attempting to climb out of bed. She has an IV cannula in her right cubi-fossa and bloods have been sent.
Question: What signs and symptoms did Mrs Lucy present with that could contribute to her fall during the night? Link this to your A-E assessment findings and discuss 3 nursing interventions and how you would manage Mrs Lucy's care.