Respond to at least two of your colleagues on 2 different days who selected a different patient than you, using one or more of the following approaches:
· Share additional interview and communication techniques that could be effective with your colleague’s selected patient.
· Suggest additional health-related risks that might be considered.
· Validate an idea with your own experience and additional research
The case study analysis assigned to me involves an 85-year-old white female living alone with no family who is in declining health. In expanding upon the case study, I utilized the SOAP note format, which is presented below:
Subjective (S): JD is an 85-year-old white woman who presents to the emergency department with concerns about declining health due to multiple falls and pain in the left hip. The falls began about a year ago and have increased in frequency and severity in the past three months. The most recent fall was today when the patient fell while getting up to use the bathroom, and she fell to the floor and landed on her left side. She immediately called 911. She states that pain in the left hip increases with weight-bearing activities, and she has been unable to put weight on the left side. She has not taken anything for the pain. She states that pain is 10/10 with any weight-bearing or ROM activities. She does not use any assistive devices for mobility. She eats one meal daily and tries to have a Boost supplemental shake daily. Patient has intermittent urine incontinence. She does not have relatives or friends available to assist her. She still drives, though she avoids driving at night.
She has a history of osteoporosis, hypertension, dyslipidemia, anxiety, and depression. Her medications include: metoprolol tartrate 50 mg twice daily, atorvastatin 20 mg daily, sertraline 50 mg daily, multivitamin daily, and vitamin D3 25 mcg daily.
Objective (O): JD is an older white woman who appears frail, malnourished, and anxious. Alert and oriented x 3. VS: 143/94, P 101, RR 20, 97% on room air at rest, and T 97.8F. Weight 91 pounds and height 5’1”. BMI is 17.2. Significant bruising was noted in the LLE from the lateral aspect of the hip that extends medially towards the groin and distally above the knee. X-rays demonstrate a left femoral neck fracture.
Assessment (A): 1.) Traumatic fracture of the left femoral neck 2.) falls 3.) malnourishment 4.) hypertension 5.) osteoporosis 6.) dyslipidemia 7.) anxiety 8.) depression.
Plan (P): Patient is being admitted to the hospital for immediate surgery for a traumatic left femoral neck fracture. Referral and transfer to orthopedics are planned. Patient was provided education on proper nutritional requirements and how to maintain a healthy weight via teach-back and literature. The provider had a conversation with the patient regarding the safety of living within her home, and the patient plans to return home accordingly. Patient is to follow up with the orthopedic surgeon, primary care provider, and cardiologist upon discharge. A discussion for plans to discharge from the hospital to a skilled nursing facility was had, and the patient agreed with this plan. Medication additions include: hydrocodone-acetaminophen 5-325 every 4-6 hours as needed. No medications were discontinued.
Communication and Interview Techniques
Providers must efficiently use several communication and interview techniques with various populations. In this case study, the patient is an elderly 85-year-old woman. One study provides evidence that the elderly population does not tend to seek out emergency department care unless severe or life-threatening injuries occur (Lutz et al., 2018). She has no hearing or visual concerns; therefore, the provider does not need to make adjustments. The provider should position themselves near the patient with as few obstacles in between as possible (Ball et al., 2019). Maintaining eye contact, having an open posture, using appropriate non-verbal cues, and utilizing appropriate follow-up questions are necessary to gain the patient’s trust (Ball et al., 2019). Since the interview is occurring in the emergency department, the interview must be focused and timely. The provider should begin with open-ended questions to ascertain the patient’s chief concern and follow up with appropriate questions to gain the patient’s trust (Ball et al., 2019). Once rapport is developed and the patient is more at ease, the provider can ask more personal questions, such as about lifestyle and socioeconomic status (Ball et al., 2019). Questions should occur one at a time and in a manner that allows for the patient to respond fully before proceeding. Though the patient’s care will be transferred to the orthopedic surgeon, education should be provided to the patient. Since the patient is in a heightened emotional state, it is necessary to provide educational materials in the form of literature for the patient to reference later (Hoek et al., 2020). Keeping the patient informed at every step of care is imperative to ease the patient’s anxiety and ensure safe outcomes.
Risk Assessment Instrument
Several risk assessment instruments would be beneficial in this case study. A fall risk assessment tool is the most common and pertinent tool for the patient in this case study. A widely used tool is the Johns Hopkins Fall Risk Assessment Tool, which consists of 7 questions about age, fall history, elimination, bowel and urine, medications, patient care equipment, mobility, and cognition (Johns Hopkins Medicine, n.d.). Scores between 6-13 are a moderate fall risk, and greater than 13 points are a high fall risk (Johns Hopkins Medicine, n.d.). Patient in this case study is a high-fall risk as demonstrated by her age (85), fall in the past six months, incontinence, medications (antihypertensive, opiate), and impaired mobility.
Another risk assessment tool that should be utilized in this case study should involve nutritional status. Significant evidence suggests that malnourishment is a risk factor for falls and should be addressed at every point of care (Adly et al., 2019). Since the patient in this case study is below the recommended BMI and only eats one meal/daily with the occasional supplemental beverage, it is necessary to provide extensive education to inform the patient of the importance of maintaining a healthy diet to prevent future falls and fractures. One of the most commonly used nutritional risk screening tools for the elderly is the Mini Nutritional Assessment Short-Form (MNA). The MNA includes various components such as loss of appetite, altered sense of taste and smell, loss of thirst, frailty, and depression, all of which are relevant in the older population (Reber et al., 2019). Information gathered from this tool allows for timely nutritional intervention. Maintaining an optimal nutritional status could lead to fewer falls.