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Question 5 Considering all the changes to Isobels’ condition on day 2 ,what are some of the risks that you would consider reporting to the Registered staff according to organization policy and procedures.

Question 5 Considering all the changes to Isobels’ condition on day 2 ,what are some of the risks that you would consider reporting to the Registered staff according to organization policy and procedures.  

Review the Day 2 handover 

Question 6 You are required to report and record any variances in the persons care as per the organization policy and procedures.

Using the progress notes below complete the variance for day 2 .

Day I Medical ward CQU hospital
Handover 0700 Nursing notes
IdentificationMrs. Isabel Churchill DOB 07/05/53 10 Mountain Creek SC UR 123098 68-year-old lady 
SituationDay 1 post fall off ladder. She states she became lightheaded whilst cleaning the gutters of her roof and slipped off the ladder just as she reached the ground, knocking the ladder over. She States that she had not eaten breakfast and wanted to clean the gutters before it became too hot.   
BackgroundPersonal history. Lives alone, DVA patient and her husband is in the Nursing home and has Parkinson’s.  Medical history GORD, Arthritis and hypertension. Currently on medications but sometimes forgets to take them.  She wears glasses, broken in the fall. She has lower dentures and she states that is has some stress incontinence. She has NKA. No smoker and has the occasional social drink but not recently.  
AssessmentAs per QADDS. GCS 14/15 E4, V4, M6 T. 36, P 110 regular, BP 140/90, O2 Sats 98% RA, Pain 7/10 sharp pain near lacerations, dull headache. Pain there since fall. States she has lost weight as per assessment.   
We implement, monitor and evaluate nursing care plans. Day 2  
Handover 0700 Nursing notes
IdentificationMrs. Isabel Churchill DOB 07/05/53 Mountain Creek SC UR 123098 68-year-old lady 
SituationDay 2 post fall off ladder. Isobel has had a restless night. Has not slept and remains confused She states she feels dizzy and her lips are cracked 
BackgroundPersonal history. Lives alone, DVA patient and her husband is in the Nursing home and has Parkinson’s.  Medical history GORD, Hypertension, Arthritis and glasses are not yet repaired. She has NKA. 
AssessmentAs per QADDS. GCS 13/15, T.36 P100 R22 BP.98/50 O2 Sats RA 95%. She is more confused. Blood pressure has scored a 2 and Mo notified. 
RecommendationMo recommends 1 hourly observation and she will review as required. Nutrition and hydration observed and IV inserted. Strict FBC. 

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