Head Injury Case Study Nursing

Mrs. V. is a 90 year old female who presented to the Emergency Department of Jewish General Hospital on October 5th, 2015 with a chief compliant of head injury. Patient had a mechanical fall at home after trying to get in bed; she missed the edge of the bed and fell. Patient’s son found her on ground with bleeding from head and laceration of the scalp and he called the ambulance. Patient did not lose consciousness, denied any headache, neck pain, limb pain or weakness. CT head was done, showing no head injury. The current plan for Mrs. V. is to admit her under geriatrics as off service, assess her mental status, suggest a skin care consult for the non-healing foot ulcer, physiotherapy and occupational therapy consult and assess for risk of falls.

Patient’s Previous Medical History Previously, Mrs. V. is known for hypertension, thyroid disease, arrhythmia, had a dual pacemaker inserted in 2010, osteoporosis, Peripheral Vascular Disease (PVD), a chronic non-healing foot ulcer on right heel , swollen pitting edema on left leg and she also is a smoker (1-2 cigarettes per day).

Social and Functional History

Mrs. V. is a widower who lives alone in an apartment in Montreal area. Patient has a son who lives in Florida, who has been visiting for the past week and a daughter who is a medical doctor and lives in New Jersey;

V.’s age increases her risk of falling as falls are the leading cause of unintentional injuries and death among older adults (Kozier, et al., 2013). Other factors in falls among the elderly are a cluttered environment, gait instability, muscle weakness, impaired balance, and chronic illness (Kozier et al., 2013) many of which Mrs. V. demonstrates. For example, Mrs. V.’s bedside was cluttered with chairs and discarded towels on the floor on which she rested her right foot. These could provide tripping hazards, especially since Mrs. V. has an unsteady gait due to her bandaged foot, non-healing ulcers, and weakness from the swelling of the left