Vasquez, Julianne Gabrielle G.

Health Assessment
BSN-Y2-11 Lecture Task
Case study: Mrs. Doris Miller

1. Demonstrate how a nurse would use the COLDSPA mnemonic to explore Mrs. Millers
presenting concerns.
Mnemonic Question Data Provided
Character Describe the sign or Right hip and leg pain with
symptom? a scale between a 5 and a 7
How does it feel, look, on a 10-point scale
smell, sound and taste?
Can you describe the pain?
Onset When did it begin? After she fell in her home
and fractured a bone
Location Where is it located? On the right and leg hip.
Does it radiate? Which increases in
Does it occur anywhere prolonged sitting with the
else? same position.
Duration How long does it last? Does
it re-occur?
Severity How bad is it? Rates the pain as 5 and a 7
Can you rate in on a scale of on a 10-point scale.
1-10?
Pattern What makes it better? Takes medicines for the
What makes it worse? breakthrough pain or as
needed. Sitting for too long
or walking in a distance and
bearing weight on right leg
makes it worse.

Associated Factors What other symptoms occur

with it?

2. Demonstrate a physical assessment of Mrs. Miller’s post –fall status by determining the
following:
Reason for home health care visit
Mrs. Miller fell in her own home 3 weeks ago and was hospitalized for the repair and pinning of
fractured right femur
History of present health concern
Dolores Ralston, Mrs. Miller’s daughter reports that Mrs. Miller can put just enough weight on her right
leg just to use a walker, but also in pain especially on her right hip and leg which increases because of
prolonged walking and sitting in the same position. Also, Mrs. Miller needs assistance in performing the
activities for daily living like bathing, clothing, and dressing. Mrs. Miller is not eating very well and
 Vasquez, Julianne Gabrielle G. Health Assessment
BSN-Y2-11 Lecture Task
seems to be choking easily especially when she is drinking and frequently complains of having a “dry
mouth”. Mrs. Miller’s use bed pads as well to manage a small amount of incontinence during the night,
and during 3:00 am, her daughter, assist her onto a bedside commode. Mrs. Miller verbalized in a very
weak and raspy voice “I don’t know how I ended up here. I don’t know what I’d do without Delores, but
if I could just walk and didn’t hurt so bad everything would be OK . . . I’ve always been able to take care
of things. This just all seems like such of a fuss over nothing.” and reaches up to wipe her eyes with a
tissue she’s holding in her right hand with noticeably contracted fingers with swan-neck deformities and
enlarged distal, interphalangeal joints.
Personal History
Mrs. Miller had a history of having Parkinson’s disease, osteoporosis, and mitral valve disease. She has
fallen numerous times, but this was the first time that she broke any bones with a fall. Mrs. Miller’s
current medications are Sinemet 25/250 mg every day; warfarin 5 mg every day; MS Contin 15 mg
every 12 hours; Morphine sulfate 10 mg oral solution (10 mg per 2.5 ml) every 8 hours prn for
breakthrough pain; levothyroxine 0.05 mg every AM; Miralax every other day as needed for
constipation.
Physical Examination Findings
Mrs. Miller is 5 ft in height and 89 lbs. in weight prior to the fall and hospitalization. Her blood pressure
is 85/45 on the right and 108/64 on the left. Heart rate is 92 and irregularly irregular. Lung sounds are
clear but only heard in the upper lobes. She happened to have a resting tremor of the hands and several
large bruises on her right shoulder, upper arm, and hip. She has slight ectropion and reddened eyes.
Presence of crepitus and a grating popping sound bilaterally, as well as increased resistance and rigidity
when assisted to raise her arms are noted as well. Skin is pale, thin, and dry in most areas, and appears
intact and well cared for. Incision line on right leg is dry, slightly red, but without swelling or drainage.
However, redness is noted on the elbows and sacrum. Antecubital spaces are moist with some beginning
maceration. Mrs. Miller has 1+ pitting edema bilaterally.

3. After collecting and analyzing the data for Mrs. Doris Miller, determine at least 2
appropriate nursing diagnosis.
Health Promotion Nursing Diagnosis
 Readiness for Enhanced Comfort
 Readiness for Enhanced Urinary Elimination
 Readiness for enhanced coping related to injury
Risk Nursing Diagnosis
 Risk for Imbalanced Nutrition related to dysphagia or decreased desire to eat and dry mouth
 Risk for Impaired Skin Integrity related to immobility, redness on the elbows and sacrum,
beginning maceration on the antecubital spaces, and 1+ pitting pedal edema bilaterally.
 Risk for impaired urinary elimination related to immobility
 Risk for disturbed thought process related to age, stress of trauma and unfamiliar
surroundings
 Risk for ineffective coping related to injury
 Risk for impaired home maintenance related to fractured right femur and impaired mobility
 Risk for trauma: getting up without assistance
 Risk for ineffective coping related to injury
Vasquez, Julianne Gabrielle G. Health Assessment
BSN-Y2-11 Lecture Task

 Risk for falls: Improper use of aids (e.g., walkers, wheelchair)

Actual Nursing Diagnosis
 Impaired physical mobility related to fractured right femur
 Self-care deficit related to impaired physical functioning as evidenced by pinning of a right
fractured right femur and pain on right hip and leg.
4. Determine collaborative problems as many as you can.
NOTE: GROUP IDENTIFIED PROBLEMS ACCORDING TO POSSIBLE AFFECTED
SYSTEM (neuro, Musculo, GI, etc.)
Neurological system
 RC – Parkinson’s disease
Musculoskeletal system
 RC – Osteoarthritis
 RC- Osteoporosis
 RC- Rheumatoid Arthritis
GI system
 RC – Malnutrition
 RC- Dehydration
 RC- Constipation
Renal / Urinary system
 RC- Urinary Tract Infection
Cardiovascular system
 RC: Syncope
 RC: Orthostatic Hypotension
Integumentary system
 RC-Skin Infection
 RC-Skin Lesions

5. 2 NCP (follow the prescribed template)

Risk for falls related to….

Assessment Diagnosis Planning Intervention Rationale Evaluation

Vasquez, Julianne Gabrielle G. Health Assessment
BSN-Y2-11 Lecture Task