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During the simulation, Mr Shepherd’s health was impacted by three priority problems:
1. Lower back pain associated with chronic osteoarthritis;
2. Impaired safety: potential for aspiration due to decreased swallow response;
3. Impaired safety: Increased falls risk related to altered level of consciousness and recent fall.Choose one priority problem and:
a. Identify all health assessments, which were conducted (or should have been conducted) during your SIM experience, relevant to the chosen problem. Using current and relevant evidence briefly explain the underlying pathophysiology to
justify why this assessment was appropriate / inappropriate.

b. Using current and relevant evidence discuss what additional health assessment data should have been collected during the episode of care and explain why.
c. State what the goal for care would be related to this problem, and discuss two evidence based independent nursing actions to meet this goal.

Question 2: Effective communication: documenting progress notes (approx. 300 words)
Based on your findings from Question 1, use the SBAR framework to write a progress note in Mr Shepherd’s
medical file related to the chosen priority problem. You entry should relate directly to your simulation experience
and should summarise:
? Findings of assessments completed during your SIM experience and related to the identified problem
? Evidence based planned care for addressing this.

Neurological Observation for Changes in Mental Status

Mr. Shepherd is an 82 year old man who was admitted to Princess Alexandra Hospital for two nights after he developed increased confusion since two days. As he was unable to ambulate using the wheelie walker and developed moderate left sided weakness, health assessment was done to indentify risk for fall and altered level of consciousness in patient. During the simulation experience, the health assessment that was conducted for Mr. Shepherd included neurological observation, assessment of consciousness by Glasgow coma scale (GCS) and ABCDE assessment was done.

The assessment of neurological observation was appropriate for Mr Shepherd because this might help to identify changes in brain function and interpret factors that could lead to increase in confusion and fall risk in patient. Increase in confusion is an indication of changes in mental status and confusions, disorientation and lethargy are some of the synonyms of altered mental state. Confusion is a symptom of delirium in elderly patients like Mr Shepherd.

Mr. Shepherd might be at risk of delirium because of fluctuating mental status evidenced by altered level of consciousness (Kennedy et al., 2014). Age of more than 65 years, acute illness, hospitalization, impaired ambulation and acute stress are some risk factors of developing confusion in elderly people (Han et al., 2014). Initial physical assessment for such patient involves assessment of neurological status as it helps to describe mental status of patients by the use of qualitative descriptors like confused, alert or orientated. This form of assessment is important to interpret neurological changes in patient (Zadravecz et al., 2015).

Altered mental status is one of the common causes of hospital admission. Han et al. (2014) justified the use of GCS as it can provide clues to the etiology of altered mental state. It is mainly done with the use of GCS to interpret verbal, motor and eye-opening response in patient.  The three categories mentioned in GCS pertain to different areas of conscious state. As it was originally developed to evaluate conscious state of patient after traumatic brain injury, it’s use is justified whenever there is a need to evaluate conscious state of a person. In addition, ABCDE is a useful approach during initial assessment of patient to understand risk factors behind fall (Chikura, Conroy & Salvi, 2018).

  1. Additional health assessment data needed for the patients:

For Mr. Shepherd, health assessment for fall risk was identified by means of neurological observation using GCS scale. However, as fall risk and altered mental status is associated with changes in gait, mobility and balance, there was a need to conduct Timed Up-and-Go Test for patient. It is a commonly used screening tool for fall risk in the inpatient setting.

Glasgow Coma Scale for Interpretation of Consciousness

The patient is time while they rise from an arm chair, walk on the floor and walk back to the chair and settle down again. During the test, patients are supposed to use their regular footwear and walking aid.  Faster time is indicative of better functional performance, whereas timing of ≥13.5 seconds is used to identify those at increased risk of fall (Barry et al., 2014). Kang et al. (2017) justified that gait instability is a risk factor for falls and the Timed Up and Go Test is a validated tool to evaluate people who are at risk of fall. After adjusting for age and gender, cutoff value of 15.96 seconds is predictive of recurrent falls in elderly population.

  1. Goal for care and two nursing actions for the patient:

In relation to the issue of fall risk and impaired safety for Mr. Shepherd, the goal of care is to prevent fall in patient and modify the environment around Shepherd so that his safety is maintained during hospital stay. Another goal of care is to provide him self-care assistance as he can no longer ambulate using the wheelie walker. To meet the above mentioned goals, two independent nursing actions that can be implemented for Mr. Shepherd are as follows:

  1. To promote safety of patient during hospital stay, it is planned to engage in environmental management by keeping the call bell within reach of patient. The side rails of the bed will be raised and all his belongings will be kept nearby. The environment around patient will be inspected to remove those objects that may increase risk of fall. The bed rails will be raised.
  2. In relation to prevention of fall, the plan is to orient patient to his surrounding and the use of call light. It will also necessary to reorient patient whenever necessary and supervise patient during bedside setting, personal hygiene and toileting (Luzia, Almeida & Lucena, 2014).

Answer 2:

In relation to the priority problem of impaired safety for Mr. Shepherd, the following are the progress note for his condition.

Situation: Mr. Shepherd, an 82 year old man has been admitted to the hospital following 2 day history of increased confusion. After returning from the hospital, he had another fall while attempting to go to the toilet. He hit his head and suffered bruises to his right forehead.

Background: The patient has a history of hypertension, asthma, type II diabetes, glaucoma, AF and right sided CVA with left sided weakness. The patient has also complained of lower back pain which was relieved by the use of Panadol, heat packs and repositioning.

Assessment: After admission to the hospital, vital signs of Mr. Shepherd were recorded and his neurological observation was done every 15 minutes. His respiratory rate was found to be in a normal value and he had irregular pulse rate indicated by value of 80-90 beat per minute. His blood pressure was high. The patient is currently taking many medications like warfarin,, aspirin, atenolol and timolol eye drops. He was taking metformin for hyperglycemia and salbutamol for his asthma. Based on neurological observation of patient using GCS scale, the patient has been found to be in a confused state. The patient is requiring transfer aids in bed and during sit out. In response to fall risk, Mr. Shepherd was repositioned, provided specialised matrix and assessment of head wound was done.

Risk Factors for Developing Confusion in Elderly Patients


            As the Mr. Shepherd has sustained head injury after fall, the plan is to provide proper wound care to patient. As he is at pressure injury state 1, the plan is to provide regular dressings to the injured area and assess the wound site each day for signs of recovery or deterioration. As patient is diabetes, it is recommended to take extra precautions while providing medications for wound healing. In response to poor vital signs, it is recommended to manage his blood pressure by regularly monitoring blood pressure every four hours and provide anti-hypertensive medication to patient (Tinetti et al., 2014).Diet changes needs to be prioritized and self-care support in the area of ambulation, feeding and toileting needs to be provided to patient (Barrett, Vizgirda & Zhou, 2017).


Barrett, M. B., Vizgirda, V. M., & Zhou, Y. (2017). Registered Nurse and Patient Care Technician Perceptions of Toileting Patients at High Fall Risk. Medsurg Nursing, 26(5), 317-323.

Barry, E., Galvin, R., Keogh, C., Horgan, F., & Fahey, T. (2014). Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: a systematic review and meta-analysis. BMC geriatrics, 14(1), 14.

Chikura, G., Conroy, S., & Salvi, F. (2018). Clinical Assessment and Management of Older People: What’s Different?. In Geriatric Emergency Medicine (pp. 75-90). Springer, Cham.

Han, J. H., Wilson, A., Graves, A. J., Shintani, A., Schnelle, J. F., Dittus, R. S., ... & Ely, E. W. (2014). Validation of the confusion assessment method for the intensive care unit in older emergency department patients. Academic Emergency Medicine, 21(2), 180-187.

Kang, L., Han, P., Wang, J., Ma, Y., Jia, L., Fu, L., ... & Guo, Q. (2017). Timed Up and Go Test can predict recurrent falls: a longitudinal study of the community-dwelling elderly in China. Clinical interventions in aging, 12, 2009.

Kennedy, M., Enander, R. A., Tadiri, S. P., Wolfe, R. E., Shapiro, N. I., & Marcantonio, E. R. (2014). Delirium risk prediction, healthcare use and mortality of elderly adults in the emergency department. Journal of the American Geriatrics Society, 62(3), 462-469.

Luzia, M. D. F., Almeida, M. D. A., & Lucena, A. D. F. (2014). Nursing care mapping for patients at risk of falls in the Nursing Interventions Classification. Revista da Escola de Enfermagem da USP, 48(4), 632-640.

Tinetti, M. E., Han, L., Lee, D. S., McAvay, G. J., Peduzzi, P., Gross, C. P., ... & Lin, H. (2014). Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA internal medicine, 174(4), 588-595.

Zadravecz, F. J., Tien, L., Robertson?Dick, B. J., Yuen, T. C., Twu, N. M., Churpek, M. M., & Edelson, D. P. (2015). Comparison of mental?status scales for predicting mortality on the general wards. Journal of hospital medicine, 10(10), 658-663.

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