Pertinent medical history:
DM with neuropathy – results in altered sensation in extremities
Osteopenia – could be associated with patient’s hx of lymphoma and
chemotherapy
Hx of bil knee fracture, T11 compression fracture, C3-C4 spinal
stenosis – compromised musculoskeletal status
History of falls
As a result of being in a new
environment – patient was living
with son and just recently moved
to an independent senior
apartment 2 days before the fall
As side effect of current
medications: Ambien,
Gabapentin, Norco,
antihypertensives
POSSIBLE CAUSES
MAY OCCUR WITH
ASSESSMENT FINDINGS
P
R
CE
N
O
EC
L
SIB
OS
N
CORRELATES TO
Decreased mobility due to pain
Increased risk for PNA
Intervention:
- Pain management: start with
ATC Tylenol, then PRN Norco
- Incentive spirometer
- Up in chair/promote
ambulation
THORACIC AND CXR FINDINGS
- multiple L-sided rib fracture
- lung contusion in posterior aspect of
bilateral lower lobes
- no pneumothorax, organ laceration,
thoracic or lumbar spine fx, free air or
free fluid throughout abd & pelvis
VS: 160/72, 98, 18, 98.1, 95% RA
Lung sounds clear on all lung fields
Heart rate regular. Pedal pulses
equal and easily palpable.
Posterior left rib area with bruising.
Reports pain 5-10/10, with
guarding. Reports difficulty taking
deep breaths due to rib pain