Thanks for reply :) I was only with my patient for 2 days (both days few hours).
Here is what i got from her chart:
She had right ankle fracture, right sided weakness with residual aphasia due to stroke. she is non-weight bearing. Fall risk: mod-high
Here is my assessment during time i was with her:
Her vital signs were R 20 shallow, pulse 69, oxygen saturation 97, T 36 degree C, BP 130/58. When i was documenting her vital signs i noticed her BP goes up sometimes (which means she is hypertensive)
First day when i saw her she said that she was in a little pain but the week after (my second day at clinical) she said that she was feeling better.
There was no breakdown of skin however, there was little redness on her bump.
She repond to loud stimuli.
ADLs i gave her full bed-bath, she is unable to do pericare. Transfer with one person, difficulty ambulating and she can feed herself but need assistance with opening food. she use commode for toiletering and is incontinence of urine (wear briefs). She almost participates in everything.
I did ask her how did she fall and she was trying to tell me about it but she was not able to express herself. she lives in banglow with stairs.
I hope it helps.