Your client is a 70 year old female admitted to the surgical unit via the Emergency Department [ED] from her home in the senior housing complex. Her admitting diagnosis is fractured RIGHT hip after a fall at home. The client was found on the floor of her apartment after not being seen for a day by her neighbors. Your client was on the floor of her apartment for 14 hours. She is one day post-operative for ORIF of the RIGHT hip. Her past medical history is significant for diabetes (controlled by diet) , CHF and atrial fibrillation. She has no past surgical history. Her family members (children) are all out of state. At 07:00 the night shift nurse reports the patient slept most of the night and was medicated for pain (level 8, 0-10 scale) once during the night at 02:45 with Morphine Sulfate 2mG IV. She has an IV of 0.45%NS at 100mL/hour into the LEFT arm. She is on the usual post-operative antibiotics for 24 hours. She has no allergies. The plan for the day is out of bed to chair and physical therapy in preparation for discharge.
NURSING ASSESSMENT:
Vital Signs: T = 99.6 F P = 118 R = 22 B/P 152/88
Lab Work Na 140, K 3.6 Cl 102 BUN 40 Creat 1.2
HgB 11.0 Hct 22% WBC 12,000
Finger-stick glucose: 21:00 110; 06:00 180.
Neuro: Awake, drowsy oriented to person confused to time and place, PEARL,
(+) blanching of the RIGHT foot warm to touch with pulses equal bilaterally.
Respiratory: Lung with crackles LEFT lung field, respirations slightly elevated;
SpO2 = 94% on 2L/min O2; post-operative chest x-ray shows consolidation in the LEFT lower lung field.
Integumentary: IV site without redness edema; surgical dressing dry intact.
Cardiovascular: HR regular; elevated; (+) pedal pulses bilaterally equal; no peripheral edema.
GI: Bowel sounds X 4 quadrants hypoactive.
GU: Foley catheter with concentrated amber urine; output at 450mL from the
previous 12 hours.
PHYSICIAN ORDERS:
DIET: Clear liquids today, advance to full liquids POD 1 if clear tolerated and then 1800 cal ADA
for dinner if full liquids tolerated for lunch.
IV: 0.45%NS at 100 mL/hour until taking full diet
ACT: Bedrest until PT evaluation POD #1.
RESP: O2 2L/min via NC
VS: q4h inclusive of pulse oximetry
FS GLUCOSE: before meals and bedtime
MEDICATIONS: Ancef 1 Gram IV q8h X 3 doses
Morphine Sulfate 2 mG IV q3h PRN for severe pain (8-10)
Percocet 2 tabs PO q4h PRN for moderate pain (5-7)
Percocet 1 tab PO q4h PRN for mild pain (<5)
Digoxin 0.125mG PO daily.
Lasix 20mG PO daily
Regular Insulin Sliding Scale AC & HS
