Reference no: EM133511353
Case: Mrs.LV, 74 Years old, is 4 days postop left hip fracture. she had a constavac that was removed yesterday. surgical dressing is clean and dry. pedal pulse on the left foot is present and the circulation ,movement ,and sensation are within normal limits. lungs sounds with fine crackles at the lower bases in both lungs. you need to encourage her to deep breathe and cough and use the incentive spirometer. Her 6:00 AM Vital signs are T 99.8 f. p-80, R-18, BP-130/82 ,pulse ox-96%. ,she does not want to move ,it seems like she is scared .i have given her acetaminophen 3 two times during the night for leg pain ,the last dose was at 6:00 AM. she is sleeping right now. following assessment in the nurse's notes:AT7:30 AM
7:30 AM Awake, alert, states "did not have a good night." Right leg pain level at 5. Left leg with pedal pulse, warm, cap. refill greater than 2 sec. Leg elevated on pillow. Dressing clean and dry. Right leg with weak pedal pulse, swelling and redness noted at calf and thigh. Tender to touch. Lung sounds with fine crackles, encouraged to take deep breaths. Bowel sounds present ×4, complaining of constipation.
Question 1) After the nurse complete her assessment at 0730, what information was missing in the 0700 report?
Question 2) Should the physician have been called? When?
Question 3) What nursing actions can you delegate/assign to the personal support worker?