Reference no: EM133398117
Case: You are assigned to Mrs. Z. a 72-year-old woman who fell at home and was admitted to the hospital with a fracture of the right hip. She was alert and oriented on admission.
Handoff Report for Mrs. Z:
Patient has an IV of D5/0.45% NS at 75 mL/hr, oxygen at 2L/min/nasal cannula, and is on a clear fluid diet. The neurovascular checks to the right leg are q4h for the first 24 hours. The right leg is warm, pedal pulse present, capillary refill around 2 seconds. IV PCA with morphine sulfate delivering 1 mg/hr continuous infusion. The following medications are ordered: FeSO4 325 mg po tid with meals (start when on regular diet), docusate sodium 100 mg po daily. The urinary catheter is draining clear urine. Current vital signs are P 80, R 18, BP 110/84. She is very restless and confused this morning.
Subjective Data
Fell at home when she tried to get up to go to the bathroom
Her husband took her to the hospital
She has a past medical history of hypertension which is well controlled by enalapril (Vasotec) for the past 6 years
She had the flu a week ago
Complains of pain in right hip
Objective Data
Blood pressure 110/84
Diaphoretic and pale skin
Pedal pulses present
Capilary refill 2 seconds
Restless
Oriented x2
Diagnostic Studies
x-ray of right hip revealed fracture
ABGs: PaO2 80 mmHg, PaCO2 35 mmHg, pH 7.42
During the follow-up assessment for the first postop day, you note the following:
- Pedal pulse present: weak in the right foot, stronger on left foot
- Hemoglobin 10.5g/dL and hematocrit 32%
- Bowel sounds hypoactive in all quadrants
- Anxious and restless
- Crackles in the lower bases of the lung
First day post op
Alert and orientated on admission - baseline
Assessed as restless and confused in the morning
other assessments :
V/S
Neurovascular - checking the pulses in her legs
Respiratory
this a concern:
Neuro status
Surgical site
Dressing has small amount dried dark red drainage - this is not a concern as this is indicative of old drainage and the amount is small.
Position of right leg and body alignment
Second day post op
Still confused
Bilateral crackles
Laboured breathing
SOBOE - R = 32
Oxygen sat = 92%
Productive cough
Skin cool, pallor
P = 108
- What else would you do in this situation with Mrs. Z?
- What other options or alternatives would you explore and why for Mrs. Z?
- What referrals might you make for Mrs. Z at this time?
- Who else on the interprofessional team would you involve in Mrs. Z's care?