Mr B.G 35years old male was brought in by ambulance due to fall.
Diagnosis : Right Humerus Fracture.
Right Pneumothorax, right ribs 4,6 fracture. Sacral,bilateral acetabular and nasal fracture .None Operable..
Right Humerus reduction done at the emergency room.Right pelvic, (B)Acetabular fracture ,Sacral percutaneous fixation of right pelvic pelvic done by doctor Don’t Hate. Dressing with tegaderm in place right hip.
No Medical History.
(No chest tube placed because it is small Pneumothorax. )
MRI done (Magnetic resonance images)
CT SCAN (Computed tomography) also done.
GU:Foley catheter in place for retention. (DON’T REMOVE FOLEY CATHETER UNLESS ORDERED)
Fever: 100.7 Tylenol 650mg po given.
Dilaudid for pain ,2mg iv Q3hours prn.
Tylenol 650mg Q6hours prn temperature.
Norco 10/325mg Q4hours prn pain.
Calcium and vitamin D capsule po Qday.
Allergy: NKDA.
Diet : Regular diet.
0.9 Normal Saline at 75ml/hr to left ac.
PT/OT for evaluation and treatment.
Incentive Spirometry 10x an hour while awake.
02 at 2l NC.
PATIENT AND NURSE:
Patient called the nurse and said that he wants to go outside and smoke. Nurse discouraged the patient but offered him nicotine patch. The patient refused the patch and said that he is not ready to stop smoking.And that the patch will make him sick.The nurse told him that the doctor could start him with the lowest dose of nicotine patch. The Side Effects are dizziness, headache, heart racing and muscle ache. These signs don’t happen to everyone.
The patient kept quiet.
When the nurse left patient started to smoke cigarette in hospital room.The nursing assistant saw him and reported him to the charge nurse. The charge nurse ran into the room and educated the patient that smoking in the room is very dangerous with the oxygen in the room. And that he can set himself on fire and the room on fire. The doctor and supervisor notified.
Most important thing is to provide quality care to the patient. Quality care is always the top most priority.
And good quality include good judgment ,standards of care, comprehensive assessment and documentation. Patient and family education is part of good quality care.
Nurses You Move Me 