441 CASE SCENARIO. MR PROUD JUDGE, RIGHT FEMUR FRACTURE DUE TO FALL.(NURSING)

Age/Sex 78years old man .

MR#Q5555533321.

Acount # Q0000991111.

Staus: Inpatient.

Attending doctor:Bigman, Jimmy. Location:Trauma unit.

Room # 43002.

Code Status: Full code.

06/21/2021

Weight: 132lbs.

Height: 5ft 2inches.

Primary diagnosis: Right femur fractures due to fall at home.

Secondary diagnosis:Hypertension, hypothyroidism, hyperlipidemia.

Isolation precautions: Standard precautions. Allergy: NKDA.

02 93% on Room Air.

Transportation by bed.

Skin intact.

Diet : NPO after midnight.

Uses urinal at bedside.

Surgical Consent to be sign ( In the chart).

Advanced Directive on the chart.NO.

SCD in place(left leg ).

Laboratory Studies:

WBC:8.3.

H/H:14/ 40.0%.

NA:136.

K=3.9.

Bun:18,Cr:1.0.

0.9NS,at 75ml/hr left forearm infusing well via pump.

Complain of pain.5/10.Morphine 2mg Q2hours given prn as ordered with relief. Reassessment of pain in 30minutes 0/10.Patientis resting comfortably in bed.

Published by edochie99

A Registered Nurse with over twenty years of hospital experience, an author with Masters Degree in Nursing,also Bachelor Degree in Nursing,graduated in 1996 from USC,University of Southern California.MSN in 2009 University of Phoenix.

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