Age/Sex 77years.Female .

Admitted 06/28/21. 0020am.

Status :Inpatient admission.

Trauma unit: Room : 550031.

Weight : 106lbs .Height : 5ft tall.

Attending doctor: Tumtum,Worry.

Kingdom of God hospital Los Angeles,California 900000.

Primary diagnosis: Right femur fracture.Patient was having a conversation with her neighbor when she slipped and fell in their driveway. Secondary diagnosis :Hypertension.

Code Status: Full code.

Is patient high risk for falls “:Yes”.

Do you have advanced Directive:No.Copy of advanced Directive on the chart.

Patient on Medicare.

Method of transportation: Bed.

Room air saturation of 96%.Alert and oriented x4.Right hip displaced,and bruises to right hip.Discolored right toe.

Allergy: NKDA.

NPO after breakfast.

Clear liquid diet.

Surgery at 1800 today .

Called Operating room for time change.

Consent signed in the chart.Preop teaching done.She demonstrated understanding.

Bucks traction 10lbs in place.

Uses the bedpan.

0.9NS at 75ml/hr right ac via pump.

Ancef 1gm on call to OR.

Complain of pain dilaudid 0.5mg IV Q4hours prn pain given x1 with relief.

Reassessment of pain in 30minutes.

Laboratory tests:


H/H :12.0,36.7%.


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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