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:
WBC:10.00.
H/H :12.0,36.7%.
K=3.8,NA=137.
Nurses You Move Me 