A 50years old man fell at home when he was cleaning his house. Develop right Femur fracture. Closed reduction, retrograde,IM nailing of right femur done by doctor Cute, Mann. Secondary diagnosis :Diabetes type 11,hypertension, chronic pain,depression, high cholesterol.
Weight bearing as tolerating.Ambulated with Physical therapist during this shift.Full code.Weight 195lbs,Height 5feet 9inches.Isolation Status: Standard Precautions. Risk for fall. ( Fall prevention protocol in place) No risk for suicide. Patient doesn’t have advance Directive. Copy of advance Directive on the chart.Alert and oriented x 4.Transportation method wheel chair. Skin integrity impaired redness noted in the coccyx area. Acewrap dressing to right leg.Myperlix applied to coccyx area for protection. Allergy NKDA.Diet Carb control diet.Voiding using the urinal at bedside. + BM ×2 during this shift. Ambulates with front wheel walker.
Medications:Dilaudid 4mg po prn Q6hours. Dilaudid 2mg IV Q4hours prn severe pain .Lovenox 30mg SubQ Daily scheduled. Regular Insulin 4units Bid 0730am ,1700 scheduled.Nebulizer Q4hours prn by Respiratory therapist. Ativan 1mg po Q6hours prn anxiety. Tylenol 650mg po Q4hours prn temperature. 0.9NS at 75ml/hour infusing via pump to left forearm 18guage Clean,patent and intact Accucheck Qac +Qhs.Laboratory test at 05am.
Plans: Short term Skilled Nursing facility in two days if medically stable. Orders in his chart.
1.Why is patient on lovenox?.
2.When is lovenox started after surgery?.
3.What are the fall prevention protocol?.
4.What actions do you need in place to prevent fall?.