A 65years old man with dislocated right hip is brought in by his son.History of right hip replacement, hypertension ,anemia.Full code. Height 5feet 6inches, weight 150lbs.Standard precautions. High risk for fall. 02 at 2liter nasal canula with saturation of 96%.Transportation method is bed.SCD bilateral lower extremity. No advance Directive but a copy is on the chart.Risk of skin integrity. Allergy to Morphine sulfate. Regular diet. Postoperative day one . Right total hip revision done.Patient is stable, able to wriggle toes.Dressing to right hip intact no bleeding. Foley catheter in place to be discontinue in 48hours. 0.9NS IV at 75ml/hour infusing via pump to left forearm 18guage .Clean ,patent and dry.Zosyn 3.378gm IV infusing. Dilaudid 2mg IV Q4hours prn severe pain. Norco 10/325gm 1tablet po Q6hours prn moderate pain.Tylenol 650mg po Q4hours prn temperature.Lovenox 40mg subQ Q24hours.Laboratory test-cbc with differential, chem 7,coagulant,lft ordered by doctor for tomorrow morning.
Vital signs Q4hours. BP 128/78,hr 76,Respiration 18,02 saturation 96%,
1.Why is patient on standard precautions?.
2.Pharmacy requested for patient weight and height.As a Registered nurse why will you provide patient weight and height to Pharmacy?.
3.What is the importance of patient ability to wriggle his toes?.
4.What are the fall risk protocol?.