Past Medical History : the Patient Was in Good Health Until This Accident. He Was Parasurfing

Ta Wang

Age: 35

Weight: 95 kg

Background

Past Medical History: The patient was in good health until this accident. He was parasurfing three days ago when he lost control and slammed into some rocks off shore. He was brought to the Emergency Department (ED) via ambulance with a fractured leg. X-rays confirmed a fracture of the left femur. Two days ago, he was taken to the Operating Room for an open reduction and internal fixation (ORIF) of his left femur. His recovery has been unremarkable. The patient’s mother and father are both in good health. Initial exam shows the patient to be alert and oriented to person, place and time. He is wearing antiembolism stockings on both extremities. The dressing is dry and intact on the left femur surgical site.

Allergies: None

Medications: None

Social History: Patient is not married but lives with his girlfriend in a two-story, single-family home. He is athletic and exercises five times a week. He works in construction.

Situation:

Ta Wang is a 35-year-old male who underwent an open reduction and internal fixation (ORIF) of his left femur three days ago. He is alert and oriented to person, place and time. He has moderate pain in L thigh.

Background:

Patient had a parasurfing accident three days ago when he lost control and slammed into some rocks off shore. He was admitted via the ED.

Assessment:

Vital signs: HR 92, BP 138/86, RR 18, SpO2 98% on room air and temperature 37.5C

Cardiovascular: Sinus tachycardia

Respiratory: Breath sounds clear and equal bilaterally

GI: Hypoactive bowel sounds

GU: Voided 800 mL during previous shift

Extremities: Antiembolism stockings in place bilaterally, left femur surgical site dressing dry and intact

Skin: Pink, warm and dry

Neurological: Alert and oriented to person, place and time; pupils equal and reactive to light and Accommodation

IVs: Saline lock in right forearm

Labs: Within normal limits

Fall Risk: High risk for falls

Pain: Left Thigh 6/10

Recommendations:

Monitor for instability and postoperative complications

Initial Healthcare Provider’s Orders:

Activity as tolerated

Regular diet

Saline lock

Antiembolic knee-high stockings

Alprazolam 0.5 mg PO HS prn for anxiety or insomnia

Ampicillin 3g in 100 mL 0.9% NS IVPB q12 hours

Hydromorphone 1 mg IV q4h prn for severe pain

Hydrocodone 5 mg/acetaminophen 325 mg 1 tab PO q4h prn

Diphenhydramine 25 mg PO q4h prn for pruritus

Ondansetron 4 mg IV q6h for nausea

Acetaminophen 650 mg PO q4h prn for temp greater than 38 Celsius

Docusate sodium 100 mg PO BID (discontinue for loose stools)

Lesson Objectives:

1.  Prepare and practice SBAR reports to the MD and correctly take phone orders.

2.  Properly administer a Heparin bolus and IV drip using a pump.

3.  Describe the S&S of VTE (DVT) and PE.

Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE)

1.  What is the pathophysiology of DVT/VTE?

2.  What is the medical and nursing management of the client with a DVT?

3.  What is the pathophysiology of a PE and how is it diagnosed? Signs & symptoms?