Nursing Clinical assignment

Client’s information collected on day of clinical to assist with completing paperwork

Date: 1/28/21

Code: Full (No ACP docs)

Allegies: NKA

Diet: Regular

Weight: 117 lb

Vitals: T-97.7, P-70, R-18, BP-123/84, 02 sats 100 % RA

Principal Problem: Hip Fracture requiring operative repair, right, closed initial encounter (HCC)

PMH: Osteoporosis, Hypoglycemia, tobacco abuse

54-year-old female was walking outside and stubbled on piece of frozen ice and fell. Landed hard on right hip. A right hip comminuted fracture was identified and patient was admitted for surgical repair.

Doctor recommended intra medullary rod fixation of this fracture. Risk-benefit alternative and possible complication and treatment injury surgery were fully discussed.

Risk include but not limited to perioperative complication such as infection, blood clot, or even death.

Patient does have significant amount of osteoporosis at her young age, tobacco abuse also complicates this.

Patient underwent surgery and surgery was successful but doctor recommend that patient follow-up with family doctor to be back on her osteoporosis medication meanwhile she can also take some vitamin D and calcium.

Medications

Xarelto-anticoagulation

Enoxaparin-Prophylaxis

Scheduled Medications

1. 0900 -Sennoside-docusate sodium (SENOKOT-S) 8.6-50 mg 2 tabs oral daily

2. 099-Multivit, Ca, mineral-iron-Fe (THERAPEUTIC-M) 9 mg iron-400 mcg tab 1 tab oral daily

3. 099- Rivaroxaban (XARELTO) 10 mg daily

4. 0900-Sodium Chloride (saline lock flush) inj 2.5 ml intravenously BID as needed

5. 2000-Famotidine (PEPCID) 20 mg tab oral nightly

6. 0900-Magnesium hydroxide (milk of magnesia) 400 mg/5ml, 30 ml oral once daily

7. Hydrocodone-Acetaminophen (NORCO) 5-325 mg 1-tab Q4H PRN for moderate pain

8. Ondansetron (Zofran) 4 mg intravenously Q6H PRN for nausea and or vomiting

9. Hydromorphone (Dilaudid) 0.5 ml inj intravenously Q3H PRN for severe pain.

Dressing: unremarkable, dressing intact on right side. No drainage, no surrounding erythema. Dorsalis pedis pulse is present bilaterally and symmetric.

Review of system

General: patient is awake, alert, in no acute distress, no fever, no malaise or unexplained weight loss.

No cardiovascular, pulmonary, endocrine or hematological disorders. Has very good functional capacity w/o symptoms. Worked as a waitress most of her life, able to walk and climb stairs easily w/o symptoms before current fall.

Labs:

COVD-19 -Negative

Glucose -98

Sodium-135

Potassium-3.3

CO2-25

BUN-6.0

Creatinine-0.06

Calcium-8.2

Magnesium 2.0

Total Protein-6.5

AST/SGOT-19

WBC-6.3

RBC-3.72

HCT-34.9

Plates-154

Hematocrit-34.9

Hemoglobin-11.0