Background  Patient History Past Medical History:  Past medical history is unremarkable  Allergie

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Asked by daphibelle

Background

 Patient History Past Medical History: 

Past medical history is unremarkable 

Allergies: No known drug allergies 

Medications: None 

Code Status: Full code

 Social/Family History: Second-year student at a local university for his bachelor of science degree with a pre-medical-school tract

Situation: 

The patient is a 22-year-old male being transferred to the General Surgery/Trauma Unit from SICU. He was admitted via the emergency department (ED) yesterday after he sustained bilateral compound femur fractures following a MVC in which he rolled his truck. On admission to the trauma center, his blood alcohol concentration (BAC) was 0.12 mg/dL. His urine and toxicology screen was negative for all other drugs. After immediate treatment in the ED, he was taken to surgery for an open reduction internal fixation (ORIF) of both femurs. Due to prolonged anesthesia and estimated blood loss (EBL) of 800 mL in surgery, he was transferred to the Surgical Intensive Care Unit (SICU) for overnight observation. He is now stable and ready for transfer.

Background:

 His diagnosis is ORIF of both femurs secondary to motor vehicle collision (MVC). His medical and surgical history is unremarkable. The patient has no known drug allergies and is awake and alert.

Assessment: 

Vital signs stable: HR 112, BP 138/75, RR 18 and regular, SpO2 has been 98% on O2 2 LPM via nasal cannula, Temperature 37.7C 

Cardiovascular: Sinus tachycardia

 Respiratory: Breath sounds clear 

GI: Normoactive bowel sounds. Has tolerated ice chips and sips of water without nausea and vomiting 

GU: Urinary output by urinary catheter is approximately 30 to 40 mL of concentrated urine per hour

 Extremities: Able to wiggle toes. Range of motion in the lower extremities is within normal limits as expected post-operatively. Normal sensation in bilateral lower extremities 

Skin: Warm and dry. Clean, dry, and intact dressings to both thighs 

Neurological: Awake, alert, and oriented to person, place, and time. Pupils equal and reactive to light. No neurological deficits IVs: 0.9% sodium chloride infusing at 150 mL/hr via triple lumen catheter 

Labs: Hemoglobin 11.8 mg/dL, hematocrit 36%, sodium 145 mEq/L, potassium 4.8 mEq/L. All other lab results are within normal limits. Chest x-ray within normal limits 

Fall Risk: High-risk

 Pain: Effective pain management with narcotic patient-controlled analgesia (PCA), including nurse-administered bolus dose for breakthrough pain

 Recommendations: Admit to General Surgery/Trauma Unit and provide general postoperative nursing care

Provider’s order

Diagnosis: Status post ORIF bilateral femurs
Full code
Admit to med/surg
Bedrest 
Vital signs every 4 hours
Notify the healthcare provider for HR greater than 140 or less than 60 
Notify the healthcare provider for SBP less than 100 or greater than 180
Notify the healthcare provider for urine output less than 240 mL/8 hours
Notify the healthcare provider for Temp greater than 38C
Notify the healthcare provider for SpO2 less than 92%
Telemetry x 24hrs, then discontinue if no dysrhythmias 
Continuous pulse oximetry 
O2 2 LPM nasal cannula titrate for sats >92 
ABG STAT for SpO2 less than 92%
Admit to med/surg
Incentive spirometry every hour while awake
Clear liquids, advance to regular diet as tolerated
IV of NS at 150 mL/hour
CeFAZolin 500 mg IV piggyback every 6 hours
Hydromorphone 0.5-1mg IV push every three hours as needed for moderate to severe pain
For pruritus: diphenhydrAMINE hydrochloride 25 mg IV push every 6 hours.
For nausea: ondansetron hydrochloride 4 mg every 4 hours IV push.
Enoxaparin 30 mg SUBCUT every 12 hours x 10 days
Bisacodyl suppository one PR on day 3 if no bowel movement, then prn for constipation

1. Explain the assessment findings that are outside of normal, provide rationale.

2. Which findings are most important and should be addressed first? Provide rationale (Requires more insights than Airway/Breathing first. etc.)

3. Based on your priorities listed above, what therapies should be implemented first and why?

4. Based on your interventions listed above, what post-intervention assessment findings would you expect to see, indicating that the therapies you selected were effective?

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