Patient Profile
D.R. is a 74-year-old obese Hispanic woman who is in the third postoperative day after an open
reduction internal fixation (ORIF), for
... [Show More] repair of a left femoral neck fracture after a fall at home.
Subjective Data
• States pain in her left hip is a 4 to 5 on a 1-to-10 scale
• States pain in her left calf area is a 3 on a 1-to-10 scale
Objective Data
Physical Examination
• Vital signs: blood pressure 140/68, pulse 64, temperature 98.7° F, respirations 20
• Oxygen saturation 93% on room air
• Lungs clear all lobes
• Bowel sounds are present in all four quadrants
• Apical pulse: 64, irregular
• Alert and oriented to person, place, and time
• Skin warm to touch bilateral lower extremities, slight erythema left lower extremity
• No edema right lower extremity, 2+ left lower extremity
• Pedal pulses 3+ right lower extremity, 1+ left lower extremity
• Calf circumference: right, 8 cm; left, 10 cm
• Left hip wound has staples; no signs or symptoms of infection
• Last bowel movement was four days ago
Interprofessional Care
Medication Administration Record
• Morphine sulfate 2 mg IVP every two hours as needed for pain scale 6-10
• Lisinopril 20 mg PO daily
• Bisacodyl 10 mg PO daily
Discussion Questions
1. What do you suspect is occurring with D.R.? What data were used to make this determination?
● LLE: diminished pedal pulse (+1), +2 unilateral LLE edema, pain, & increased
circumference relative to RLE, erythematous, risk due to 3 day post operation
○ Indicates DVT of LLE calf
■ Difference in calf circumference and unilateral edema + pain indicate
DVT
2. What are the priority nursing interventions at this time?
● Oxygen with the goal of reaching at least 96% SPO2
● Perform a full neuro exam, obtain an EKG, assess vital signs (specifically pulse
oximetry), ask if patient is experiencing cough, chest pain, or dyspnea: If patient is
Downloaded by Simon Kamau ([email protected])
lOMoARcPSD|25111999
positive for a DVT, monitor for blood clot moving to the lungs which can result in a PE,
the heart which can result in a myocardial infarction, or the brain which can result in a
cerebrovascular accident.
3. Using SBAR, what would you report to the provider?
Situation: 74-year-old obese Hispanic woman who is in the third postoperative day after
an open reduction internal fixation (ORIF), for repair of a left femoral neck fracture after
a fall at home.
Background:
Assessment:
● General: A&O x4
● Respirations - 20
○ Oxygen 93%
● Cardiac:
○ Apical pulse: 64
● Peripheral
○ LLE: diminished pedal pulse (+1), +2 unilateral LLE edema, pain, &
increased circumference relative to RLE (8 to 10), erythematous
●
Recommendation:
Provide and monitor O2
safety and comfort
4. What diagnostic studies would [Show Less]