Patient History Past Medical
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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