Fractures of the tibia and fibula often occur in association with each other and tend to result from a direct blow, falls with the foot in a flexed position, or a violent twisting motion. splint: dev ... ice designed specifically to support and immobilize a body part in a desired position DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS ANTICIPATED NURSING INTERVENTIONS vSim ISBAR ACTIVITY STUDENT WORKSHEET INTRODUCTION Karen Brito RN , Med Surge Unit Your name, position (RN), unit you are working on SITUATION Marilyn Hughes, 45 year old female, suffered a left mid-shaft tibia- fibula fracture Patient’s name, age, specific reason for visit BACKGROUND Primary diagnosis is compartment syndrome after the surgery , date of admission 4/12/2020, current orders are morphine and to assess vital signs and assess post operative dressing Patient’s primary diagnosis, date of admission, current orders for patient ASSESSMENT Lower left leg looks cyanotic, dressing seems really tight, prolonged capillary refill in the toes on the left side, normal skin turgor, skin is cool and she is very sweaty Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs RECOMMENDATION Recommendations is to loosen dressing, assess pedal pulses, vital signs q 15 mins, provide PRN medication for pain, assess pain, circulation Any orders or recommendations you mayhave for this patient PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: morphine hydrochloride CLASSIFICATION: Therapeutic class: Opioid analgesics Pharmacologic class: Opioids SAFE DOSE OR DOSE RANGE, SAFE ROUTE Adults: Initially, 10 mg (based on 70 kg individual) IM or 0.1 to 0.2 mg/kg IV every 4 hours p.r.n. Or, 15 to 30 mg (immediate-release tablets) PO, or 10 to 20 mg (oral solution) PO, or 10 to 20 mg PR every 4 hours p.r.n. PURPOSE FOR TAKING THIS MEDICATION Severe pain (the 20 mg/mL oral solution concentration should only be used in opioid-tolerant patients). PATIENT EDUCATION WHILE TAKING THIS MEDICATION ● Instruct patient how and when to ask for pain medication. ● May cause drowsiness or dizziness. Caution patient to call for assistance when ambulating or smoking and to avoid driving or other activities requiring alertness until response to medication is known. ● Advise patient to change positions slowly to minimize orthostatic hypotension. ● Caution patient to avoid concurrent use of alcohol or other CNS depressants with this medication. ● Encourage patients who are immobilized or on prolonged bedrest to turn, cough Clinical Worksheet Date: 4/12/2020 Student Name: Karen Brito Assigned vSim: Marilyn Hughes Initials: MH Diagnosis: Compartment Syndrome HCP:N/A Isolation:N/A IV Type: Location: RUA Critical Labs:N/A Other Services:N/A Fall Risk: Age: Consults:N/A Consults Needed:N/A 45 Length of Stay: N/ATran Fluid/Rate: IV of Lactated Ringer’s infusing at 75 mL/hour M/F:F 1 sfer:N/A Code Status:Full dayAllergies:N /A Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: Patient is in hospital because she suffered a left mid- shaft tibia-fibula fracture when she slipped on icy stairs this morning. She was taken to surgery for an open reduction with internal fixation (ORIF). Health History/Comorbities (that relate to this hospitalization): Shift Goals/ Patient Education Needs: 1. Loosen Dressing 2. [Show More]
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