nursing 3-4 PATIENT WITH FRACTURED TIBIA AND ASTHMA 2300 Handoff Report: The pat
ID: 139379 • Letter: N
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nursing
3-4 PATIENT WITH FRACTURED TIBIA AND ASTHMA 2300 Handoff Report: The patient in 205 was admitted with a fractured right tibia and is 1 day postop. He has a cast on. He has been quiet most of the evening. He just started coughing and is experiencing some SOB. He says he has a history of asthma and that he gets this way every now and then. I did not detect any wheezing. Vital signs are T 98.8"F, P 90, R 28, BP 140/88, pulse ox 92%, pain level 3 out of 10 on the pain scale. Circulation. movement, and sensation are WNL in the right leg. S The following information is obtained from the patient's electronic medical record: Patient:TW Age:48) Sex: M : ID#C5670) Room:205 Drug allergies: LNKDA_] Food allergies: Tone Time: 2300 Dx: Fractured Right Tibia ] Patient Plan of Care Up in chair PT to teach crutch walking Diet: Regular Patient:Ty Age: 48 Sex: M ID# 5870| Room: 205 Drug allergies: NKDA Food allergies: None Time: 2300 IV: D5/0.9% NaCl at 75 mLhr IV site: RFA #20 g angiocath Dx: Fractured Right Tibia History and Physical Circ. movement, sensation and temp. (CMST) right leg q4h Elevate leg on one pillow Smokes 1/2 -1 pack of cigarettes/day Respiratory infection 1 month ago Uses cromolyn inhaler prn Lab work done on the day of admission: Medication Record PRN PCA-morphine sulfate 1 mg on demand; 8 min lock out, 4 hour dose limit 30 mg ESR Collaborative Learning Activity: With a partner, use the clinical situation and the electronic o medical record to: 1. Identify the pertinent 2. Identify the pertinent 3. Review the data in patient information made known to you in the handoff report.electronic medical record. patient information madecolumns 1 and 2 and known to you from the identify information that needs follow-up. ·Explanation / Answer
1. The information in the handoff report are:
• Coughing with SOB
• History of asthma
• T: 98.8F, P: 90, R: 28, BP: 140/88, pulse ox 92%
• Pain level 3 out of 10
2. The information in electronic health record are:
• PCA- morphine sulphate 1 mg on demand
• ESR is elevated
• IV site: right femoral artery
• Circulation, movement, sensation and temperature of right leg q4h
• Elevated leg on pillow
3. The following needs follow up care:
• Vital signs assessment
• Pulse of is 92% so oxygen to be given
• Assessment of pain
• Check for ESR level
• Assess the level for circulation, movement, sensation and temperature of right leg
2330: Vital signs and pain assessment
2345: Oxygen therapy to be given
2400: send blood sample for ESR
2430: Assess the right leg
0000: Administer inhaler
0030: PCA given accordingly
0100: Administer IV fluids
0130: Teach crutch walking
The following nursing intervention needs immediate follow up:
• Check oxygen saturation
• Take ABG
• Report to physician
The following can be delegated to unlicensed personnel:
• Checking oxygen saturation
• Administration of nebulizer
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