Complete attached template in all sections
Dx: Left hip fracture
Summary :
is an 85-year-old white female with a history of osteoporosis. She lives at home by herself where she fell and broke her left hip yesterday evening, after having complaints of dizziness, weakness, and fatigue. She is scheduled to have surgery in 2 days.
Medications:
· Enoxaparin sodium 40 mg SQ daily
· Docusate sodium 100 mg PO daily
· Morphine sulfate 4 mg IV q4h prn for pain
· Metoprolol 25 mg PO BID
· Furosemide 20mg PO daily
Orders:
· Vital signs every 4 hours
· Activity: Bed rest
· Anti-embolism stockings on both legs (knee-length)
report
S: Mrs. Jacobson is an 85-year-old white female who was admitted last evening after falling and fracturing her hip. X-rays have been taken and show left intertrochanteric hip fracture. Mrs. Jacobson is scheduled for surgery in 2 days.
B: Mrs. Jacobson has a 10-year history of osteoporosis and was newly diagnosed with congestive heart failure last year. Her daughter reports that recently Mrs. Jacobson has been having dizzy spells, fatigue, and weakness. Mrs. Jacobson lives alone and is usually able to perform all her ADLs independently. She does have a cane at home but often times refuses to use it because she “doesn’t think she needs it”. Mrs. Jacobson is usually pretty active, but has been much more sedentary lately due to increasing weakness and fatigue due to medication non-compliance with her heart failure medications.
R: You will need to reposition Mrs. Jacobson as she needs to be turned every 2 hours. You should perform a focused musculoskeletal assessment, reinforce safety, and provide patient education on fall risk. Assess her pain level and medicate for pain if needed.
