Question

Handoff report at 7 AM

Mrs. LV, 74 years old, is 4 days postop left hip fracture.

She had a ConstaVac that was removed yesterday.

Surgical dressing is clean and dry.

Pedal pulse on the left foot is present and the circulation, movement and sensation are within normal limits.

Lung sounds with fine crackles at the lower bases in both lungs.

You need to encourage her to deep breathe and cough and use the incentive spirometer.

6 AM signs: T99.8 F, P 80, R 18, BP 130/82, pulse ox 96%.

She does not want to move. It seems like she is scared. I have given her acetaminophen #3 two times during the night for leg pain, the last dose was at 6 AM.

She is sleeping right now.

Patient Care Kardex

• VS: q shift

• Diet: Soft

• Hard of hearing

• I & O

• Ambulate with PT

• LBM (2 days ago)

• IV: Saline lock left forearm #22 g angiocath

• Inserted day of surgery

Routine Medications:

• Digoxin 0.125 mg po qAM 0900

• Furosemide 10 mg po qAM 0900

• FeSO4 300 mg po tid c– meals 0800 - 1200 - 1700

• Lovenox 30 mg subcut daily 0900

PRN:

• Acetaminophen with codeine #3 tab i po q4h prn pain

Medical History:

• Elderly female brought into the Emergency Department (ED) after falling at home.

• A fracture of the left hip was diagnosed.

• She was taken to surgery and an open reduction internal fixation (ORIF) was performed.

• Hgb 9.4 g/dL, Hct 28% on admission.

She lives alone, has one son, and her husband died 2 years ago from a cardiac condition. Patient has a history of atrial fibrillation.

1.After you complete your assessment at 0730, what information was missing in the 0700 report?

2.Should the physician have been called? When?

3.What nursing actions can you delegate/assign to the personal support worker?

Answer 1

1.it doesn't show how much drain has been removed and the drain's color. She also didn't give the reports on pain assessment.

2. She should have contacted the concerned Doctor when the patient expressed pain during the night the second time.

3. I would assign the personal support worker to get the reports from previous shifts on what has occurred during the unit and the proceeds to complete the morning care. I assign her to put more focus on the physical aspects of care.

3