Associate Degree Nursing CLINICAL PREPARATION TOOL Client Initials: R.B. Date of Admission: 4-4-12 Age: 87 Sex: F

Student Name: Date(s) of Care:

Amber Butler 4/06/2012 (Week 12)

Admission Diagnosis: Left-side Pelvic Fracture Surgery(ies) Done: N/A Allergies: Tape Fell at home; Suffering a left pelvic fracture. Denies

Date(s) of Surgery(ies): N/A Co-Morbidities/Secondary Diagnosis(es): N/A

History of present illness (onset, duration of symptoms, aggravating/relieving factors of symptoms): any chest pain or shortness of breath.

Past medical history and surgeries, significant family history: Coronary artery disease, degenerative joint disease, hypertension, hypothyroidism, hypercholesterolemia, Parkisons Disease. Hernia Repair, cataract implant, percutaneous transluminal coronary angioplasty with three stents, myocardial infarction x2 & bowel resection. Family History-positive for cancer, stroke, and heart disease. Current medications in hospital (drug, category, classification, route, timeinclude prns): Aspirin-81mg for 60 days Prevastatin Sodium (Pravachol)-80mg-4 TAB oral H.S. for 60 days Atenolol (Tenormin)-50mg for 60 days Levothyroxine Sodium (Synthroid)-75mcg for 60 days Calcium Carb/Vit D (Oscal)-500mg for 60 days Multivitamin w/minerals (Centrum)-1 TAB for 60 days Ezetimbel (Zetia)-10mg for 60 days Ocuvite=1 TAB Q 2hrs for 60 days BASELINE VITAL SIGNS (within last 24 hours): SAFETY Restraints (type) Hearing Aid Glasses MOBILITY Activity order Assistance needed Position Order Assistive Aid HYGIENE Independent Assist Dependent Oral Care T 35.5C P 86 R 16 B/P 117/62 Ht N/A Wt N/A

N/A N/A YES BEDREST N/A TURN Q 2HRS N/A N/A N/A X1 OR X2 SET-UP

FLUID BALANCE Intake and Output Fluid restriction Diet order % taken of food Supplement (type) IV fluids (type/rate) Aspiration precautions Assist with meals Independent with meals Indwelling catheter Incontinence Bowel movement Date describe

I O N/A cc/day REG DIET 75-100% ENSURE (EVERYMEAL) NORMAL SALINE-60mL/hr N/A SET-UP N/A N/A N/A LAST BM 4-4-12

TREATMENTS Wound care (site & equip): N/A O2 management: N/A L/min: Pulse oximetry: 95 Deep breathing/coughing (freq): PER RESPIRATORY DEPT. Incentive spirometry (freq): PER RESPIRATORY DEPT. Aerosol therapy (type, freq): N/A Inhaler use (type, freq): N/A NG suction: N/A Enteral feedings *type, freq): N/A Specimens needed (type, reason): N/A PAS or TED Stockings N/A

LABORATORY STUDIES CBC RBC Hgb Hct WBC

Latest Values/Date 3.64 10.7 32.1 8.6 81.3 6.8 1.6 0.3 117 138 4.3 107 46 17 115 1.0 8.8 6.7 4.0 13.2 1.02 26.8

Laboratory Norms 3.85-5.1 11.8-15.3 36.5-46.6 3.8-11 36.8-73.2 15.7-50.5 0.0-1.2 0.1-1.2 155-404 135-145 3.5-5.1 98-112 22-34 7-23 65-100 0.5-1.4 8.5-10.5 6.2-7.6 3.7-4.8 11.3-14.5 0.85-1.16 22.1-35.3

Evaluation of Lab Data Low Low Low High Low Low

X-rays / Diagnostic Tests (date, test, abnormal results): 4-4-12: There are moderately displaced fractures of the superior pubic ramus and inferior pubic ramus on the left. Bone density is very low. There are no additional discernible fractures. There is no sign of underlying pathology. Conclusion: Left-sided Pelvic Fracture.

Differential Neutrophils Lymphocytes Eosinophils Basophils Platelets Chemistry Na K Cl CO2 BUN Glucose Creatinine Calcium Total protein Albumin Prothrombin Time INR APTT

High

24 Hour Summary from previous 24 hours prior to time of clinical prep data collection: Patient vital signs stable. Urinating frequently; Urine specimens collected (hazy yellow). Non-weight bearing per Physical Therapy. Normal Saline at 60mL/hr. Last BM 4-4-12. Regular diet. Patient requests shower on 4-6-12.

Discharge needs: N/A TEXTBOOK RESEARCH (Note Source TEXT: Author, Title, Edition, Copyright year; ARTICLE: Author, Title, Journal, Date) Definition of admission diagnosis: Pelvic fracture is a disruption of the bony structure of the pelvis, including the hip bone, sacrum and coccyx. The most common cause in elderly is a fall, but the most significant fractures involve high-energy forces such as a motor vehicle accident, cycling accidents, or a fall from significant height. Diagnosis is made on the basis of history, clinical features and special investigations usually including X-ray and CT. Because the pelvis cradles so many internal organs, pelvic fractures may produce significant internal bleeding which is invisible to the eye. http://en.wikipedia.org/wiki/Pelvic_fracture

Textbook signs and symptoms: Inability to move immediately after a fall, severe pain in your hip or groin, inability to put weight on your leg on the side of your injured hip, stiffness, bruising and swelling in and around your hip area, shorter leg on the side of your injured hip, turning outward of your leg on the side of your injured hip. http://www.mayoclinic.com/health/hip-fracture/DS00185/DSECTION=symptoms Usual treatment: Nonsurgical Treatment: Stable fractures, such as the avulsion fracture experienced by an athlete, will normally heal without surgery. The patient will have to use crutches or a walker, and will not be able to put all of his or her weight on one or both legs for up to three months, or when the bones are healed. The doctor may prescribe medication to lessen pain. Because mobility may be limited for several months, the physician may also prescribe a blood-thinner to reduce the risk of blood clots forming in the veins of the legs. Some pelvic fractures are treated with only bed rest. Pelvic fractures may involve months of recovery and months or years of rehabilitation. Surgical Treatment: Pelvic fractures that result from high-energy trauma are often life-threatening injuries because of the extensive bleeding. In these cases, doctors may use an external fixator to stabilize the pelvic area. This device has long screws that are inserted into the bones on each side and connected to a frame outside the body. The external fixator allows surgeons to address the internal injuries to organs, blood vessels and nerves. What happens next depends on the type of fracture and the patient's condition. Each case must be assessed individually, particularly with unstable fractures. Some pelvic fractures may require traction. In other cases, an external fixator may be sufficient. Unstable fractures may require surgical insertion of plates or screws. http://orthoinfo.aaos.org/topic.cfm?223topic=A00