“Patient Introduction and Assessment in the Orthopedic Unit”

Patient IntroductionLocation: Orthopedic Unit
Time: 15:00
Situation:
The patient is Marilyn Hughes. She is a 45-year-old female who arrived on the Orthopedic Unit at 1345 from the recovery room following an open reduction with internal fixation for a left mid-shaft tibia-fibula fracture sustained when she slipped on some stairs this morning.
Background:
She has no remarkable past medical or prior surgical history and has no known allergies. She is married with teenage children.
Assessment:
Her vital signs have been stable. The last set was: temperature: 99 °F (37.2 °C); heart rate: 88; respiratory rate: 16; BP: 130/82; and SpO2: 97% on room air. She has a 20-gauge left forearm saline lock and is tolerating liquids well without nausea. Her diet is scheduled as regular evening meal.
The left lower leg has an ace/splint dressing. Pedal pulses are palpable with neurovascular checks within normal range. She was given prn oxycodone 10 mg at 1400 for a pain level of 8 out of 10 when the regular medication with acetaminophen and gabapentin were started.
Recommendation:
Every 2 hours you need to obtain her vital signs with neurovascular checks.