Acute Care – Post-Operative Case Study  This final case study is based

Acute Care – Post-Operative Case Study  This final case study is based on what you have learned in the course. Please reflect on the following  prior to completing this case study:  1. What two general characteristics must your documentation include? Explain how these characteristics  apply to your documentation?  2. What are some risks or adverse events that may occur in a post-operative acute care setting?  3. For these risks, what are the essential components of your documentation?  4. Are there inappropriate abbreviations or ambiguous terms? Scenario  The following is a fictitious scenario in an acute care setting (some details may be missing). Use  day/month/year and metric time, and use your name and designation. Begin your documentation when  Mrs. Smith arrives on your unit post-op. Client background information: • Mrs. Alice Smith – 64 years old  • Dr. D. White – primary physician  • Dr. G. Greene – surgeon  • Family contact – Glenda Matheson, daughter and named agent on personal directive • Medical diagnoses – hypertension, osteoporosis, osteoarthritis to both hips, Type 2 diabetes, fractured  left hip.  • Functional – independent with activities of daily living (ADLs) at home; ambulatory with cane.  What happened?  Mrs. Smith recently fell at home and sustained an introchanteric fracture of the left hip. Client states  that there was no loss of consciousness (LOC) during her fall. Because of short staffing and after  spending an exhausting ten hours in ER, she is admitted to Unit 4, Room 101 at 0600 and is booked for  surgery (left hemiarthroplasty). Her family is upset at the long wait in ER and has threatened to call the  Health Minister.  She arrives on your unit via stretcher with 5 pounds of Buck’s traction. VS: BP 143/89, T 37. 2 C (t) P97, R  18, O2 sats – 96% RA. She was given 2.5 mg Morphine IM at 0430 for pain.  New orders: traction and CTEMPS routines. NPO for OR today at 1000. Foley catheter draining 700 mls  of clear amber urine. IV of NS infusing in right hand at 100 ml/hr.Mrs. Smith’s daughter asks the care provider what a “hemiarthroplasty” is. She also asks how long her  mother’s hospital stay will be.  Mrs. Smith went to the OR at 0930 and returned to the unit at 1430. Her GCS is 14 (there is a flow sheet  for GCS). She received morphine 5 mg IV at 1330. Her incision is well approximated and dressing intact  with a small amount of sero-sanguinous drainage.  Hemovac intact with 30 mls of sanguineous drainage. CTEMPS stable. VS: 126/84, T 37.1 C (t), P88, R18,  SaO2 95%. O2 running at 2 l/minute via nasal prongs. IV of NS in right hand intact and infusing at 150  mls/hr. Foley catheter intact and draining 200 mls of clear amber urine. Oriented. Mrs. Smith has  minimal pain now when asked.  Her daughter points to the Hemovac and asks: “What is this contraption?” The care provider assesses  and settles the client on return from the recovery unit and answers her daughter’s s and  concerns.  Health Science Science Nursing NSG 5000 Share EmailCopy link Comments (0)

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