Reference no: EM133847607
Questions :
1. Which medications needs to be hold based on patients vital signs or labs ?
2. Which labs are missing ?
3. Is there any more necessary medication needs to be given to this patient ?
Mrs. LM is a 74-year-old, came to the emergency room via ambulance. Her admitting diagnosis is Left Hip Fracture.
She is 2-day post-ORIF left hip. JP left hip. Her primary care provider is Who Cares, MD.
Her pedal pulse on the left foot is present and circulation, movement and sensation are WNL.
Foley catheter in place.
Lung sounds have fine crackles at the lower bases bilaterally anterior and posterior.
She does not want to move around. She states, "it hurts when I move". She was medicated during the night twice with pain medication (Reported pain of 8 both times).
She lives alone, has one son living 6 hours away, husband died 2 years ago from a cardiac condition.
Orders: VS every 4 hours, Diet: 1800 ADA soft, Accu-check before meals, I & O every 12 hours,
Ambulate with physical therapy three times a day. Remove Foley catheter
W: 125 pounds
VS: T: 38 C, Apical pulse: 90, R: 19, BP 138/88, O2 sat 95%
Hx. of AF, falls, DM, stress incontinence
Patient is hard of hearing
IV lock # 20 left forearm
Last BM: Just before Surgery, hard, brown, form, amount "normal for me".
Void:
JP to be removed today (report to MD first).
Dressing dry and clean (assess every 4 hours).
Routine Medications:
Digoxin 0.125 mg PO every day at 0900
Furosemide 10 mg PO every day at 0900
FeSO4 300 mg PO three times a day with meals 0800, 1200, 1700
D5W ½ NS @ 50 mL/H
Lantus 10 U HS
Novolog / pen 3 U for glucose 130-150, 5 U 151-180, 7 U 181-200, 8 U 201-250, 10 U 251-300,
above 300 call MD
PRN Mediations:
Vicodin 1 tab PO every 4 hours, PRN, pain 3 and above
Tylenol Supp. 650 mg per rectum every 4H PRN for temperature greater than 101°F.