Marily Hughes
INTRODUCTION
SITUATION
BACKGROUND
ASSESSMENT
RECOMMENDATION
Good Afternoon, My name is Bredget Whisnant and I am the RN with
Keiser Hospital on the 6th floor. Am I speaking to Dr. K?
I am calling about patient Marilyn Hughes, a 45 year old female who
came into the hospital after falling on the ice this A.M. She suffered a left
Tibia-fibula fracture when slipped and fell. She began complaining of pain
shortly after returning from surgery and was given 6 mg IV morphine
sulfate at 1415, she is now 30 min postop.
Patient is on fall precautions
Patient is a full code
Patient has been occupied by her husband, she is a Christian faith and
attends church regularly with her husband and family. Patient has no
culture preferences.
Ms. Hughes was admitted to the hospital on 9/14/2020 and diagnoses
was a left tibia-fibula fracture on admission. Ms. Hughes returned from
surgery @1345 with a below the knee ace/splint dressing. Ms. Hughes is
now 30 min post op with current orders are morphine sulfate 6 mg IV q 46 hr, Lactated Ringers at 75 mL/hr, no weight bearing on left leg and
elevation of the left leg
On assessment the pedal pulse on the left foot is absent, Patient
complains of pain at a level 8 on the pain scale, and was given 6 mg
morphine sulfate at 1415, left leg is becoming cyanotic. Normal skin
turgor, skin is cool and she is very sweaty. Patient states left foot feels
numb. IV at a 20 gauge, site has no signs of redness, swelling or
infiltration, bleeding or drainage. The dressing was dry and intact.
Vital signs are: BP 158/94 HR 110 RR 21 Temp 99 SpO2 97% RA
Last bowel movement was 9/13/2020 in the evening normal for patient
Pillow was removed from under the leg to place leg at level of heart
Loosen dressing or remove dressing completely if condition worsens