Patient Assignment
D.H. is a 32-year-old female who came into the emergency department (ED) today after a fall while iceskating. She states that when she fell she must have extended her right arm to break the fall because
she hurt her right arm. She has a displaced, closed fracture of the right radius. She had an open
reduction internal fixation (ORIF) of her right radius 2 hours ago (1400), and has just been admitted to
the orthopedic unit.
Report at 1640 from the post-anesthesia care unit (PACU) nurse: Patient is stable after general
anesthesia surgery for ORIF right radius and is allergic to penicillin (PCN). VS: T 99.5° F, BP 122/70, P 78
and regular, R 20 regular and shallow. O2 saturation 96% on RA. A&O to person, place, and situation.
PERRLA positive. Answering questions appropriately and sleeping intermittently. Lungs clear AP.
Abdomen soft and non-tender with hypoactive BS in all four quadrants. Voided 200 mL clear, amber
urine. Pedal pulses 2+. Left radial pulse 2+. Unable to palpate right radial pulse because of surgical
splint placement below elbow to the middle of the hand. Patient administered 4 mg morphine IV in the
PACU at 1600 for a pain level of 8/10. States pain level is now 5/10.
Admission Orders
Admit to orthopedic unit
Up ad lib
VS q 2 hr. x 2, then q 4 hr.
I&O
Neurovascular checks of right hand q 2hr
Saline lock
Flush lock with 10 mL NS q 8 hr.
Clear liquid diet, advance as tolerated
Morphine 2 mg IV q 2 hr. PRN for moderate (4-7/10) to severe (8-10/10) pain
Tramadol 100 mg PO q 6 hr. PRN for moderate (4-7/10) to moderately severe (7-8/10) pain
Acetaminophen 500 mg two tablets PO q 6 hr. PRN for mild (1-3/10) to moderate (4-7/10) pain
Docusate 100 mg PO q 12 hr.
Ice to right wrist
CBC and BMP in the morning
Assessment Update
1700: VS: T 98°F, BP 120/72, P 76 and regular, R 22 regular and unlabored. Pain 5/10 in right wrist and
hand, dull and throbbing. Height 67 inches, weight 60 kg. A&Ox4. Patient is talking to her husband who
is at bedside. PERRLA +. Apical pulse 76 and regular. Lungs clear AP. Abdomen soft with BS present in
all four quadrants. Mobility assistive equipment (MAE) include splint on right lower arm dry and intact.
Skin warm and dry. Braden score 22. Patient has sensation and movement in right fingers with no
numbness or tingling. 24-gauge saline lock in left hand with no redness or swelling at insertion site.
D.H. states, “She went ice skating this morning with her 8-year-old daughter and some friends and their
children.” Her daughter is with friends, and her husband was notified at work when she realized she had
to have surgery. She states that she has never been hurt or in the hospital before except for the birth of
her daughter by uncomplicated vaginal delivery. She is right-handed and is allergic to penicillin.