Tee Pham Case Study - Nursing Assignment Help

Assignment Task

INTRODUCTION
Patient’s Name:
Tee Pham
Hospital ID. MRN 170654 Date of Birth. 10/05/1945 (76 yrs.)
SITUATION
*Diagnosis and or
Problem/s
Right Fractured Neck of Femur
Transferred to theatre from ED with right #NOF after a fall at home. Son discovered Mrs. Pham at home 6 hours post fall. On arrival the paramedics found Mrs. Pham responsive and orientated to person, and place but not to time (GCS14). Mrs. Pham was also hypothermic from lying on a cold floor (T 35.1o C).
Mrs. Pham is booked into theatre for an emergency Right Hip Hemiarthroplasty Symptoms Pain, decreased mobility Stable/ Unstable Stable

BACKGROUND
Previous History/
symptoms
Osteoporosis
Relevant
history/comorbidities
Angina, hypertension, GORD, knee replacement (12mths), DVT post op
IVC/CVAD YES NO
IVC left hand (14 GF)
IVF Yes NO
Rate: 80ml/hr.
Type of fluid: Normal Saline
Analgesia
In ED:
Paracetamol 1g
Oxycodone 15 mg
Diazepam 5 mg
VTE assessment
No
Allergies, reaction type
Ampicillin
Own Medications/ medications ordered
• Angina – Aspirin 162.5 mg (SR)
• Hypertension – Atenolol 50mg mane
• GORD – Pantoprazole 40 mg mane
• Other – Caltrate Plus 600/2000 mane
• Metformin 500mg nocte
Antiemetic: Yes No
PRN
Diabetes: Yes NO
Type II
Alerts** Pressure Injury Risk, MRSA – positive colonization in nasal swab
ASSESSMENTS
AirwayPatent
Speaking in full
sentences
Breathing: Rate/rhythm/ Air entry/Effort
• 18bpm, regular
• Air entry equal bilaterally
• Oxygen therapy – Nasal prongs @ 3L
• SP02 96%
 Circulation: BP, HR
BP 142/100
PR 90bpm

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