Patient Name: F K
Date of Birth: 09/25/1933
History/Information:
An older widowed female adult was brought into the Emergency Care Center (ECC) after slipping and falling at the grocery store. She underwent a total right hip replacement two days ago. The client lives alone in a two-story house with her dog, Renny, which she adores. Her medical history includes: Congestive Heart Failure (CHF) and Hypertension (HTN). Three months ago she was diagnosed with Atrial Fibrillation and began Warfarin (Coumadin). Her INR is checked every 2 weeks. She has Cataracts and is Hard of Hearing (HOH) but unable to purchase any hearing devices due to the cost. Ms. Knight is on her second post-operative day.
Healthcare Provider’s Orders:
Low Sodium Diet as tolerated
IV D5 0.45% Sodium Chloride with 20 meq Potassium Chloride (KCL) at 75 ml/hour
Up with assist
Physical therapy for hip rehabilitation
Abduction pillow
Sequential Compression Device (SCD)
Change surgical dressing once a day
Foley catheter to continuous drainage. Discontinue Foley catheter on second post-operative day
Vital Signs and O2 Saturation every 4 hours
Intake and Output every shift
Incentive Spirometer x 10 every 1 hour while awake
INR/PT daily and call healthcare provider with results
Digoxin (Lanoxin) 0.125 mg po once a day at 1400
Metoprolol Tartrate (Toprol) 12.5 mg PO twice a day
Enoxaparin (Lovenox) 40 mg SQ every 12 hours
Warfarin (Coumadin) 2 mg PO once a day at 1800
Hydrocodone 5 mg/Acetaminophen 500 mg 1 tab PO every 6 hours prn pain for a pain level less than 6
Hydromorphone Hydrochloride (Dilaudid) 0.5 mg PO every 6 hours prn pain for a pain level greater than 6
Laboratory Tests
Laboratory Results
Normal Value Range
White Blood Cell (WBC)
7,500 /mm3
Hemoglobin (Hgb)
9 gm/dl
Hematocrit (Hct)
32%
Platelet Count
198,000/cu mm
International Normalized Ratio (INR)
2.9
Prothrombin (PT)
17 seconds
Sodium (Na+)
140 mEq/L
Potassium (K+)
4.0 mEq/L
Creatinine (Cr)
1.1 mg/dL
Blood Urea Nitrogen (BUN)
21 mg/100 ml
Glucose
118 mg/dL
