Mrs. Martin is a 75 year old female with a past medical history
of A-fib, COPD, Arthritis and Hyperlipidemia. She lives alone in an
apartment in a senior citizen complex and has been independent for
ADLs and IADLs. Her medications regime is as follows: Digoxin 0.125mg po daily Plavix 75mg po daily Zocor 20 mg po daily at bedtime Tylenol 1-2 tabs every 4-6 hours prn arthritic pain Yesterday morning one of Mrs. Martin’s neighbors
found her lying on the floor of her home. Mrs. Martin was
conscious, but weak and lethargic. She reported she tripped over a
throw rug in the home and fell 2 days ago. She is complaining of
severe pain in her left hip radiating to her LLE. Mrs. Martin is
transported to the local hospital and was admitted to your medical
surgical unit yesterday evening and is to be scheduled for ORIF of
her left hip. Your morning assessment findings reveal that the client is: Awake, lethargic and weak tachycardic (with and irregular rhythm) and dyspnic, BBS w/ scattered rales and wheezes abd is soft and flat with BS + x 4 quadrants, LBM 3 days ago pt is oliguric and u/o is dark ROM is WNL in all extremities except the LLE which has
limited ROM secondary to injury and pain Skin is dry with poor turgor, mucus membranes are dry and
sticky Mrs. Martin’s lab reports reveal WBC 11.4 K+ 3 RBC 3.9 Na 152 HGB 11.2 GLUCOSE 102 HCT 49 BUN 30 PLATELETS 250 CREATINE 3 P.T 14 DIGOXIN LEVEL 2.4 INR 1.5
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