Ocampo, Lydia MR #7691627451

NNeeiigghhbboorrhhoooodd HHoossppiittaallEmergency Department Record

Date: Tuesday Arrival Time: 0330 Method of Arrival: Ambulance Condition upon arrival: stable Triage Assessment Time: 0340 Information Obtained From: Husband Name: Ocampo, Lydia Age: 69 Vital Signs: T: 36.4C RR: 20 HR: 104 BP: 112/80 O2 Sat: 98% 2L 02 Pain: ? /10 Gender: F Race: Asian Marital Status: M Occupation: Retired Ht: Wt: LMP: 15 years ago Pregnant: No Allergies: NKDA Medications: donepezil 5 mg po qd, MVI 1 tab po qd. Reason for Seeking Care: L hip pain Slipped while going to bathroom, fell on hard ceramic floor 1 hour ago. Husband states she has been holding hip and crying in pain since the accident; 911 was called for treatment/transport to ED. Pt unable to provide additional history.

Past Medical Hx: Alzheimer’s dementia X 5 years

Significant Family Hx: Mother – deceased age 72 breast CA; Father deceased age 59 CAD. Brother deceased age 64 CAD; Brother deceased age 72 CAD; Sister deceased age 70, sepsis.

Examination Findings: Elderly F in acute distress, holding L hip; moaning. External rotation noted to L leg; + pulses LLE, warm.

Social Hx: Tob: neg ETOH: neg Illicit Drug Use: neg Domestic Violence: neg Possible Crime Victim: neg

Immunizations: Childhood: up to date Hep B: yes Influenza: yes Tetanus: >10 years Pneumococal: yes Others:

Triage Interventions: None.

Triage Level: B Disposition: ED Bed 6 Triage Nurse Signature: Katlin Rogers, RN

Nursing Assessment: Time: 0355 ER Bed #: 6

Mental Status/Neuro Anxious, confused. PERRLA; pupil size 3 mm.

Glasgow Score: N/A

Skin

Color: pinkish tones, even color Moisture: dry Temp: warm

Head/Neck: Normocephalic, facial features symmetrical, carotid pulses +3

Respiratory: Breathing even, unlabored; RR= 20/min. Lungs clear to auscultation in all lung fields; oxygen saturation = 98%

Oxygen: 2 liters by N/C

Cardiovascular HRRR; no murmurs or extra heart sounds.

Monitor Rhythm: Sinus Tachycardia; HR rate = 106

Eyes/Ears: Deferred.

Visual Acuity: L: ________ Rt:_________ Both:_____________ Corrected Y N

Abdomen: Abd flat, + bowel sounds all quadrants; soft, non tender.

GU/Genitalia Deferred

Musculoskeletal: External rotation & shortening of LLE; pedal pulses ++, foot warm, pink. Moves all other extremities well.

RN signature: Angelo Bengy, RN

Ocampo, Lydia MR #7691627451

Physician Assessment/Notes: Time: 0415 HPI Elderly female fell to floor while ambulating 1 hour ago; complaining of severe pain since that time to L hip.

Examination Findings Neuro: Confused; CN 2-12 grossly intact ENT: Neg CV: HRRR; no murmurs Resp: Lungs Clear; Resp even, unlabored, symmetrical chest rise/fall GU: WNL Mus/Skel: shortening L leg; external rotation hip; + pulses; + cap refill; moves toes; + sensation Impression: R/O L hip fx

Physician Orders: Time Order Signature/Time

Completed Comments

0420 CBC, Chem 12, PT, PTT, UA, BUN, Creatinine

AB/ 0415 Hgb 14 g/dL; Hct 41%; Na+ 137mEq; K+ 3.9 mEq; Ch 100 mEq; PT, PTT WNL; UA – Neg; BUN 19 mg/dL; Creatinine 1.0 mg/dL

0420 IV 0.9% NaCl TKO AB/0415 0420 L hip, Chest X-ray KK/0430 Intertrochanteric fracture L hip; chest clear 0420 Morphine 2-4 mg IVP q 1

hour prn for pain. AB/ 0420 AB/0550

2 mg IVP 2 mg IVP

0510 12-lead EKG KK/0530 NSR; tracing WNL 0510 Foley Cath KK/ 0510 0510 NPO

Consultation: Charles Ryder, Orthopedics Arrival Time: 0610

Diagnosis: Fracture, Left Hip Admit: OR

Physician Signature: James Gordon, MD

Ocampo, Lydia MR #7691627451

Emergency Department Nursing Flow Sheet

Time BP HR RR T O2 Sat

Pain Assessment/Response Initials

0415 114/80 106 20 ---- 98% ? Assessment complete; IV #18g to R FA x 1 attempt; NaCl 1 liter hung TKO rate; blood drawn. Moaning unable to rate pain.

AB

0420 2 mg morphine sulfate IVP for pain. AB 0430 110/78 100 18 ----- 98% ? Pt. less restless; less moaning; husband states he believes pain

medication has been helpful. To X-Ray. AB

0450 Returned from X-ray; stable; husband at bedside. AB 0510 12-Lead EKG completed. KK 0520 Foley inserted per order. KK 0550 112/82 98 18 --- 96% ? Moaning/crying out; husband states she is in pain. 2 mg

morphine sulfate IVP. AB

0610 112/80 94 16 --- 97% Sleeping; IV infusing at TKO rate; site without edema. Dr. Ryder here to evaluate patient.

AB

0645 110/82 96 16 36.8C 97% OR consent signed by husband; report called to Cheryl Wylie, RN in OR. Pt. is stable condition.

AB

0650 Transported to OR via cart by Kevin Kendall Tech. AB

Fluid Intake Fluid Output Time Type Amount Running

Total Time Type Amount Running

Total 0645 IV fluid 0.9% NaCl 150 mL 150 mL 0645 Urine 240 mL 240 mL

Discharge Instructions Given N/A Disposition: OR

Time Discharged from ED: 0650

RN Signature Angelo Bengy, RN RN Signature ___________________________

RN Signature ____________________________________ Tech Signature Kevin Kendall

Ocampo, Lydia MR #7691627451

NNeeiigghhbboorrhhoooodd HHoossppiittaall

Physician Progress Notes Tues 1110

S/P ORIF L hip, POD #1. Procedure without complications; blood loss < 200 mL; stable condition to recovery room. To be admitted to Orthopedics following PACU. Charles Ryder, MD

Tues 1730

S/P ORIF L hip. Stable, doing well. Pain controlled with morphine. Confused. CV: HRRR; Lungs Cl. JP output 56 mL. Temp 36.4.Hem 12 g/dL; Hct 38%. Distal pulses +, sensation intact. Charles Ryder, MD

Wed 0630

S/P ORIF L hip POD #2 RNs report difficult night; pulling out tubes; emesis. Restraints/sedatives ordered after less invasive measures unsuccessful as reported by RNs. Dressing intact, minimal drainage; JP output: 96 mL. Temp 37.3.Hem 11 g/dL; Hct 37%. CV: HRRR; Lungs Cl; Abd soft; + distal pulses, slight edema LLE. Charles Ryder, MD

Wed 1700

Disoriented, but calmer today. Moderate po intake. RN reports intolerance to morphine at 4 mg dose. Progressing well. Spoke with husband about nursing care. Charles Ryder, MD

Ocampo, Lydia MR #7691627451

NNeeiigghhbboorrhhoooodd HHoossppiittaallPhysician Order Sheet

Drug Allergies: NKDA Date Time Order Tues 11:10 Admit to Orthopedics Service

Diet: Cl liq; advance as tolerated to regular Vitals: hourly x 2, every 4 hours x 24 hours; then every 8 hours. Activity: Bed rest with abductor pillow tonight, up with assistance beginning in the morning. Physical therapy to see patient starting Wednesday. Sequential Compression Device to Legs Incentive Spirometer q hour while awake Oxygen 2-4 liters n/c as needed to keep O2 Sat >90% Foley to gravity drainage JP drain L hip I&O q 8 hours IV D5 0.45% NaCl rate: 100/hour Meds: Ancef 1 gram IV every 8 hours Donepezil 5 mg by mouth every day Morphine Sulfate 2-4 mg IV every 1-2 hours as needed for pain Lovenox 30 mg SQ every day - beginning tomorrow AM Tylenol 650 mg by mouth every 4-6 hours as needed for temp > 38.0 C Promethazine 12.5-25 mg IV every 4-6 hours as needed for nausea. Labs: CBC, Lytes now and in AM

Signature: Charles Ryder, MD Print Name: Charles Ryder, MD

Drug Allergies: NKDA Date Time Order Wed 0200 Soft restraints to upper extremities to prevent tube dislodgement

Lorazepam 0.5 mg slow IVP x 1 dose, now. Signature: Charles Ryder, MD Print Name: Charles Ryder, MD

Drug Allergies: NKDA Date Time Order Wed 1700 Percocet 1-2 tablets by mouth every 4-6 hours as needed for pain.

Reduce IV infusion rate to 50 mL/hour. DC infusion when oral intake is adequate. Change morphine dose to 2 mg IV every 1-2 hours as needed for breakthrough pain. Soft restraints to upper extremities to prevent tube dislodgement.DC Foley in am.

Signature: Charles Ryder, MD Print Name: Charles Ryder, MD

Ocampo, Lydia MR #7691627451

NNeeiigghhbboorrhhoooodd HHoossppiittaall Date: 0700 Tuesday – 0700 Wednesday

Medication Administration Record Scheduled Medications Order Date

Medication Dose, Route, & Frequency Sched Times

Administered

Tues 11:10

Ancef 1 gram IV every 8 hours 08 16 24

1600 KN 2400 SD

Tues 11:10

Donepezil 5 mg by mouth every day – beginning tomorrow

08

Tues 11:10

Lovenox 30 mg SQ every day - beginning tomorrow AM

08

Non-Scheduled and One Time Medications Order Date

Medication Dose, Route, & Frequency Administered

Tues 11:10

Morphine Sulfate 2-4 IV mg every 1-2 hours as needed for pain

1210 2 mg KN 1600 2mg KN 1900 2 mg SD 0010 4 mg SD 0300 4 mg SD

Tues 11:10

Tylenol 650 mg by mouth every 4-6 hours as needed for temp > 38.0 C

Tues 11:10

Promethazine 12.5-25 mg IV every 4-6 hours as needed for nausea.

1340 KN 1900 SD

Wed 0200

Lorazepam 0.5 mg slow IVP x 1 dose, now 0200 SD

Diagnosis: Left Hip Fx Signature InitialAdmission Date: Tuesday Kim Nygen KN Physician: Ryder Steve Dawson SD Allergies: NKDA

Ocampo, Lydia MR #7691627451

NNeeiigghhbboorrhhoooodd HHoossppiittaall Date: 0700 Wednesday – 0700 Thursday

Medication Administration Record Scheduled Medications Order Date

Medication Dose, Route, & Frequency Sched Times

Administered

Tues 11:10

Ancef 1 gram IV every 8 hours 08 16 24

0800 BS 1600 BS 2400 SR

Tues 11:10

Donepezil 5 mg by mouth every day – beginning tomorrow

08 0800 BS

Tues 11:10

Lovenox 30 mg SQ every day - beginning tomorrow AM

08 0800 BS

Non-Scheduled and One Time Medications Order Date

Medication Dose, Route, & Frequency Administered

Tues 11:10

Morphine Sulfate 2-4 mg IV every 1-2 hours as needed for pain

0800 4 mg BS 1120 2 mg BS 1500 2 mg BS

Tues 11:10

Tylenol 650 mg by mouth every 4-6 hours as needed for temp > 38.0 C

Tues 11:10

Promethazine 12.5-25 mg IV every 4-6 hours as needed for nausea.

Wed 1700

Percocet 1-2 tablets by mouth every 4-6 hours as needed for pain.

2215 2 tablets SR

Wed 1700

Morphine Sulfate 1-2 mg IV every 1-2 hours as needed for breakthrough pain.

0410 2 mg SR

Diagnosis: Left Hip Fx Signature InitialAdmission Date: Tuesday Bobby Schofield BS Physician: Ryder Sandy Ryder SR Allergies: NKDA

Ocampo, Lydia MR #7691627451

NNeeiigghhbboorrhhoooodd HHoossppiittaall Nurses Flow Sheet – Medical Surgical Units

Date: 0700 Tuesday – 0700 Wednesday

Initial Shift Assessment (Day Shift) Time Assessment Completed: 12:20 pmMental Status/Neuro Orientation: Confused Pupils: 3 mm bilaterally Glasgow: N/A Psychosocial: anxious Other: Fall Assessment Score: 9 High Risk for Falls

Skin Braden Score: 10 High Risk Color: pink Moisture: dry Temp: warm Wounds: L hip dressing clean, dry, intact Drains: JP to L hip; serousanguinous drainage Other:

Head/Neck: Eyes: clear, without drainage Ears: hearing intact Nose: clear, without drainage Mouth: mucous membranes pink, moist, no lesions noted. Lymph: deferred

Respiratory: Respiratory Effort: Even and unlabored Breath Sounds: Clear all lung fields Equipment: Oxygen 2 L n/c Other:

Cardiovascular Cardiac Rhythm: HRRR Heart Sounds: S 1 & 2; no murmurs Edema: absent Pulses: 2+ L and R lower extremities Cap Refill: < 2 seconds L & R LE IV Sites: RFA;site without redness/swelling Equipment: SCDs bilaterally Other:

Musculoskeletal: Movement: moves all extremities; Sensation: + sensation toes/feet bilaterally Equipment: Abductor Pillow between legs Other:

Abdomen: Contour: flat, non-distended Bowel Sounds: + all quadrants Palpation: soft, non-tender Equipment: n/a Other:

GU/Genitalia Urine: clear, yellow Genitalia: WNL, no breakdown noted Equipment: Foley; patent Other:

Special Equipment or Additional Assessment

Initial Shift Assessment (Night Shift) Time Assessment Completed: 20:15Mental Status/Neuro Orientation: Confused Pupils: 3 mm bilaterally Glasgow: N/A Psychosocial: calm Other: Fall Assessment Score: 9 High Risk for Falls

Skin Braden Score: Color: pink Moisture: dry Temp: warm Wounds: L hip dressing clean, dry, intact Drains: JP to L hip; serousanguinous drainage Other:

Head/Neck: Eyes: clear, without drainage Ears: hearing intact Nose: clear, without drainage Mouth: mucous membranes pink, moist, no lesions noted. Lymph: deferred

Respiratory: Respiratory Effort: Even and unlabored Breath Sounds: Clear all lung fields Equipment: Oxygen 2 L n/c Other:

Cardiovascular Cardiac Rhythm: HRRR Heart Sounds: S 1 & 2; no murmurs Edema: absent Pulses: 2+ L and R lower extremities Cap Refill: < 2 seconds L & R LE IV Sites: RFA; site without redness/swelling Equipment: SCDs bilaterally Other:

Musculoskeletal: Movement: moves all extremities; Sensation: + sensation toes/feet bilaterally Equipment: Abductor Pillow between legs Other:

Abdomen: Contour: flat, non-distended Bowel Sounds: + all quadrants Palpation: soft, non-tender Equipment: n/a Other:

GU/Genitalia Urine: clear, yellow Genitalia: WNL, no breakdown noted Equipment: Foley; patent Other:

Special Equipment or Additional Assessment

Ocampo, Lydia MR #7691627451

NNeeiigghhbboorrhhoooodd HHoossppiittaallNurses Flow Sheet – Medical Surgical Units

Date: 0700 Wednesday – 0700 Thursday

Initial Shift Assessment (Day Shift) Time Assessment Completed: 0730 amMental Status/Neuro Orientation: Confused Pupils: 3 mm bilaterally Glasgow: N/A Psychosocial: anxious Other: Fall Assessment Score: 9 High Risk for Falls

Skin Braden Score: 10 High Risk Color: pink Moisture: dry Temp: warm Wounds: L hip dressing clean, dry, intact Drains: JP to L hip; serousanguinous drainage Other: No breakdown noted.

Head/Neck: Eyes: clear, without drainage Ears: hearing intact Nose: clear, without drainage Mouth: mucous membranes pink, moist, no lesions noted. Lymph: deferred

Respiratory: Respiratory Effort: Even and unlabored Breath Sounds: Clear all lung fields Equipment: Oxygen 2 L n/c Other:

Cardiovascular Cardiac Rhythm: HRRR Heart Sounds: S 1 & 2; no murmurs Edema: absent Pulses: 2+ L and R lower extremities Cap Refill: < 2 seconds L & R LE IV Sites: R hand ;site without redness/swelling Equipment: SCDs bilaterally Other:

Musculoskeletal: Movement: moves all extremities; Sensation: + sensation toes/feet bilaterally Equipment: Abductor Pillow between legs Other: Soft restraints to upper extremities for patient safety. Pulses 2+; cap refill <2 sec. Restraint protocol and flow sheet in place.

Abdomen: Contour: flat, non-distended Bowel Sounds: + all quadrants Palpation: soft, non-tender Equipment: n/a Other:

GU/Genitalia Urine: clear, yellow Genitalia: WNL, no breakdown noted Equipment: Foley; patent Other:

Special Equipment or Additional Assessment

Initial Shift Assessment (Night Shift) Time Assessment Completed: 2010 Mental Status/Neuro Orientation: Confused Pupils: 3 mm bilaterally Glasgow: N/A Psychosocial: anxious Other: Fall Assessment Score: 9 High Risk for Falls

Skin Braden Score: 10 High Risk Color: pink Moisture: dry Temp: warm Wounds: L hip dressing clean, dry, intact Drains: JP to L hip; serousanguinous drainage Other: No breakdown noted.

Head/Neck: Eyes: clear, without drainage Ears: hearing intact Nose: clear, without drainage Mouth: mucous membranes pink, moist, no lesions noted. Lymph: deferred

Respiratory: Respiratory Effort: Even and unlabored Breath Sounds: Clear all lung fields Equipment: Oxygen 2 L n/c Other:

Cardiovascular Cardiac Rhythm: HRRR Heart Sounds: S 1 & 2; no murmurs Edema: absent Pulses: 2+ L and R lower extremities Cap Refill: < 2 seconds L & R LE IV Sites: R hand ;site without redness/swelling Equipment: SCDs bilaterally Other:

Musculoskeletal: Movement: moves all extremities; Sensation: + sensation toes/feet bilaterally Equipment: Abductor Pillow between legs Other: Soft restraints to upper extremities for patient safety. Pulses 2+; cap refill <2 sec. Restraint protocol and flow sheet in place.

Abdomen: Contour: flat, non-distended Bowel Sounds: + all quadrants Palpation: soft, non-tender Equipment: n/a Other:

GU/Genitalia Urine: clear, yellow Genitalia: WNL, no breakdown noted Equipment: Foley; patent Other:

Special Equipment or Additional Assessment

Ocampo, Lydia MR #7691627451

Date: 0700 Wednesday – 0700 Thursday

Vital Signs (day shift) Vital Signs (night shift)Time BP HR RR T O2

Sat Pain BG Time BP HR RR T O2

Sat Pain BG

0700 1900 0800 110/80 90 16 37.7 96% 8 2000 114/72 88 18 37.8 96% 5 0900 112/80 10 2100 1000 8 2200 8 1100 2300 1200 112/76 84 16 36.4 99% 4 2400 112/70 84 16 37.7 95% 2 1300 0100 1400 0200 1500 7 0300 1600 116/84 92 16 36.8 98% 2 0400 114/78 90 18 38.1 96% 8 1700 0500 1800 0600

Fluid Intake Fluid Output Time Type Amount Running

Total Time Type Amount Running

Total 0700 D5 .45% NaCl 100 100 0700 0800 D5 .45% NaCl

Ancef in D5W 100 50 250

0800

0900 D5 .45% NaCl 100 350 0900 1000 D5 .45% NaCl

Oral 100 120 570

1000

1100 D5 .45% NaCl 100 670 1100 1200 D5 .45% NaCl

oral 100 200 970

1200

1300 D5 .45% NaCl 100 1070 1300 1400 D5 .45% NaCl 100 1170 1400 Foley

JP Darin 970 cc 40 cc 1010 cc

1500 D5 .45% NaCl 100 1270 1500 1600 D5 .45% NaCl

Ancef in D5W 100 50 1420

1600

1700 D5 .45% NaCl 50 1470 1700 1800 D5 .45% NaCl

Oral 50

180 1700 1800 Foley 620 1630

1900 D5 .45% NaCl 50 1900 2000 D5 .45% NaCl 50 1800 2000 2100 D5 .45% NaCl 50 2100 2200 D5 .45% NaCl 50 1900 2200 2300 D5 .45% NaCl 50 2300 2400 D5 .45% NaCl 50 2000 2400 0100 D5 .45% NaCl 50 0100 0200 D5 .45% NaCl 50 2100 0200 0300 D5 .45% NaCl 50 0300 0400 D5 .45% NaCl 50 2200 0400 0500 D5 .45% NaCl 50 0500 0600 D5 .45% NaCl 50 2300 0600 Foley

JP Drain 740 22

2392

24 hour intake total 2300 24 hour output total 2392

Ocampo, Lydia MR #7691627451

Date: 0700 Wednesday – 0700 Thursday

Nursing Notes (Day Shift) Nursing Notes (Night Shift)Time Time 0800 Report received. AM Meds given with difficulty; pt disoriented 2010 Received report; assessment complete. Patient awake

uncooperative with oral med; was administered, but Calm; husband remains in room; no restraints in place at with difficulty. MD notified during rounds. Soft restraints this time. Placed in a supine position. Husband plans to remain in place for patient safety. Administered pain med Stay the night. ------------------------------------------------ SR Due to restlessness and moaning. -------------------------------BS 2215 Patient crying out; husband believes she is in pain.

0845 Reassessment following pain meds reveals RR of 10. Administered 2 Percocets.---------------------------------- SR Oxygen saturation = 94%; increased oxygen to 4L n/c. 2250 Patient dosing off and on; husband reports the pain Turned to a supine position; ABD pillow in place. Patient is medication has been effective. Turned to R side in a lethargic. MD notified.---------------------------------------------- BS supported position--------------------- ----------------------- SR

0915 Pt RR up to 16; sleeping. ------------------------------------------ BS 0230 Assessed patient; sleeping; husband at side.------- SR 1020 Husband in room; upset regarding restraints and confusion. 0410 Patient screaming; husband upset; attempting to calm

ABD pillow found on floor next to bed. Attempted to explain her. Patient completely disoriented; does not appear to Situation. Husband will attempt to feed patient breakfast - BS Recognize husband. Administered 2 mg morphine- SR

1120 Medicated 2 mg morphine for pain. ----------------------------- BS 0420 Patient now calmer; crying softly; husband talking with 1230 Husband at bedside; patient confused, but calm. RR=16; her. Turned to R side. ------------------------------------ SR

Positioned on R side, supported with pillows; ABD pillow 0620 Sleeping.--------------------------------------------------- SR In place. Restraints remain off; husband to inform staff if he leaves the unit. ----------------------------------------------BS

1500 Patient continues to be calm, but very confused; in pain morphine administered. Husband at bedside – restraints are off. Turned to supine position with ABD pillow in place. Ate small amount of lunch; no emesis today. -------BS

1700 Husband asleep in chair; patient has pulled off dressing and Is scratching the incision. Replaced dry dressing over incision. Remains confused, but calm. -------------------------BS

1800 Fair appetite at dinner; husband in room feeding. Placed on Right side after dinner. ------------------------------------------- BS

Day Shift: Night Shift: RN signature: Bobby Schofield RN signature: Sandy Ryder RN signature: RN signature: Nursing Tech: Randi Jones Nursing Tech: