Documentation Case study

Instructions

Case Study

Marcella Schmidt (M.S.) is a 73-year-old, widowed female admitted to the hospital after a right hip fracture sustained when she tripped and fell in a parking lot. She had open reduction and internal fixation of her right hip 24 hours earlier. Her medical history indicates that she is in good health, with no other medical diagnoses. She is employed part time at the community library. She is allergic to penicillin and states she got hives all over her body when she took it for strep throat several years ago. 

M.S.’s vital signs are T 36.6° C (97.9°F ), P 80 and regular, R 18 and unlabored with an SpO2 of 97% on 2 L oxygen via nasal cannula, and BP 140/80. She ambulated to the bathroom twice with assistance but grimaced while walking. She transferred from bed to chair with assistance to eat lunch. The physical therapist worked with her on ambulation during the afternoon. She indicates that she is anxious to get moving so she can go home. 

Her right hip incision is well approximated, without swelling or excessive redness, and there is no drainage on the dressing. She rates her pain at 7/10 and states that she has “sharp pain that shoots from my hip to mid-calf when I move.” She received oral hydrocodone 5 mg/acetaminophen 500 mg at 0800, 1200, and 1600. At 45 minutes after being medicated she reported pain of 3/10. The nurse responsible for her care on the 12-hour day shift needs to document care according to facility policy, which mandates the SOAPIE format.

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