Case history
Stéphanie Tremblay, 72, retired, is very active. She volunteers for the underprivileged in her community. She is known to have Type-2 diabetes and HBP for a few years. Six days ago she fell at home and fractured her right hip, and as a result underwent surgery three days ago (THA). Postoperation care is going well, except that she feels only partly better and refuses to get up.
Interservice report:
Ms. Tremblay, in bed # 3320, three-day post-op for right THA. She slept well until 2:00 and then became agitated and reported pain assessed at 6/10. Analgesic received per os. Same situation at 6:00 this morning. Right now, she is unable to sleep. She assesses her pain at 4/10. VS: BP 130/85, respiration 20/min, pulse 90/min. Temperature 38.1 °C and saturation at 94% with NC at 2 l/min and glycemia at 6.3. The lungs are free of secretions.
At the end of the report, the nurse asks you to complete the dose of analgesics to relieve the patient, that is, to give her another 2 mg in accordance with the medical prescription. On your visit at 8:30, the patient is resting calmly, but is still suffering considerably. You give her the analgesic. VS: BP 130/95, respiration 19/min, pulse 92/min, temperature 37.1 °C and saturation 94% with NC at 2 l/min.
It is 10:00 and you have to change the patient’s bandage. You go into the room and follow through as required by the situation.