SWIFT RIVER LATEST
MEDICAL-SURGICAL
Wight Goodman | Room 301
Patient Overview
wight_goodman.jpgWight GoodmanPatient was admitted to the
floor last night from the ER for an orbital fracture. He was hit in the
left eye by a softball yesterday. Apparently, he was pitching, and the
batter hit a line drive hitting him in the right side of the face. They
applied some ice to his face, and he decided to go to the post game
keg party instead of coming to the ER. The patient stated that there
was significant swelling, but his vision was fine, and the pain was
controlled with beer and 800mg of Motrin. He was unable to sleep
later in the evening as the pain became worse, and his vision became
more impaired. Patient states, "I'm afraid I will be permanently
scarred"! The Maxillofacial surgeon was consulted, and they will see
him this morning. They were not concerned as his intraocular
pressure was normal in the ER. There is significant edema and
discoloration to the left side of his face, and his left eye is almost
completely swollen shut. His visual acuity is diminished, and the
whites of his eyes are hemorrhaged. His pain has been well
controlled with IV morphine 4 mg, q3 hours. He has a 20g SL to his
right hand, that was started in the ER. He has no other health
concerns. He's being admitted for pain control, close observation of
his intralocular pressure, and head injury.
Educational Needs- Increased
Fall Risk- Increased
Health Change- Increased
Neurological- Increased
END OF
PAGE
1
, SWIFT RIVER LATEST
MEDICAL-SURGICAL
Pain Level- Increased
Psychological Needs- Increased
Wight Goodman
Wight Goodman Patient was admitted to the floor last night from
the ER for an orbital fracture. He was hit in the left eye by a softball
yesterday. Apparently, he was pitching, and the batter hit a line
drive hitting him in the right side of the face. They applied some ice
to his face, and he decided to go to the post game keg party instead
of coming to the ER. The patient stated that there was significant
swelling, but his vision was fine, and the pain was controlled with
beer and 800mg of Motrin. He was unable to sleep later in the
evening as the pain became worse, and his vision became more
impaired. Patient states, "I'm afraid I will be permanently scarred"!
The Maxillofacial surgeon was consulted, and they will see him this
morning. They were not concerned as his intraocular pressure was
normal in the ER. There is significant edema and discoloration to
the left side of his face, and his left eye is almost completely swollen
shut. His visual acuity is diminished, and the whites of his eyes are
hemorrhaged. His pain has been well controlled with IV morphine 4
mg, q3 hours. He has a 20g SL to his right hand, that was started in
the ER. He has no other health concerns. He's being admitted for
pain control, close observation of his intralocular pressure, and
head injury.
Acute discomfort
Alteration in comfort
END OF
PAGE
2
, SWIFT RIVER LATEST
MEDICAL-SURGICAL
Potential for bleeding
Knowledge deficit
Potential for infection
Wight Goodman Scenario 1
Wight GoodmanMr. Goodman has been scheduled for surgery to
repair a supraorbital rim fracture, but he is very concerned about
any scaring that may affect his appearance. He is alert and oriented
and has signed the surgical consent. The nurse notices a small
amount of blood coming from the patient's nose. He does not
remember his nose bleeding initially or in the ER. VS BP140/82 P74
R 20 T 98.7 F, 37.1 C.
1- Wash hands and assess
2- Complete Neurological assessment
3- Check the blood from his nose for CSF
4- Pre-op education
5- Ask Surgeon to discuss with patient the potential facial scarring
Wight Goodman Scenario 2
Wight GoodmanThe blood from the nose was positive for CSF. An
MRI is ordered, and reveals a small Orbital roof fracture. The
neurosurgeon is consulted. The maxillofacial surgeon will repair the
suborbital rim fracture first, and the neurosurgeon will monitor the
patient postoperatively as well as be available to assist if the orbital
roof fracture becomes unstable. IV antibiotics are ordered to be
administered ASAP. The patient will need to sign another surgical
END OF
PAGE
3
, SWIFT RIVER LATEST
MEDICAL-SURGICAL
consent for potential neurosurgery. The surgeon also orders Neuro
checks q2 hours, his Glasgow Coma Score is 15.
1- Complete Neurological assessment
2- Educate patient of plan of care
3- Evaluate patients understanding of care
4- Administer IV antibiotics
5- Sign additional surgical consent
Wight Goodman Scenario 3
Mr. Goodman is first day post-op from his suborbital rim fracture
repair, and his orbital edema has been greatly reduced. His CSF
with rhinorrhea has subsided. The neurosurgeon has decided to
continue to observe his recovery, instead of surgical intervention to
repair the orbital roof fracture. The patients VS are stable, and he is
afebrile. Patient does not have medical insurance, so he is wanting to
leave today. The patient is emotionally distraught, and angry as face
appears to have drooping of his eyelid and his visual acuities have
not improved. While the swelling has decreased there is still
periorbital edema (Ptosis).
1- Complete Neurological Assessment
2- Educate patient and family of necessity for q2 hour neuro checks and
visual acuities
3- Inform Healthcare Provider that patient is medically indigent, and
wanting to go home today
4- Contact social services to discuss options for payment
5- Extensive discharge planning and education
END OF
PAGE
4
MEDICAL-SURGICAL
Wight Goodman | Room 301
Patient Overview
wight_goodman.jpgWight GoodmanPatient was admitted to the
floor last night from the ER for an orbital fracture. He was hit in the
left eye by a softball yesterday. Apparently, he was pitching, and the
batter hit a line drive hitting him in the right side of the face. They
applied some ice to his face, and he decided to go to the post game
keg party instead of coming to the ER. The patient stated that there
was significant swelling, but his vision was fine, and the pain was
controlled with beer and 800mg of Motrin. He was unable to sleep
later in the evening as the pain became worse, and his vision became
more impaired. Patient states, "I'm afraid I will be permanently
scarred"! The Maxillofacial surgeon was consulted, and they will see
him this morning. They were not concerned as his intraocular
pressure was normal in the ER. There is significant edema and
discoloration to the left side of his face, and his left eye is almost
completely swollen shut. His visual acuity is diminished, and the
whites of his eyes are hemorrhaged. His pain has been well
controlled with IV morphine 4 mg, q3 hours. He has a 20g SL to his
right hand, that was started in the ER. He has no other health
concerns. He's being admitted for pain control, close observation of
his intralocular pressure, and head injury.
Educational Needs- Increased
Fall Risk- Increased
Health Change- Increased
Neurological- Increased
END OF
PAGE
1
, SWIFT RIVER LATEST
MEDICAL-SURGICAL
Pain Level- Increased
Psychological Needs- Increased
Wight Goodman
Wight Goodman Patient was admitted to the floor last night from
the ER for an orbital fracture. He was hit in the left eye by a softball
yesterday. Apparently, he was pitching, and the batter hit a line
drive hitting him in the right side of the face. They applied some ice
to his face, and he decided to go to the post game keg party instead
of coming to the ER. The patient stated that there was significant
swelling, but his vision was fine, and the pain was controlled with
beer and 800mg of Motrin. He was unable to sleep later in the
evening as the pain became worse, and his vision became more
impaired. Patient states, "I'm afraid I will be permanently scarred"!
The Maxillofacial surgeon was consulted, and they will see him this
morning. They were not concerned as his intraocular pressure was
normal in the ER. There is significant edema and discoloration to
the left side of his face, and his left eye is almost completely swollen
shut. His visual acuity is diminished, and the whites of his eyes are
hemorrhaged. His pain has been well controlled with IV morphine 4
mg, q3 hours. He has a 20g SL to his right hand, that was started in
the ER. He has no other health concerns. He's being admitted for
pain control, close observation of his intralocular pressure, and
head injury.
Acute discomfort
Alteration in comfort
END OF
PAGE
2
, SWIFT RIVER LATEST
MEDICAL-SURGICAL
Potential for bleeding
Knowledge deficit
Potential for infection
Wight Goodman Scenario 1
Wight GoodmanMr. Goodman has been scheduled for surgery to
repair a supraorbital rim fracture, but he is very concerned about
any scaring that may affect his appearance. He is alert and oriented
and has signed the surgical consent. The nurse notices a small
amount of blood coming from the patient's nose. He does not
remember his nose bleeding initially or in the ER. VS BP140/82 P74
R 20 T 98.7 F, 37.1 C.
1- Wash hands and assess
2- Complete Neurological assessment
3- Check the blood from his nose for CSF
4- Pre-op education
5- Ask Surgeon to discuss with patient the potential facial scarring
Wight Goodman Scenario 2
Wight GoodmanThe blood from the nose was positive for CSF. An
MRI is ordered, and reveals a small Orbital roof fracture. The
neurosurgeon is consulted. The maxillofacial surgeon will repair the
suborbital rim fracture first, and the neurosurgeon will monitor the
patient postoperatively as well as be available to assist if the orbital
roof fracture becomes unstable. IV antibiotics are ordered to be
administered ASAP. The patient will need to sign another surgical
END OF
PAGE
3
, SWIFT RIVER LATEST
MEDICAL-SURGICAL
consent for potential neurosurgery. The surgeon also orders Neuro
checks q2 hours, his Glasgow Coma Score is 15.
1- Complete Neurological assessment
2- Educate patient of plan of care
3- Evaluate patients understanding of care
4- Administer IV antibiotics
5- Sign additional surgical consent
Wight Goodman Scenario 3
Mr. Goodman is first day post-op from his suborbital rim fracture
repair, and his orbital edema has been greatly reduced. His CSF
with rhinorrhea has subsided. The neurosurgeon has decided to
continue to observe his recovery, instead of surgical intervention to
repair the orbital roof fracture. The patients VS are stable, and he is
afebrile. Patient does not have medical insurance, so he is wanting to
leave today. The patient is emotionally distraught, and angry as face
appears to have drooping of his eyelid and his visual acuities have
not improved. While the swelling has decreased there is still
periorbital edema (Ptosis).
1- Complete Neurological Assessment
2- Educate patient and family of necessity for q2 hour neuro checks and
visual acuities
3- Inform Healthcare Provider that patient is medically indigent, and
wanting to go home today
4- Contact social services to discuss options for payment
5- Extensive discharge planning and education
END OF
PAGE
4
