Head-to-Toe Nursing Assessment of Marilyn Hughes After ORIF Surgery

Head-to-Toe Nursing Assessment of Ms. Marilyn Hughes

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Head-to-Toe Nursing Assessment of Ms. Marilyn Hughes

Patient Overview

Marilyn Hughes is a 45-year-old female patient who had a left mid-shaft tibia-fibula fracture after having slipped on icy stairs this morning. She has undergone orthopedic surgery for an Open Reduction Internal Fixation (ORIF) of the fractured limb and came back from the surgery at 1345 Hours with the below-knee splint dressing. Her Vital signs have been stable and neurovascular checks under control. She is on IV Lactated Ringer’s solution at 75ml/hr. She has severe limb pain and has been advised morphine 6mg IV at 1415. She has been on every 30 minutes Post-operative Vital signs. Following is the head-to-toe assessment done at 1500 Hrs:

Vital Signs: 

The vitals at 1510 Hrs show that she is breathing at 21 breaths per minute. Pulse oximeter shows SPO2 – 98%. The pulse is strong, at the rate of 100 per minute and regular. The BP is 158/94 mm Hg, and the Temperature is 99 degrees Fahrenheit.

General Appearance:       

At 1500 Hrs, Marilyn is awake, alert and oriented. Though her Glasgow Coma Scale (GCS) is 15, she is discomforted because of pain in her left leg after having undergone ORIF post her mid-shaft tibia-fibula fracture. 

Skin, Hair, and Nails

Her skin is cold and very sweaty and has normal skin turgor. The Capillary refill time is 

< 2 seconds. On examination of the skin of abdomen and pelvis and arms, the skin is found to have normal turgor and there is nothing else to find on these regions. On examination of the skin of legs, it has been found that the lower left leg is cyanotic, the dressings are very tight, and there is prolonged capillary refill on toes on the left-hand sided lower limb. However, the skin has normal turgor and is very sweaty. 

Head and Neck Assessment

The HEENT is examined. Mrs. Hughes has normal eye range of motion; Pupils are 7 mm and react to light.  She is awake, with her corneal reflexes and eyelash reflexes being present. There is no obvious airway obstruction. On auscultation of the neck, there are no bruits. 

Carotid pulse in the neck is again strong, regular and 105 per minute. 

Chest and Cardiovascular Assessment

On inspection, the chest is moving normally on both sides. The Respiratory assessment indicates breathing at the rate of 21 breaths per minute and here are no chest tubes.

The lung auscultation shows the breath sounds are normal. The heart sounds are normal, but the heart rate is fast. The ECG shows Heart Rate of 104 and heart rhythm indicates sinus tachycardia as it is 105 beats per minute.

Abdominal Assessment

The bowel sounds in the abdomen are normal. 

Extremity and Pain Assessment:

Mrs. Hughes has severe Pain in the left leg, and she measures pain on a scale of 9/10. The pain worsens when someone touches her leg and feels the bandages are too tight and when asked if anything makes pain better then she says that nothing makes pain better rather she feels worst of the throbbing pain. She has been experiencing pain ever since she got back from surgery, and lastly, she needs something soothe the pain as she feels pain is worst even after the medication,

The Pedal pulse is strong, measured as 105 per minute and regular, though it is absent on the left side. The Radial Pulse is also strong, regular and 105 per minute. 

Tubes, Drains, and IV Assessment

On examination of the IV, there is no redness, swelling, infiltration, bleeding or drainage, and the dressing is dry and intact. IV Infusion is at the rate of 75 ml/hr of lactate ringer solution.  

Assessment of the Postoperative dressing indicates the dressing to be really tight. 

The Vitals reassessed at 1540 Hrs show breathing to be at the rate of 21 breaths per minute, SPO2 levels being 98%. The pulse is 105 beats per minute, strong and regular, BP to be 158/94 mmHg and Temperature to be 99 degrees Fahrenheit. 

References

BC Campus (n.d.) Clinical Procedures for Safer Patient Care: Head-to-toe Assessment. 

Available at https://opentextbc.ca/clinicalskills/chapter/2-2-head-to-toe-assessment-checklist/

vSim for Nursing (2021) Surgical Scenario 1: Marilyn Hughes. Available at 

https://phoenix-sim.thepoint.lww.com/titles/9781975175849/content/categories/vsim-asset-list