CASE SCENARIO FOR GRADED PRACTICE CHARTING

Zeny, 58 years old, female, is working for a gigantic pharmaceutical company. She gets
to deliver medicines to retailers in their town. While she was driving, a cat suddenly
appeared on the road, so she panicked and got disturbed. Her car ran through a steel
fence and she was left unconscious. Rescuers got into the scene and took her off her car
with a splinted left elbow. Zeny is then rushed to the nearest ER, where Xray revealed
fracture of her left distal humerus. She is scheduled for ORIF of left humerus the next
day at 10AM.

INSTRUCTIONS: Create a COMPREHENSIVE type of PHASE 1 and PHASE 2

Charting.

Special Endosements:
 Ongoing IVF: PNSS 1L (20gtts/minute regulation and 700cc level)
 IFC fr. 16 inserted
 With Tramadol Drip (D5W 500mL plus 2 ampules of tramadol; 250cc
level)
 Splinted Left elbow

POST OPERATIVE ORDERS:

 Transfer patient to PACU
 02 support @ @LPM per NC
 Position on moderate high back rest
 IVF TF: D5LRS 1L x 8hrs
 Repeat Xray, Left Forearm
 Meds: Continue Gentamicin 40mg IV q8
d/c tramal drip
shift to ketorolac 30mg IV q8 ANST