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STUDE
NT WORKSHEET

INTRODUCTION
Gabriella, RN on the Med/Surg unit

Your name, position (RN),

unit you are working on

SITUATION The patient's name is Wanda Steel. She is an 80-year-old

Patient’s name, age, specific reason for
the visit
female who came in today from the ER after a fall at the
grocery store. The fall resulted in a right humeral head
fracture. She is awaiting a consult from orthopedics, but in
the meantime, a triangle sling has been applied to stabilize
and support the arm. She is alert and orientated. No known
drug allergies.

BACKGROUND
Patient’s primary diagnosis, date of
admission, current orders for patient
The humeral head fracture was confirmed with x-rays. Past
medical history includes MI 15 years ago, PE 12 years ago,
OA in bilateral fingers, coronary artery disease, high
cholesterol, hypertension, and gastric ulcers 7 years ago for
over use of NSAIDS for arthritis. Her home medication
includes ASA, Metoprolol, Ramipril, Apixaban, Lipitor,
Pantoprazole, and Tylenol.

ASSESSMENT
Current pertinent assessment data
using head to toe approach,
pertinent diagnostics, vital signs
With the pain assessment completed, Ms. Steel reports her
pain is 8/10. She has received a PRN of Tylenol, 2 tabs of
acetaminophen 300mg + codeine 30mg. CSMT q1hr and
neurovascular assessment q1hr are currently are currently
ordered and completed. The last CSMT assessment showed
normal colour, cap refill is <3sec, adequate sensation,
range of motion is decreased in her right shoulder, able to
move fingers, wrist, temperature of her right arm is stable
compared to the left.

RECOMMENDATION
 With Tylenol ordered, I am worried if you need an accurate
weight on the patient to ensure she is receiving the correct
dose.
Would you like to repeat x rays?
Any orders or recommendations you
may have for this patient