please can anyone help me with nursing assessment please..thank u

[Thinkabel]

Scenario - Compound fracture

Mr X is a 40 year old man, who lives alone, except for Truddy (his cat), in a three storey terrace house. He and a two other friends went on a skiing holiday in the Highlands of Scotland. While skiing, he fell and sustained a compound fracture to his right tibia and fibula. One friend stayed with him on the mountainside, while the other alerted the emergency services, who arrived quickly. The paramedic team applied a clean dressing over the open wound and splinted his leg. In the air ambulance, Mr X was given intravenous Morphine analgesia as he was in severe pain.

One of his friend did mention to the paramedic staff that X does suffer from a peptic ulcer for which he has omeprazole twice daily, amoxicillin 500 mg three times daily, metronidazole 400 mg three times daily and aluminium hydroxide 500 mg four times daily and as required. He smokes approximately 20 cigarettes and drinks three cans of lager daily.

On arrival at the accident and emergency department, the named nurse recorded his observations and they were within normal range. The duty orthopaedic doctor examined Jonathan and ordered an X-Ray of his right leg which confirmed that he had fractured his tibia and fibula. A clean dressing was reapplied to the open wound and it was decided to admit Mr X to the ward for surgery later that day, for an external fixation of his right leg.

[thereisalight]

Im not really sure on what youre really wanting? Is it help on how to write the assessment?

[Thinkabel]

yes please. its something like the assessment you will do for this patient if say this patient has been transferred to your ward. thx

[thereisalight]

Pt is a 40 year old man who lives alone. He was on a skiing trip where he fell and sustained a compound fx to his R tib/fib. Medics on the scene placed a clean dressing over wound and splinted the leg. Pt was given Morphine by medics. ER vitals were normal and Xrays were completed confirming the compound fx. Clean dressing was reapplied to wound and pt was admitted for OR later today. Pt has a hx of peptic ulcer, a smoker and drinks 3 lagers daily. He takes Omeprazole BID, Amoxicillin 500 mg TID, Metronidazole 400 mg TID, and Aluminium Hydroxide 500 mg QID.