11. Scenario 11 PREOPERATIVE DIAGNOSIS
Open Calle fracture left wrist
2
POSTOPERATIVE DIAGNOSIS
Open Colles fracture left wrist.
PRIMARY PROCEDURE
OPEN REDUCTION INTERNAL FIXATION LEFT OISTAL RADIUS FRACTURE WITH DEBRIDEMENT OF OPEN FRACTURE
SITE
BRIEF HISTORY
This 59-year-old female presents with an open Colles fracture of the left wrist due to an automobile accident. The
patient was a passenger in the vehicle that was struck by another vehicle. It was determined that closed
treatment was insufficient for fracture treatment.
350
1
PROCEDURE
After the attainment of adequate general anesthesia, the left upper extremity was prepped and draped. A skin
marker was used to dentify the appropriate location using the position on the forearm for the radius pins. The
fracture and open wound were addressed. The wound required significant debridement of the skin and
subcutaneous tissue prior to proceeding with the repair of the fracture. After adequate debridement the
fracture was reduced to the appropriate anatomic position. Excellent stable foration was obtained Rotational
alignment appeared to be satisfactory. The wound was irrigated, suured closed and dressed with Xerotto, cast
padding and Ace wrap. The patient tolerated the procedure well and arrived in the recovery room in good
condition
M25.46
Note External cause code(s) apply
ICD-10-CM
ICD-10-CM
CPT

Rita schmidt, 74 years of age, is a female patient who was admitted to the surgical unit after undergoing removal of a section of the colon for colorectal cancer. the patient does not have a colostomy. the patient has several small abdominal incisions and a clear dressing over each site. the incisions are well approximated and the staples are dry and intact. there is a jackson-pratt drain intact with minimal serous sanguineous drainage present. the patient has a salem sump tube connected to low continuous wall suction that is draining a small amount of brown liquid. the patient has no bowel sounds. the foley catheter has a small amount of dark amber-colored urine without sediments. the patient has sequential compression device (scd) in place. the nurse performs an assessment and that the patient's breath sounds are decreased bilaterally in the bases and the patient has inspiratory crackles. the patient's cardiac assessment is within normal limits. the patient is receiving o2 at 2 l per nasal hg; heart rate 110 bpm; respiratory rate 16 breaths/min; and the patient is afebrile. the patient is confused as to place and time. cannula with a pulse oximetry reading of 95%. the vital signs include: blood pressure, 100/50 mm. a. explain the assessment parameters used to provide clues to detect postoperative problems early and the interventions needed. b. what gerontological postoperative considerations should the nurse make?