Mr J.D. 49years old male was admitted into Medical/ Surgical Floor.
Admitting Diagnosis:
Necrotic Fasciitis Cellulitis.
Secondly Diagnosis: Hypertension, diabetes poorly managed. Blood sugar in Emergency department 800.Insulin NPH 20units ,and 5units,of regular insulin given subQ to his right lower abdomen.Left leg red ,swollen with wound.
Left leg elevated on pillows. SCD to the right lower extremity.
Incentive Spirometry 10 ×an hour while awake. Full code.Room Air.
Ambulates with crutches. Uses urinal at bedside.
Alert and oriented × 4.Lungs clear.
Diet: Clear liquid diet.
Voiding: Using urinal at his bedside.
No skin tissue except the wound to the Left leg.
PLANS : NPO after midnight.
Incisions and debridement in am by doctor DON’T HATE.
Woundvac to be placed in OR.(Operating Room)
Woundvac dressing change Monday, Wednesday and Friday.
0.9NS @ 125ml/ hr. right hand.
Zosyn 375gm intravenously Q8hrs.
Vancomycin 1gm Iv Q12hours.
Morphine 4mg iv Q4hours prn breakthrough pain.
Norco 10/325mg po Q6hours prn pain.
Blood sugar Q6hours with sliding scales coverage.
Norvasc 10mg po 09am daily.
Labs in Am :CBC with differential.
Chem 7 and liver function panel.
Nurses You Move Me 