Mr A.J. 44years old man came into the Emergency room. Alert and oriented ×4 .Full code.
Diagnosis: Diabetic foot infection Right great toe and second toe abcess,blister pop opened.
Consultation: Podiatrist doctor consulted. ( Doctor Too Cute)
Adaptive dressing change Qday.
Incisions and drainage to be done at 1045am.
NPO after midnight.
Room air.
Lungs clear.
Voiding with his urinal at bedside.
Laboratory in am: CBC with differential and Chem 7.
CHG bath given.
Blood sugar check Q6hours while NPO.
Medications:
Vancomycin 750mg iv Q12hours.
Zosyn 375gm iv Q8hrs.
Norco 10/325mg 1 to 2tablets po Q6hours prn pain.
Morphine 2mg iv Q3hours prn pain.
Saline lock right ac.
0.9NS at 75ml/hr to be started after midnight.
Language Barriers: Spanish speaking only. Uses the blue phone for interpretation.
Allergy: NKDA.
Diet: regular diet. NPO after midnight.
stethoscope for assessment of patients.
PLAN: Discharge home after surgery. No Medical insurance. (Undocumented)
Nurses You Move Me 