9TH CASE SCENARIO(Nursing).TRAUMA FELL AT HOME.

09/7/2004.

Medical Record:Q0000089654

Mrs D.V.D 74years old female fell at home and hit her head on the floor, witnessed by her daughter.

Diagnosis: Altered Mental Status,Seizures disorder.

Attending doctor: Dr.Don’t Hate.

CODE STATUS: Full code.

PMH: Left sided weakness resolved

Daughter is a Poor historian.No English.

Consults: Neurology consult.

General surgery consult.

Keppra 1000mg given intravenously.

0.9NS at 50ml/hour.

C.T Scan of head negative.

MRI done result pending.

Neurocheck Q4hours.

Vital sign Q4hours.

Diet : Heart Health diet.Patient must be fully awake and sitting in upright position. Assist with feeding.

Monitor CBC .H/H Q8hrs.

Voiding: Uses the bedpan.

Activities: Bedrest.

Bowel movements: yesterday. (09/06/2004

Mental Status:Alert and Oriented to self only.

PLAN:

Physical therapist and Occupational therapist evaluation and treatment.

Discharge home with family when medically stable.

Published by edochie99

A Registered Nurse with over twenty years of hospital experience, an author with Masters Degree in Nursing,also Bachelor Degree in Nursing,graduated in 1996 from USC,University of Southern California.MSN in 2009 University of Phoenix.

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