Age/ Sex 35years Male,named Mike Wine,full code
Attending doctor: Erosion,James.
CODE STATUS: Full code.
Medical record number:Q0000664505
Diagnosis: Etoh abuse,Altered mental status. Drug overdose, Aspiration Pneumonia. Lethargic.
Allergy: NKDA.
Diet : Strict NPO. Jevity 1.0 at 55ml/hr. Left nare.
Medications:
IJ : Right subclavian 0.9NS @75ml/hr.
Levaquin 750mg IV Q24hours.
Zosyn 3.375gm IV Q8hrs.
Morphine 4mg IVP Q4hours prn pain.
Patient removed the ngt,removed the IJ, bleeding from site,pressure applied to stop his bleeding from central line site.And his removal of Foley catheter for critical output documented. Not replaced. Patient environment modified.Placed patient in sitter room for adequate monitoring. Reorient the patient frequently and keep the room well lite.Patient attempted to get out of bed several times. High risk for fall .Placed patient on Fall risk precautions, and on low bed.Called the doctor and notify him.The doctor ordered to restrain patient. Two point of soft restraint with the help of the charge nurse applied. The decision to place in restrained must be clinically evaluated and justified. Nurse to evaluate patient immediate situation and reactions to treatment regimen given.This is Non-Violent, self- destructive ( Also referred to as Medical-Surgical Restraint)
The use of restraint is done only when restrictive methods have been attempted,documented but failed. The doctor (licensed physician)will order the restraint sign it with date and time.The doctor should include the type of restraint, the rationale for the restraint, and the length of time. Medical restraint is documented every 2hours and eyeballing every 15minutes.
GI Consultation done.Dr.Gastric,Anthony
Keep patient NPO after midnight for peg tube placement in am.(Ngt tube feeding of Jevity 1.0 stop at Midnight)
Peg tube placement. Will transfer patient to SNF after tube placement.
Nurses You Move Me 