18TH CASE SCENARIO. (NURSING)APPENDICITIS.

Age/Sex 37years Male.

Unit : Q00000071

Admitted. 07/19/2007

MR:Q0008242624.

Diagnosis Acute Appendicitis.

Secondary Diagnosis : Hx ESRD HD Monday/Wednesday/Friday. Left kidney removal 06 /01/2004.

Left permacatheter for Hemodialysis.

General Surgery consult: Dr. Not Nice.

On 07/19/2007 S/P Laparoscopic Appendectomy.

Allergy: NKDA.

Lungs clear on RA(Room air)

DIET: Renal diet.

Patient on dialysis = 90g protein, 3gNA,3k, 1gm phosphorus.

No Dialysis = 60g protein, 2gm Na,2gk,Igm phosphorus.

Medications:

Zosyn 3.375gm IV Q8hrs.

Zyvox 600mg po Q12hours.

Dilaudid 0.5mg IV Q3hours prn pain.

Norco 5/325mg po Q4hours prn pain.

Laboratory:

WBC =11.2mm

H/H 10.0g/dl

31.5%

NA = 132mEqkcl

K. = 5.1mEqkcl

CR =10.50

BUN = 65.

DISCHARGE:

Discharge home with pain prescription of Norco 10/325mg po Q4 prn pain. Colace 100mg po Q8hrs.

CASE SCENARIO B.

Age/Sex 34years old female.

Name Theresa Nogod.

Unit Q000020110

Admitted 06/25/2011.

Attending doctor: Don’t Hate.

Medical record number Q00333560

Location 4NORTHEAST.

CODE STATUS Full code.

Diagnosis Acute Appendicitis.

Secondary diagnosis Hypertension.

S/P Laparoscopic Appendectomy 06/27/11 Abdominal incision × stitches.

Height 5ft 6inches

Weight 190lbs.

Allergy NKDA.

Diet Clear liquid diet.

Hgb 11g/dl.

Hematocrit 35%

K 3.8mEqkcl

NA 140mEqkcl.

PLAN.

Advance diet to soft diet in am.If tolerated discharge home with family.

Discharge orders and prescriptions in the chart.

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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