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.