Follow your facility policy and procedures.

Age/Sex :66years/Male.

Unit :Q0021219998.

Admission Date: 05/12/13.

Status Inpatient: Admission.

Attending Doctor: Tumtum,Worry.

Patient name:Tony Golden.

Location : Orthopedic/Trauma department.

Room 44326.

Primary Diagnosis: L3,4,L4,5,L5S1.

S/P L4,5 surgery 05/14/13.TLIF( Transforminal interbody fusion)Spinal fusion surgery, awaiting physical therapy. TLSO Brace at the bedside. Blisters anterior chest, abrasions right and left elbows, incision posterior back.Back pain.

Secondary diagnosis: Hypertension, Gout.

Risk for fall : Yes.

Isolation precautions: Universal PRECAUTION.

Advanced directive:No .Copy of advanced Directive in the chart.

02 at 2liter NC.

Transportation style: Bed.

Code status: Full code. Lethargy.

Allergy: NKDA.

Diet: NPO ex Medication.

Tube feeding: None.

TPN : None.

Ngt to right nare for decompression of stomach. Tongue remains swollen.

CT Scan with contrast today.

BM: Three loose stools today.

Incontinent of bowel.

Foley catheter in place. 16 fr.Strict intake and output.

IVF: D51/2NS at 75ml/hr left upper arm.

Dilaudid 0.5mg IV Q3hours prn pain.

Morphine 2mg IV Q8hrs prn pain.

Norco 10/325mg 1tablet Q6hours prn pain via ngt.

Zosyn 3.375gm IV Q8hrs.

Plans:PT/OT evaluation and treatment. (TLSO BRACE at bedside)

Discharge to SNF when stable.


H/H 9.4/25.8

Na = 136.

Potassium =4.1.

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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