446 CASE SCENARIO. POSTERIOR NECK DEHISSENCE.

KINGDOM OF GOD HOSPITAL LOS ANGELES,CALIFORNIA900000.

Interdisciplinary Kardex.

Age/Sex: 59years old male.

MR# :Q444400565.

Account #Q00000555.

Admission date: 06/23/21 0630am.

Attending doctor: Don’thate,Big.

Code Status: Full Code.

Isolation status: Standard precautions.

Primary diagnosis: Posterior neck Dehissence.Jackson pratt drainage to the neck with bloody drainage.

Secondary diagnosis Quadriplegia,HTN,HLD/DM.

No movement of lower extremities.

Abdominal binder in place .

Straight Catheter Q4hours.

Bowel movement x2 after rectal suppository. Is patient at risk for fall.Yes.

Advanced Directive No.Copy of Advanced Directive on the chart.

Medications:

0.9NS @75ml/hr.

Kefzol 250mg po Q6hours.

Accucheck Qac and Qhs.

Norco 10/325mg po Q4hours prn pain.

Zofran 4mg IV Q4hours prn nausea/Vomiting.

Laboratory tests.

WBC 7.0.H/H: 9.6/30.0%.

K=3.7.NA=138.

Allergy NKDA.

Diet: Regular diet.

Plans:

Discontinue Jackson Pratt today. Patient transferred back to: “Preferable than Home” Skilled Nursing facility,Los Angeles, California 900000

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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