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
Nurses You Move Me 