454 CASE SCENARIO. DEHYDRATION/PYELONEPHRITIS/RENAL FAILURE/ANEMIA.

KINGDOM OF GOD HOSPITAL ,LOS ANGELES,CA 900000. INTERDISCIPLINARY KADEX.

Age/ Sex 30years Male.

Status :Inpatient admission .

Account #Q000000069.

MR# Q00453601178.

Date of admission: 03/24/21 12noon.

Location 4Center.

Room 456003.

Primary diagnosis: Dehydration, Pyelonephritis, Renal failure, Anemia. 03/29/21 S/P Revision of prolapsed colostomy, and partial colon resection by doctor Cute James.

Secondary diagnosis: Paraplegic ; Gunshot 6years ago,PTSD.

Weight 140lbs.

Height =5ft 8inches.

Isolation status: Standard precautions.

Is patient at risk for falls:No.

Is patient at risk for Suicide No.

Allergy NKDA.

Diet: Regular diet. Ensure with meals tid.

Foley Catheter.

Pressure ulcer left groin.

Stage 111 to the coccyx. Clean wound with normal saline, apply Therapeutic honey pack with 2×2 and cover with Mypilex QOD and prn.

Laboratory tests:

WBC = 9.4.

H/H =8.6/28.5.

NA =135.

K=4.2.

Magnesium=2.1.

Plans:

Zyvox po Q12hours x2days starting 03/30/21.

Discharge patient home in two days.

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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