KINGDOM OF GOD HOSPITAL,LOS ANGELES,CA 900000. INTERDISCIPLINARY KADEX.
Age/Sex 66years.Female.
Account number : Q0096654444.
MR# Q000099933771.
Location 4th Floor. (MedTelemetry)
Room 400129.
Patient name: Miliky Worda.
Attending doctor : Tumtum,Worry.
Code Status: DNR.
Primary diagnosis:Sepsis/UTI/MRSA Wound.
Secondary diagnosis: diabetes mellitus, hypertension, stroke, glaucoma, Seizures.
Is patient at risk for falls?:Yes.
Do you have an advanced Directive:No.
Copy of advanced Directive on the chart.
Isolation Status: Contact Isolation.
Method of transportation: Bed.
02 at 2liter NC. Wheezing atimes.
Old Trach site clean Q4hours.
Allergy:Zosyn (erythema rashes),Vancomycin (rashes all over)
Left forearm saline lock 20guage,patent/clean/dry.
Zyvox 600mg po Bid x10days.
Merrem IV Q6hrs.(Urine culture gram+ rod)
Strict NPO. Jevity 1.0 at 50ml/hour.
Flush with 100ml/Q4hours.
Peg tube intact. Clean peg tube site Qshift +prn.
Abdominal binder in place.
Excoriation to bilateral buttocks.Antibiotic ointment applied as ordered by the doctor.
Right side flaccid.
Purwick for urination.
Accucheck Q6hours.
Laboratory tests:
WBC:12.0.
H/H:8.9/26.9%.
K=4.0.
NA=138.
Plan:
Case manager and Social worker consulted.
Discharge patient to SNF when stable.
Nurses You Move Me 