455 CASE SCENARIO. SEPSIS/UTI/MRSA WOUND.

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.

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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