456 CASE SCENARIO. GALLBLADDER REMOVAL.

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

Age/Sex: 51years old female.

Account # Q678000543.

Status: Inpatient admission.

Medical Record number: Q00557813096.

Location: General surgery unit.

Room 300016.

Attending doctor : Don’thate,Big.

Patient name: Pinsol,Great.

Alert and oriented x4.

No respiratory distress.

02 at 2liter NC,saturation of 94%.

Is patient risk for falls No.

Patient at risk for Suicide: No.

Isolation status : Standard precautions.

Do patient have advanced Directive No.

Copy of advanced Directive on the chart. Primary Diagnosis:Gallbladder Removal. Secondary diagnosis: diabetes mellitus, hypothyroidism, hypertension.

Diet: Clear liquid diet.Tolerating well.

No bowel movement, not passing gas.Voiding well using the bathroom.

Ambulates with steady gaits to the bathroom. Medications:

Norco 10/325mg po Q4hours prn pain.

Dilaudid 0.5mg IV Q3hours prn severe pain. Zofran 4mg IV Q4hours prn nausea/Vomiting. D51/2NS at 75ml/hour to right ac via pump .Right hand saline lock 20guage,patent/clean/dry.

Laboratory tests:

WBC 7.4.

H/H10.6/32.5.

NA135.

K=4.2.

Magnesium=2.0

Plans : Patient will be discharged home in am.

Will continue to monitor and follow doctor’s orders.

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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