459 CASE SCENARIO. RIGHT FEMORAL FRACTURE DUE TO FALL.

KINGDOM OF GOD HOSPITAL, LOS ANGELES, CA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex: 59years old female.

Account number :Q0096600089.

MR # Q866660043005.

Admission date: 04/23/21.

Status: Inpatient admission.

Location: Trauma Department.

Room 456014.

Does patient have advanced Directive: No.Copy of advanced Directive on the chart. Patient has been provided with information on advanced Directive.

Is patient at risk for falls: Yes.Fall precautions protocols are in place.Is patient at risk for suicide: No.

Code status Limited treatment.Comfort care only.Neurology altered.

Isolation status : standard precautions.

Primary diagnosis: Right femoral neck fracture. S/P ORIF of right hip by doctor Hatem,Pounda.

Secondary diagnosis:Bipolar, DM,HTN,Hypothyroidism.

Influ and pneumonia vaccine given.

Allergy: NKDA.

Vital signs: BP 140/67,Temperature 99.0,Pulse 82,Respiration 16. 02 saturation 92%.

Patient did not void.Obtained orders for insertion of Foley catheter from Obnos,Minis D O.Foley catheter placed, cleared yellow amber urine draining.

02 at 4liters NC.

Case manager to arrange for SNF upon discharged.

No new laboratory tests ordered.

MEDICATION’S :

Tylenol 650mg po Q6hours prn temperature.

Lovenox 40mg SubQ Q24hours.

Metoprolol 12.5mg po Q12hours.

Multivitamin 1tablet po daily.

Zolpidem 5mg po Bedtime.

Hydralizine 5mg Q4hours prn Hypertension. Norvasc 5mg po daily.

CeftriaXone 1FM IV Q24hours.

Ferrous sulfate 325mg po daily.

Pregabalin 150mg po Bid.

Senna 2tablets po Daily.

Guaifenesin 200mg po QID.

Simvastatin 20mg Bedtime.

Insulin levemir 10unis SubQ Bedtime.

Insulin humalog Qac/hs sliding scale.

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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