461 CASE SCENARIO. GI BLEED.(NURSING)

KINGDOM OF GOD HOSPITAL LOS ANGELES,CALIFORNIA 900000.

INTERDISCIPLINARY KARDE.

Age/Sex 86years old female.

Account number : Q0966566225.

Status: Inpatient admission.

Date of admission:07/02/21.

MR# Q56660094447.

Location: MedTelemetry.

Room:410019.

Patient name: Jemison,Godwishe.

Attending doctor: Tumtum,Worry.

Code Status: DNR.Co-signature done.

Primary diagnosis:Anemia, GI bleed.

Secondary diagnosis:Anemia, Asthma, severe hypothyroidism HLD,Dm,orif of left leg,disease of aorta, left pleura effusion. Colonoscopy and EGD done: Polyps removed. H/H 8.9/27.7 after transfusion of 1 unit of PRBC.+ Occult blood.

Thoracentesis done 450ml removed.Lower lobe atelectases noted.

Skin integrity impaired: Yes.Excoriation to bilateral buttocks.

Is patient at risk for fall: Yes.Language barrier.

Is patient at risk for suicide :No.

Picc line right subclavian.

Diet:Cardiac heart health diet mechanical ground.Thin liquid. Ensure tid.

02 at 2liters NC . Saturation of 93%.Ejection fraction of 25%.

PT evaluation done.No treatment recommended at this time.

Patient will be transferred to Beautiful Comfort Skilled Nursing Facility in Los Angeles, California 909999.

Laboratory tests:WBC:4.7.H/H 8.9/27.7.K:4.9.NA : 135.