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.

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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