462 CASE SCENARIO. PNEUMONIA/ HEART FAILURE.

KINGDOM OF GOD HOSPITAL,LOS ANGELES,CA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex 89years old female.

Admission date:01/21/21.

Status: Inpatient admission.

Location 4Center.

Room # 430016.

Patient name: Pineapple, Grace.

Attending doctor: Don’thate,Big.

Code status: DNR( DO NOT RESUSCITATE)

Account #: Q066399932 .

MR#Q00000009961.

Primary diagnosis:Pneumonia/ Heart Failure. Secondary diagnosis: Severe developmental delay, paget’s disease uti,nonverbal, generalized weakness, difficulty to swallow.

Is patient at risk for falls: yes.

Do patient have advance Directive: No.Copy of advance Directive on the chart.

Isolation status: Contact Isolation.

MRSA in the blood.

Confuse: Alert and oriented ×1.

Contracted bilateral upper and lower extremities. Turn and reposition Q2hours for pressure redistribution and for comfort.

Wounds in all bony prominence areas.

Stage 11.

Wound care consult ordered.

Wound care team is following patient.

TPN @ 80ml/ hour.

Lipid @ 20ml/hour right central line triple lumen.

0.9NS @5ml/hour

NPO due to dysphagia.

Failed swallow evaluation.

DNR and peg tube placement per ethics committee.

Respiratory therapists on board.

Patient has difficulty to cough up phlegm. Suction Q2hours and prn.

Patient has no family.

Live in boarding house all her life.

History of Hiatal Hernia.

Case manager, social workers, home care worker on board.

Transportation is bed.

Allergy : NKDA.

Laboratory tests:

WBC:14.9.

H/H: 11.3/32.8.

K=3.6.

NA=142 .

Gram positive cocci in the blood.

Myperlix bilateral buttocks for prevention. Vancomycin 1gm IV Q12hours.

Vancomycin trough: 14.0

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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