466 CASE SCENARIO. RIGHT FOOT DIABETIC ULCERS/INFECTED WOUND.

KINGDOM OF GOD HOSPITAL LOS ANGELES,CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex 69years female.

Account number : Q00009944868.

MR# :Q00888866467.

Date of admission: 01/20/21.@ 1900.

Attending doctor: Don’thate,Big.

Location: General surgery.

Room :30017.

Patient name: Watermelon, Micheline.

Code Status: Full Code.

Chief complaint: Right foot Diabetic wound that needs amputation.

Height: 5ft 2inches.

Weight:180lbs.

Primary diagnosis:Right foot diabetic ulcer/ infected wound.

Secondary diagnosis: HLD/DM/CVA/HTN.

Is patient at risk for falls:Yes.

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

Risk for suicide: No.

02 @ 4liter NC.

Allergy: NKDA.

Diet: Carb controlled diet. Consistency: Regular. Orthopedic consult: Doctor Saveme,Jonathan.

PT/ OT Consultation for evaluation and treatment.

Dressing with splint to right leg.

Alert and oriented x4. Right lower Extremity swollen. Elevated on pillows .

SCD to left lower Extremity.

Wound culture (+)Staphylococcus.

Laboratory tests.

WBC :13.2.

H/H=11.1/32%

Bun =22.

Creatinine =1.4.

Vancomycin through 18.7.

Blood sugar:176.

Medications: Norco 10/325mg po Q4hours prn pain.

Zofran 4mg IV Q4hours prn nausea/Vomiting. Purwick placed at 8pm.

Saline lock right AC 20guage,patent/clean/dry.

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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