468 CASE SCENARIO. ACUTE KIDNEY INJURY/DEHYDRATION.

KINGDOM OF GOD HOSPITAL LOS ANGELES, CA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex 65years old man.

Account number Q00099694.

MR#Q77000065487.

Admission Date:01/26/210340am .

Admission status: Inpatient.

Location MedTelemetry.

Room 43006.

Attending doctor: Tumtum,Worry .

Patient name:Luckyman,Features. Resuscitation Status: Full Code.

Allergy: NKDA.

Weight:170Ibs.

Height:5ft 9inches.

Primary diagnosis: AKI,DEHYDRATION. Secondary diagnosis dm,htn,hypothyroidism, amputation of right foot.

Isolation Status: Standard Precautions.

Is patient a high risk for falls: No.

Transportation: Wheelchair.

Skin integrity impaired: No.

Diet: Carb controlled diet.

Laboratory tests:

WBC:7.3.

H/H:9.8/30% .

K: 4.4.

NA:140.

Medications:Norco 5/325mg po Q4hours prn pain.

Zofran 4mg IV Q4hours prn nausea/Vomiting. Zosyn 3.375gm IV Q8hrs.

Morphine sulfate 2mg IV Q3hours prn pain.

0.9NS @ 125ml/hour IV right ac 20guage,patent/clean/dry.

Vital signs Q4hours.

Strict intake and output measurements.

CBC with differential, Chem 7 in am.

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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