469 CASE SCENARIO. MULTIPLE LOWER EXTREMITIES FRACTURES.

KINGDOM OF GOD HOSPITAL, LOS ANGELES,CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex Age/Sex 28years old Male.

Account number Q00093299.

MR# Q64450006654.

Admitted 04/12/2105pm.

Status: Inpatient admission.

Location: Trauma Department.

Room 60021.

RESUSCITATION STATUS :Full code. Primary diagnosis:Motor vehicle accident.Fell asleep and hit the tree/ Bilateral acetabular fractures, facial laceration.

Isolation Precautions: Standard Precautions.

Is patient at risk for falls: Yes. Star falling, yellow signs in place.Yellow gown and yellow ID.

02 @2liter NC. Saturation of 94%.

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

Allergy: NKDA.

Operating Room:Facial fracture surgery today. ORIF Right ankle 04/01/21..Splint with IMMOBILER in place.

High income.Not quality for support.

NPO × MEDICATION.

Facial stitches removed. Right zygomatic complex fracture repaired .

Voiding well using the urinal.

Bowel movement ×2 today.

External fixation right leg.

Laboratory tests:

WBC:12.2.

H/H9.4/28%.

K:4.2.

NA 137.

Medications:

Merrem 1mg IV Q8hrs.

Vancomycin 1gm IV Q12hours.

Dilaudid 0.5mg IV Q3hours prn pain.

Norco 10/325mg po Q4hours prn pain.

Flexeril 5mg po Q8hours prn muscle spasms. 0.9NS @ 125ML/Hour.

Urinal at the bedside.

Plans:

Discharge to Acute Rehabilitation when stable.

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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