472 CASE SCENARIO. INTRACTABLE NAUSEA/VOMITING/FAINTING.

KINGDOM OF GOD HOSPITAL LOS ANGELES,CA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex 92years old male.

Account number Q002696229.

MR#Q00004335697.

Admitted 05/23/21 @02am.

Status: Inpatient admission.

Location: General Surgery department. Room:62014.

Attending doctor: Tumtum,Worry.

Patient name: Paulinus Firewood.

Resuscitation status: Full Code.

Weight: 150lbs.

Height:5feet 6inches.

Allergy: NKDA.

Primary diagnosis: Intractable nausea/Vomiting/ Fainting.

Secondary diagnosis:Prostate cancer 2009,HTN,CVA,HTN,HYPOTHYROIDISM, COPD,ASTHMA, CKD.

Alert and Oriented ×2.Dementia.

Isolation Status: Standard Precautions.

Is patient at risk for falls: Yes( Age/language/Dementia)

Do patient have advance Directive: No .

Copy of advance Directive on the chart.

Risk for Suicide: No.

02 at 2liters NC. Respiration:rales,rhonchi,coughing out blood, refused CPAP machine.

Doctor aware.

Left pacemaker.Abdomen distended.

Voiding frequently 100ml amber colored urine. Patient is very weak,reposition frequently. Redness to his buttocks. Nonblanchable. Laboratory tests:

WBC= 5.9.

H/H=11.3/33.8%.

K=3.9.

NA=136.

Bun=19.

Medications:

Levaquin 500mg IV Q24hours.

Norco 10/325mg po Q4hours prn.(crush medication and mix with apple sauce.)

Right sided weakness.

Right wrist saline lock.

Diet: Cardiac Heart Health diet.

Nectar thicken liquid. Ensure Bid.

Family member: Johnsone Firewood.

Phone number 555-555-5555.

Patient belongings taken home by his son.Plan: Discharge home with God Choice Home Health Services.

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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