474 CASE SCENARIO.FALL:L2,FRACTURES, NSTEMI.

KINGDOM OF GOD HOSPITAL , LOS ANGELES,CA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex 83years female.

Account number: Q009897234.

MR# Q000798678454.

Admission Status: Inpatient admission.

Location MedTelemetry.

Room :45012.

Attending doctor : Don’thate,Big. Allergy:NKDA.

Primary diagnosis: L2,L3 Fracture ,NSTEMI. Secondary diagnosis:Dementia, Failure to Thrive.

Isolation Status: Standard Precautions.

Is patient at risk for falls: Yes.

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

Room air with saturation of 95%.

Cardiac Heart Health diet.

Alert and oriented ×1,vocal but does not make sense.Pulled out saline lock.

New saline lock 20guage,patent/clean/dry left arm.

Performed Straight catheter as ordered 800ml of clear yellow urine. Straight catheter Q6hours.

Incontinent of stool x2 during day shift. Laboratory tests:

WBC:8.1 .

H/H:9.0/27.2%.

Medications:Norco 10/325mg po Q4 prn pain.

Dilaudid 0.5mg IV Q3hours prn pain.

Zosyn 3.375gm IV Q8hrs.

0.9NS at 75ml/hr left forearm 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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