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.