473 CASE SCENARIO. FELL AT HOME/ UROSEPSIS.

KINGDOM OF GOD HOSPITAL ,LOS ANGELES,CALIFORNIA 900000. INTERDISCIPLINARY KARDEX.

Age/Sex 69years.Female.

Account number: Q004388939.

MR# :Q00087563498.

Date of admission:02/20/21 @0320am.

Status: Inpatient admission.

location: MedTelemetry.

Room 42113.

Allergy: PCN.

Weight : 160lbs.

Height :5ft 4inches.

Primary diagnosis: Fall, Urosepsis.

Secondary diagnosis : Osteoarthritis/DM,HTN,HYPOTHYROIDISM/Depression.

Isolation status: Standard precautions.

Is patient at risk for falls:Yes.

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

Is patient at risk for Suicide: No.

Skin integrity: No.

Transportation : Stretch.

MRI done (-)CT Scan done(-)

Lumbar puncture done.Diet: Cardiac Heart Health diet.Glucerna shake 1can TID.

Encough patient to try to eat more. Standby assisst.

D545NS c 20mEqkcl at 75ml/hour.

(+) Bowel movement. Voiding well.

Laboratory tests: WBC:11.9.

H/H:10.3/32.0%.

K=4.3.

NA=142 .

Medications:

Rocephin 1gm IV Q24hours.

Zosyn 3.375gm IV Q8hrs.

Vancomycin 1mg IV Q24hours.

Norco 10/325mg po Q4hours prn pain.

Zofran 4mg po Q4hours. Zofran 4mg IV Q4hours prn nausea/Vomiting.

Plans:

Discharge to: Calm and Beautiful Behavioral Health facility, Los Angeles California 900000.

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.

Leave a comment

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.

%d bloggers like this: