479 CASE SCENARIO. ACUTE HYPOXIC RESPIRATORY FAILURE.

KINGDOM OF GOD HOSPITAL , LOS ANGELES,CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex 59years female .

Account number Q002696922.

Q00043387645.

Admission date: 03/11/21@0130am.

Admission Status: Inpatient admission.

Location MedTelemetry.

Room 42311.

Attending doctor: Tumtum,Worry.

Patient name: Engwoma Johbaby.Resuscitation Status: Full Code .

Allergy:NKDA.

Weight:147lbs.

Height : 5ft 2inches.

Isolation Status: Standard precautions. Primary diagnosis:Acute Hypoxic Respiratory failure.

Secondary diagnosis: Hypertension, HLD/DM,Schizophrenia disorder, Depression, anxiety, Sinus infection.

Is patient at risk for falls:Yes.Fall risk prevention protocols maintained.

Do you have advance Directive:No.

Copy of advance Directive on the chart.

Risk for suicide:no.Intubated and extubated.

02 @2liter NC.Saturation of 94%.

Alert and oriented x4. One person assistance. Ambulates to the bathroom with front wheel walker.

Monitor intake and output.

Saline lock left forearm 20guage,patent/clean/dry .

Diet: Cardiac Heart Health diet ( Mechanical Soft ground) Thin liquids. Okay for patient to use straw.

PT/ OT evaluation and treatment done.

Laboratory tests:

WBC: 5.9.

H/H9.3/30.0.

K= 4. 0.

NA=138.

Medications:

Septra 800mg po bid.

Azithromax 250mg IV Q24hours .

Rocephin 1gm IV Q24hours.

Prednisone 20mg po daily at 09am.

Plans: Discharge with Parameters.

Discharge home if patient is able to ambulate without assistant. CBC, BMP,ANCA,VASCULITIS LAB before discharge home.

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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