480 CASE SCENARIO. FALL: TEMPORAL BONE/MASTOID BONE FRACTURE.

KINGDOM OF GOD HOSPITAL LOS ANGELES,CA 900000.

INTERDISCIPLINARY KARDEX. Age/Sex:83years old man.

Account number:Q004446719.

MR # Q00060243098.

Location: ICU Unit.(WATERSIDE)

Room : 32116.

Resuscitation Status:DNR but need some treatment. Not comfort care.

Allergy : NKDA.

Weight: 165lbs.

Height : 6feet 2inches.

Primary diagnosis : Fall: SDH/ TEMPORAL BONE/MASTOID BONE FRACTURE,ALOC .( Traumatic brain injury.Traumatic intraparenchymal hemorrhage.

ICU for close monitoring. )Secondary diagnosis dm,htn,hypothyroidism seizures disorder, HLD,Hypertension,Dementia.

Isolation Status: Standard Precautions.

Is patient at risk for falls: yes. Fall precautions protocols implemented. Do you have an advance Directive: YES.Copy of the advance Directive on the chart: NO.

Diet: Carb control diet (100% feeder)

Head CT Scan done: Subdural hematoma.Patient is a transfer from Glorious Hospital Downtown to KINGDOM of God hospital Los Angeles for higher level of care.

Lethargy, nonverbal. 02 @2liter NC.

MRSA done.Both nares swabbed.

D5NS @50ml/hour.

Condom catheter in place.

On Keppra 1000mg IV Q8hrs.

Accucheck QAC/QHS.

Myperlix to coccyx for protection.

Arousable.

Turn and reposition Q2hours for comfort and pressure redistribution.

SCD to bilateral lower extremities in place to keep circulation going.

Hospice consult.

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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