482 CASE SCENARIO. LEFT HIP DISLOCATION.

KINGDOM OF GOD HOSPITAL ,LOS ANGELES,CA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex 70years Female.

Account #Q002275657.

MR# :Q0004994938.

Admitted date: 04/21/21@ 05am.

Status: Inpatient admission.

Location: Trauma Unit.

Room :32110.

Attending doctor : Tumtum,Worry.

Patient name: Monkse Scott.

Resuscitation status: Full Code.

Allergy: NKDA.

Weight:128lbs.

Height: 4feet 11inches.

Primary diagnosis: Left hip dislocation. Secondary diagnosis dm,htn,hypothyroidism, Chronic Anemia,CHF,forgetfulness.

Isolation Status: Standard Precautions.

Is patient at risk for falls: Yes.

Implement falls prevention protocols.

(Yellow armband, yellow gown,Falling yellow sign at patient door.)

Diet Carb controlled cardiac health diet.

NPO sign on the door.

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

Plans:

NPO after Midnight. Left hip fixation in am by doctor Happime,Goodness.

Consent signed.

Cardiologist consult.

Cardiology clearance done.Ejection fraction 40%.

Abduction pillow in between leg.

D5.9NS @ 75ml/hour right ac 20guage,patent/clean/dry.

Dilaudid 0.5mg IV Q3hours prn pain. Morphine sulfate 2mg IV Q8hrs prn pain. Zofran 4mg IV prn nausea/Vomiting. Laboratory tests:

WBC:5.9.

H/H9.0/29.8%.

K=4.6.

NA=132(low)

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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