483 CASE SCENARIO. NONPRODUCTIVE COUGH ×25DAYS.

KINGDOM OF GOD HOSPITAL LOS ANGELES,CA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex 59years Male.

Account number Q00369694.

MR#Q0005458769.

Admission date 03/13/21 0730am.

Status: Inpatient. Location: Med/Oncology 5Northwest.

Room 43211.

Attending doctor: Tumtum,Worry.

Patient name: Pintos Garden.

Resusitation Status:Full Code.

Allergy: NKDA.

Height:5ft 8inches.

Weight :166lbs.

Primary Diagnosis: Nonproductive cough x25days.

R/O TB,generalized pain especially in the joints and extremities.

Secondary diagnosis dm,htn,hypothyroidism, Rheumatoid arthritis.

Isolation Status: Airborne Isolation precautions. Suicidal risk: No.

Is patient at risk for falls: Yes.

Do you have advance Directive:No.

Copy of advance Directive on the chart.

Patient belonging list done.

Non-ambulatory patient.

Bilateral lower extremities:

Redness and swollen.

Chronic bilateral upper Extremity pain.

Plans:AFB × 3□,□,□.

Morphine sulfate 2mg IV Q3hours prn pain. Norco 10/325mg po Q6hours prn pain.

Saline lock 22guage,patent/clean/dry.Initial 02 of 3liters NC saturation of 99%.

D/C oxygen,encourage deep breathing. Room air with saturation of 94%.

Condom catheter in place,change everyday,+ prn.

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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