485 CASE SCENARIO. PNEUMONIA WITH BLOOD TINGED SPUTUM× 4DAYS.

KINGDOM OF GOD HOSPITAL, LOS ANGELES,CA 900000.

INTERDISCIPLINARY KARDEX.

AGE/SEX : 79years man.

Acount number: Q00989635.

MR# Q00034598764.

Admitted: 04/21/21@04am.

Status: Inpatient admission.

Location :MedTelemetry.

Room:42113.

Resuscitation Status: Full Code.

Allergy: NKDA.

Weight: 130lbs.

Height: 5feet 8inches.

Primary diagnosis:PNEUMONIA.

Secondary diagnosis dm,htn,hypothyroidism, BPH. UTI.Intractable back pain, inguinal hernia, weight loss. Blood tinged sputum ×4days. Diet :Carb controlled cardiac heart health diet. Isolation Status: Standard Precautions.

Is patient at risk for falls: Yes. (Unsteady gait.Language barrier)

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

Suicidal risk: No.

Plans:

02 @3liters NC.

SATURATION 93%(+) Rales.

Azithromax 250mg iv Q24hours.

Rocephin 1gm IV Q24hours.

Norco 10/325mg po Q4hours prn pain.

Colace 100mg po daily.

Ambulate with assistant. (Cane at the bedside)Patient belongings Checklist done.Daughter to take belongings home.Signed /Nurse signed and dated.Nurse Jennifer Lovegod,RN 04/21/21.

Sputum culture ■ done. Pan culture □.

Left forearm 20guage,patent/clean/dry.

SCD BLE.

Incontinient of urine × 3.

Discharge home when stable.

Echocardiogram done.

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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