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.
Nurses You Move Me 