KINGDOM OF GOD HOSPITAL, LOS ANGELES,CALIFORNIA 900000.
INTERDISCIPLINARY KARDEX.AGE/SEX KARDEX.
Age/Sex 68years man.
Resuscitation Status: Limited DNR.
Account number Q00454987.
MR# Q0006962243.
Admission date:01/31/21 @0340am.
Status: Inpatient admission.
Location ICU – MedTelemetry.
Room : 42113.
Attending doctor: Tumtum,Worry.
Weight: 86lbs .
Height:5feet 7inches.
Allergy: NKDA.
Primary diagnosis:Rhabdomyolysis, Pneumonia, Sepsis. ( Altered mental status)
Secondary diagnosis:ESRD/HTN/ Failure to Thrive. ( Patient was found down at home by caregiver) MRI test shows acute infarct left white matter.Initially admitted to ICU for respiratory failure.Intubated at beside medications of vasopressors given,self extubated. History of respiratoryfailure and sepsis. (Hypercapnic with CO2 of 109mEq/L .Normal chloride in the blood is between 98 to 107mEq/L)Specimens sent to the laboratory, CT Scan of abdomen done.
Isolation Status:Standard precautions.
Do patient have advance Directive:No.Copy of advance Directive on the chart.
Is patient at risk for falls : yes. Patient belonging Checklist done and signed.
Diet: Strict NPO. Tube feeding : No.None.TPN/PPN.
Medications:
D5w/20mEqkcl at 50ml/hour right ac 20guage,patent/clean/dry.
Central line left chest clean,intact and patent.Will discontinue when transferred to MedTelemetry.
Zosyn 3.375gm IV Q8hrs.
Accu check Q6hours.
0.9NS flush Q6hours. DJ sdcc
02 @4 liter NC.
Transportation: bed.
Laboratory tests:
WBC:13.9.
H/H9.7/31.1%.
K=3.9.
NA=133.
All of the organs of the body are susceptible to damage from sepsis. Sepsis can cause cellular injury that may be caused by lack of oxygen to tissues. The most common site for infection that will lead to sepsis and septic shock is the respiratory tract following a respiratory infection such as pneumonia.
Nurses You Move Me 