488 CASE SCENARIO. INFECTION OF GT SITE/ PNEUMONIA.

KINGDOM OF GOD HOSPITAL LOS ANGELES,CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex/ 92years old female.

Account number :Q00469694.

MR# :Q0008499966.

Admission date: 05/13/21@09am.

Status: Inpatient.

Location MedTelemetry.

Room: 42114.

Attending doctor: Tumtum,Worry.

Patient name: Beauina Yosemita.

Resuscitation Status:DNR.

Allergy: Norco,Morphine.

Weight:160lbs.

Height 4ft 11inches.

Isolation Status: Contact Isolation.

Is patient at risk for falls : yes.

Suicidal risk: No.

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

Diet : Strict,NPO.

PPN infusing via pump at 42ml/ hour.

Picc line double lumen.patent / clean /intact.

Vancomycin 500mg IV Q24hours.

Merrem 1gm IV Q24hours.

Dressing to GT site Qshift.

Dilaudid 0.5mg IV Q8hrs prn pain.

Zofran 4mg IV Q4hours prn

Accucheck Q6hours while NPO.

Nonverbal communication.

Able to nod her head or blink her eyes.

Discharge to Skilled Nursing Facility in two days after Ngt placement.

Incontinent of bowel and bladder.

Patient is clean and dry.

Turn and reposition frequently for comfort and pressure redistribution.

Laboratory tests: WBC:11.2.

H/H9.3/28.8%.

K=3.8.

Na= 136.

Laboratory tests of LFT in am.

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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