489 CASE SCENARIO. URINARY TRACT INFECTION (UTI),DEMENTIA.

KINGDOM OF GOD HOSPITAL LOS ANGELES,CA 900000. INTERDISCIPLINARY KARDEX.

Age/Sex: 90years old female.

Account number: Q00263469.

MR# Q00046539687.

Admission date:07/12/21 @0545am.

Status: Inpatient.

Location: MedTelemetry. Room 42111.

Attending doctor: Don’thate,Big.

Resuscitation status:Full Code.

Allergy: NKDA.

Primary diagnosis: UTI/ DEMENTIA. (Brought in by son)

Secondary diagnosis :dm,htn,hypothyroidism, altered mental status,frequent falls.

Alert and oriented ×1.

Weight 102lbs.

Height: 5ft 0inch.

Diet : Cardiac heart health diet.

Incontinent of bowel and bladder.

Bladder scan Q6hours.

Bladder scan after incontinent.

Isolation Status: Standard precautions.

patient at risk for falls: yes.

Suicidal risk: No.

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

MRI of head revealed Enlarged middle cranial tossa.

Medications:

Rocephin 1gm IV Q24HOURS. ( UTI)

Flomax po Qday.

Decadron 4mg po Q6hours. (Dexamethasone)

Laboratory tests:

WBC: 6.9mm3.

H/H13.3/40.4%.

K=4.0mEqkcl.

Na=141mEqkcl.

Plan:

Discharge patient to Skilled Nursing Facility. CBC with differential 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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