490 CASE SCENARIO. CEREBRAL VASCULAR ACCIDENT. (CVA)

KINGDOM OF GOD HOSPITAL LOS ANGELES,CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex 75years old man.

Account number: Q00645743.

MR# Q0002299936.

Admitted date: 01/20/2010 @ 0520am.

Location: 5Northwest.

Room 52116.

Attending doctor: Miranda Lovingston.

Resuscitation status:Full Code.

Primary diagnosis CVA,left distal vetebral Stenosis. Secondary diagnosis dm,htn,hypothyroidism, IGT(Impaired Glucose Tolerance)

Weight 144lbs.

Height 5ft 5inches.

Procedures: CT scan of the head.

MRI of the head.CTA of head and neck.

Allergy : NKDA.

Diet: Cardiac heart health diet.Pureed diet, crush medications, feeder,no straws.Slurred Speech.

Right sided weakness. Right side is flaccid. Patient on room air.Reposition for comfort and pleasure redistribution.

GI/ GU: Incontinent of bowel and bladder.

IVF: D51/2ns at 80ml/hour.Accucheck Qac/Qhs.

Iv site patent intact clean. Rt Ac.

Hydralizine given for blood pressure of 170/90.

Plan: Discharge patient to SNF( SKILLED NURSING FACILITY) when medically stable. Need to follow up with Medical/Medicare.

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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