491 CASE SCENARIO. 20WEEKS IUP/ CERVICAL INCONTINENCE.

KINGDOM OF GOD HOSPITAL LOS ANGELES,CA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex: 28years old female.

Alert and oriented x4.

Allergy:NKDA .

Account number #Q0061432055.

MR# Q0004992935.

Admission date: 06/09/2021@09am.

Status: Inpatient.

Location: 5NorthEast.

Room 52114.

Resuscitation Status :Full Code.

Isolation Status: Standard Precautions.

Primary diagnosis:Cervical Incontinence (20weeks IUP) S/P Cerclage placement 06/10/ 21.

Suicidal risk: No.

Do patient have advance Directive:No.

Copy of advance Directive on the chart.

Diet: Clear liquid diet. Advance to full liquid diet for dinner.

Discontinue Foley catheter tomorrow @ 05am.

VS Q4hours.

CBC with differential and Chem 7 05am.

Medications:

Tylenol 650mg po Q8hours prn temperature. Tylenol #3 1tablet po Q4hours prn pain.

Tylenol #3 2tablets po Q6hours prn pain. Zofran 4mg IV Q4hours prn nausea/Vomiting. Ambulate in the hallway Qshift.

Discharge home tomorrow.

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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