492 CASE SCENARIO. GROUND LEVEL FALL.

KINGDOM OF GOD HOSPITAL LOS ANGELES,CALIFORNIA 900000.INTERDISCIPLINARY KARDEX. Age/Sex: 64years female.

Admission date:03/21/21 @0430am.

Status : Inpatient admission.

Account Number: Q00269542.

MR # Q0006999328.

Location: MedTelemetry.

Room 42116.

Attending doctor: Tumtum,Worry.

Patient name: Monica Woodutter.

Allergy: NKDA.

Primary diagnosis: S/P Spinal Fusion by neurosurgery doctor Exceptional Tional MD. ( Ground level fall. Fell at home on 03/21/21@ 0230am)Posterior dressing intact/ dry and clean.

Secondary doctor: Htn,dm,hypothyroidism. Isolation Status: Standard precautions.

Is patient at risk for falls: yes.

Do patient have advance Directive:No.

Copy of advance Directive on the chart. Suicidal risk: No.

Transportation: bed.

Room air.Cough and deep breathe.

Incentive Spirometry every 1hour while awake

Doctor orders:

Physical therapy for evaluation and treatment. Transfer to Skilled Nursing Facility rehabilitation when medically stable.

Diet: Carb controlled cardiac health Mechanical Soft diet.

Follow up with Neurosurgery in 2- 3 weeks. Follow up with her Primary Care Physician in 12 weeks. CBC with differential, LFT ,Chem 7 in laboratory tests: WBC: 6.9.

H/H9.3/30.8%.

K=3.7.

NA: 138.

Medications: Norco 5/325mg 2tablets po Q6hours prn pain.

Tylenol 650mg po prn temperature.

Dilaudid 0.5mg IV Q3hours prn pain. Morphine sulfate 4mg IV Q4hours prn pain. Zofran 4mg IV Q4hours prn nausea/Vomiting. Hydrochlothyzide 25mg po Qday.

Colace 100mg po Qday.

Zosyn 3.375gm IV Q8hrs.

Accucheck Qac/Qhs.

0.9NS @ 75ml/hour right hand patent ,clean and dry.

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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