496 CASE SCENARIO. STOMACH TUMOR.

KINGDOM OF GOD HOSPITAL 🏥LOS ANGELES, CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex 73years old man 👴.

Account number :Q006543245.

MR # : Q00069693422.

Admitted : 04/23/21@0535am.

Status: Inpatient.

Location: General Surgery.

Room : 62115.

Attending doctor: Niceman,Tom.

Patient name:

Blanca Woodrobe.

Resuscitation status : Full Code.

Weight: 149lbs.

Height : 4feet 11inches.

Primary diagnosis: Stomach tumor.

S/P Lap Gastrectomy.

Secondary diagnosis: Hypertension.

Isolation Status: Standard Precautions.

Is patient at risk for fall?. Yes.

Fall prevention protocol in place.

Do patient have advance Directive: No.

Copy of advance Directive on the chart.

Diet : Cardiac health heart diet.

02 @ 2liter NC.Saturation 96%

Transportation method: 🛌 Bed.

Abdominal dressings × 5 intact.

Allergy:Shell fish,morphine sulfate.

Doctor orders.

Dilaudid 0.5mg IV Q3hours prn pain.

Norco 10/325mg po prn Q4hours pain. Phenergan 12.5mg IV Q8hours prn nausea/Vomiting.

Ambulate on the hallway Qshift.

Discontinue foley catheter today .

Banana bag @ 83ml/ hour × 24hours.

D545NS at 100ml/hour @ Left hand 20guage,patent/clean/dry and intact.

Laboratory tests:

WBC 6.5.

H/H 9.6/28.8%.

Na :142.

K: 3.9.

Plans:

Discharge home to the wife in two days.

Home health office visit three times a week after discharge home. Abdominal dressing change QOD.

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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