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.
Nurses You Move Me 