Age/Sex 77years old woman.

Account number : Q006543233.

MR# :Q00069693416.

Admitted 04/30/2021 @0400.

Status: Inpatient.

Location : MedTelemetry.

Room : 42114.

Attending doctor: Tommy Rootbeer.

Patient name :Londona Bridge.

Resuscitation Status: Full code.

Primary diagnosis :Right knee infection. S/P Right total knee Arthoplasty.

Secondary diagnosis:Hypertension, Hld, old abdominal scar.diabetes, CHF. Hx of degenerative joint disease.

Weight : 245lbs.

Height: 5ft 7inches.

Isolation Status: Contact Isolation right knee infection.

Is patient at risk for fall: No.

Suicidal risk: No.

Do you have advance Directive: No.Copy of advance Directive on the chart.

Diet Car Controlled Cardiac health diet.Consistency: Mechanical chopped.

CT SCAN right ■ done.

Ultrasound of right knee ■done.

Alert and oriented ×4.

Allergy: PCN.

Laboratory tests:

WBC 11.5.H/ H 8.9 ,25.5%.Na 140,K:4.2.

BSC at her bedside .

Uses front Wheel Walker.

Doctor orders:

Ambulate on the hallway using front wheel walker TID.

0.9NS at 50/ hour infusing well via pump right ac 20guage intact, patent and clean.

Morphine sulfate 2mg IV Q3hours prn pain.

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

Dilaudid 0.5mg IV Q4hours prn pain.

Vancomycin 1gm IV Q12hours.

Zosyn 3.375gm IV Q8hours.

Lisinoprol 10mg po.

Hctz 12.5mg in am. Qdaily.

Accucheck Qac/Qhs.

Wound dressing with santyl cover with Guage Qday +prn.

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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