498 CASE SCENARIO.ISCHEMIC STROKE, HIGH CHOLESTEROL.

KINGDOM OF GOD HOSPITAL LOS ANGELES, CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex 79years old. 👴

Account number : Q006543237.

MR # : Q00069694462.

Admitted :05/21/21 @0545am.

Status: Inpatient.

Location :MedTelemetry.

Room :42114.

Attending doctor:Tommy Johnjus.

Patient name: Kilmanjeo Benson.

Resuscitation Status :Full code.

Primary diagnosis:Ischemic stroke,Dyslipidermia( high cholesterol). Secondary diagnosis: DM,Hiccups resolved, sinus bradycardia, Hypertension, left sided flaccid, left facial droopy, left upper and left lower extremities flaccid. TPA.Bilateral Buttocks discoloration.

Risk for fall: Yes.Fall prevention protocol in place. Fall signs at the door 🚪, patient is wearing a yellow gown,and yellow wrist band.

Suicidal risk:No.

Do you have advance Directive. Copy of advance Directive on the chart.

Room air 94%.Non-productive cough.

Diet: Cadiac health diet.Consistency : Pureed. Thin liquid diet.Crush medications give with apple sauce. Feeder.Patient to sit up on the chair during feeding. No straw.

Incontinent of bowel and bladder. Vital signs:

Temperature 37.0,Hr 59,Respiration: 18.BP: 131/62.94% RA.

Laboratory tests:

WBC 8.5.

H/H 12.0,37.2%.

Na= 134.

K= 4.2.

Medications:

Robitussin 15ml Q8hours prn cough.

Lortab 1table spoon Q6hours prn pain.

Zosyn 3.375gm IV Q8hours.

Saline lock 20guage left forearm.

Heparin 5000unit SubQ for DVT.

SCD to bilateral lower extremities.

Plan :

Transfer to SNF – Great Green Forester Rehabilitation center,Los Angeles, California 900000 in am 05/24/21.

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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