499 CASE SCENARIO. FALL ACUTE T12 AND L2 FX.

KINGDOM OF GOD HOSPITAL 🏥LOS ANGELES, CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex 80years old female.

Account number: Q006543246.

MR # :Q000524356798.

Admitted : 03/18/21 @0456am.

Location : MedTelemetry.

Room 42121.

Attending doctor: Tomtom,Worry. Patient name:Jesenter Ohodum.

Resuscitation Status: Full code.

Primary diagnosis: Fall acute T12,L2 fractures. Secondary diagnosis:Hypertension, Dyslipidermia, Seizure disorder.

Weight: 170lbs.

Height:5ft 8inches.

Allergy: NKDA.

Isolation Status: Standard Precautions.

Is patient at risk for falls: yes.Daughter at her bedside 24/7.Reposition for comfort and pressure redistribution Q2hours,log rolling, spinal Precautions.

Suicidal risk: No.

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

Diet : Cardiac heart health diet.

Transportation:Bed.

Doctor orders:

TLSO at all time,aspen collar in place.

MRI Lumbar ■ T12: 96% Stenosis.

L2 20% Compression fracture.

Ultrasound of left arm ■ negative .

Picc line place for long term antibiotics at home with home health.( Home Sweet home health Agency,Wilshire Blvd Los Angeles, California 900000)

Discharge home to wife in two days with home health nurse, physical therapist/Occupational therapist. (Wife refused discharge to SNF or Rehabilitation center)

Gram + cocci in the blood/ stool.

Alert and oriented ×3.

Lung sounds diminished.

Discontinue IV at 10am today.Saline lock right forearm 18guage,patent, intact and clean.

Laboratory tests:

WBC 9.5.

H/H 9.6, 28.8 %.

Na:144.

K: 4.0.

Repeat blood culture ,CBC, and Chemistry today.

Hx of seizure disease. 🛌Bedrails well padded.And the floor around the bed is also well padded.

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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