504 CASE SCENARIO. SMALL BOWEL OBSTRUCTION( SBO).DECOMPRESSION OF ABDOMEN.

KINGDOM OF GOD HOSPITAL

LOS ANGELES ,CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex 60years old female.

Account number: Q001336343.

MR Q00061655442.

Admision date 08/23/21 @ 0450am.

Location MedTelemetry.Room : 42113.

Attending doctor: Tomtom Worry. Resuscitation Status :Full code.

Primary diagnosis SBO.

Secondary diagnosis: Hypertension.

Allergy: NKDA.

Isolation Status: Standard Precautions.

Is patient at risk for fall: No.

Do you have advance Directive: No.

Copy of advance Directive on the chart.

Patient belongings: Done.

Skin intergrity impaired: No.

Transportation method: Bed.

Room air with saturation of 97%.

NPO × Ice chips.

Doctor orders:

Ngt to low wall suction.

D5ns @ 150ml/hour left forearm 18guage clean/dry/ patent .

Morphine sulfate 2mg IV Q3hours prn pain. Zofran 4mg IV Q4hours prn nausea/Vomiting. Encourage ambulation.

Ngt to decompress the stomach.

Incentive Spirometry Q1hour while awake. Surgery consult. Surgery team to follow up. Zosyn 3.375gm IV Q8hours.

CBC with differential, Chem 7 in am.

Strict documentation of intact and output. Laboratory tests:

WBC 11.5.H.

H/H 16.0 44.2%.

Na:140 .

K: 3.8%.