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%.

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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