505 CASE SCENARIO. DEPRESSIVE DISORDER/ UROSEPSIS.

KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX. Age/Sex:72years.

Account number: Q001665897.

MR #Q0005677893.

Admission date: 05/21/2021@03am.

Status Inpatient admit.

Location MedTelemetry.

Room 42111.

Attending doctor: Haters, Johnson. Resuscitation Status: Full Code.

Weight 152.

Height: 5feet 6inches.

Primary diagnosis: Depressive Disorder, Urosepsis.

Secondary diagnosis:Hypertension, DM, HLD.Alert and oriented ×1.

Depressed crying all the time.Psy consult ordered.

Room air.Telepsy done met criteria for Psychiatric 5150 hold.

5150 hold documents in the chart.(To qualify for SNF Psychiatric patient must be able to ambulate without assistive device.)

Generalized weakness. Person assist to bedside commode.

D5NS @ 75ml/hour right forearm 20guage clean, intact and dry.

Laboratory values:

WBC 13.5H.

H/ H 12.0/38.9%.

NA: 140.

K: 4.2.

SEPTIC PANEL (+).

Allergy: Norco (rash).

Accucheck Qac/ Qhs.

Diet : Cadiac Heart health diet.

Mechnical soft.

Glucerna shake 1can tid.

Is patient at risk for fall: Yes.

Fall precaution protocol maintained.

Do you have an advance Directive: No.

Copy of advance Directive on the chart. Medications:

Vancomycin 1gm IV Q12hours.

Zosyn 3.375gm IV Q8hours.

Rocephin 1gm IV Q24hours.

Meformin 750mg po Qam.

Seroquel 100mg po Qpm.

Tylenol 650mg po Prn Q4hours pain/ temperature.

Plan:

Skilled Nursing Psychiatric facility when medically stable.

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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