Age/Sex 65years old man.

Account number: Q006543299.

MR #: Q00098367543.

Admission date :06/13/21@04am.

Status:Inpatient admit.

Location: MedTelemetry.

Room: 42111.

Attending doctor: Greener Intent.

Patient name:

Lucky man, Daniel.

Resuscitation Status: Full code.

Primary diagnosis ETOH WITHDRAWAL, Abdominal Discomfort.

Secondary Diagnosis: Hypertension, DM, Alcoholism.

Isolation Status: Standard Precautions.

Is patient at risk for fall: Yes.

Fall prevention protocol in place.( Yellow gown,yellow armband, and yellow falling star in from of patient door)

Weight: 170lbs.

Height: 5ft 7inches.

Do you have an advance Directive: No.

Copy of advance Directive on the chart.

Diet: Liquid diet.

Sit in upright postion during meals.

Transportation method:Bed.

02@ 2liter NC.

Skin intergrity impaired: Yes.

Allergy: NKDA.

On CIWA Protocol ativan 1mg po given Q6hours.

CIWA 9,12 during this shift.

Side rails well padded.

Alert and oriented x2.

Noncompliance with plan of care.Takes off SCD and IV.

0.9NS @75ml/hr left forearm 20guage,patent/clean/dry.

Blood pressure slightly elevated 145/90.

Blood pressure medication:

Maxzide 25mg po daily.

Hctz 12.5mg po daily. Accucheck Qac/Qhs.

Uses urinal but sometimes incontinent.

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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