KINGDOM OF GOD HOSPITAL 🏥LOS ANGELES, CALIFORNIA 900000.
Age/Sex 65years old man.
Account number: Q006543299.
MR #: Q00098367543.
Admission date :06/13/21@04am.
Attending doctor: Greener Intent.
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)
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.
02@ 2liter NC.
Skin intergrity impaired: Yes.
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.