KINGDOM OF GOD HOSPITAL LOS ANGELES, CALIFORNIA 900000.INTERDISCIPLINARY KARDEX. Age/Sex 65years old female.
Account number :Q000634342.
MR # Q00069593424.
Admitted date: 08/21/2020.
Status : Inpatient admit.
Attending doctor: Tomtom Worry.
Location: MedTelemetry.
Room : 42121.
Resuscitation Status: Full code.
Primary diagnosis Right Femur Fracture due to fall.
Secondary Diagnosis: Chronic pain, Hypertension, DM, Depression, HLD.
Isolation Status: Standard Precautions.
Risk for fall?. Yes.
Suicidal risk: No.
Do you have advance Directive?.No.
Copy of Advance Directive on the chart.
Diet: Cardiac heart health diet.
Height: 5ft 8inches.
Weight: 185lbs.
Allergy:NKDA.
Medications 💊Reconciliation done.
Skin intergrity impaired:Yes.Monitor for skin breakdown. Reposition frequently for pressure redistribution.
02 @ 2liter NC.
Doctor orders: Surgery today:Closed Reduction Retrograde IM Nailing right femur by doctor Good Blessings.Consent signed.
Incision Anterior Right leg.
Right leg dressing from knee to lower 🦵leg moderate swelling.Right leg elevated on two pillows. SCD to left lower extremity.
Lactated Ringers @ 125ml/hour. 18guage Clean/Dry/Patent.
Dilaudid 1mg IV Q3hours prn pain.
Norco 10/325mg 2tablets po Q4hours prn pain.
Ativan 1mg iv Q8hours prn agitation.
Zofran 4mg IV Q4hours prn nausea/Vomiting.
Uses Urinal .
Ancef 2gm IV Q8hours x3 first during Surgery at 11am,second dose @ 1900 and third dose to be given at 03am.
Accucheck: Qac/Qhs.
Transportation : Bed.
Good Family Support: Mr :Godwin Dontliketrouble.phone number: 939-000-0000.
Felicia Lookings : 676-000-0000.
Laboratory results:
WBC: 8.5.
H/H 13.0,39.2.
K=4.0.
NA: 140.
Magnesium 2.0.
Nurses You Move Me 