RIGHT FEMUR LEG FRACTURE DUE TO FALL.

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 šŸ’ŠReconciliation 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 šŸ¦µleg 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.

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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