KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000.INTERDISCIPLINARY KARDEX. Age/Sex 53years old Female.
Account number :Q006634322.
MR # :Q00063593429.
Admitted :01/05/2021.
Status : Inpatient admission.
Attending doctor : Tommy Holbib.
Patient name: Berlin Australia.
Location :MedTelemetry.
Room : 42114.
Resuscitation status: Full Code.
Weight:160lbs.
Height: 5feet 6inches.
Allergy: NKDA( No known allergy).
Primary diagnosis:Small Bowel Obstruction/ Etoh intoxication. (BAC level: 0.08%)
( Shaking with alcohol in her breath, could not spell her name)
Secondary diagnosis : Diabetes type 2,Anxiety disorder, depression, history of domestic violence,divorced three years ago.
Isolation Status: Standard Precautions.
Is patient at risk for fall: yes.
Fall prevention protocol in place.
Suicidal risk : No.
Transportation method : Bed.
02 at 2liter NC.
Do patient have advance Directive: No.
Copy of advance Directive on the chart.
Diet: NPO x ice chips.
Skin intergrity impairment risk : Yes.
Language barrier: No.
Doctor Orders:
Ngt to Low intermittent Suction.
Morphine sulfate 2mg IV Q3hours prn pain.
Reglan 4mg IV Q8hours.
Dilaudid 0.5mg IV Q4hours prn pain.
Zofran 4mg IV Q4hours prn nausea/ Vomiting. Accucheck Qac/ Qhs.
Ativan 2mg Q8hours.
CIWA Protocol.
Encourage ambulation.
CBC with differential, Comprehensive Metabolic panel, magnesium level in am.
Abdominal xray 1V PORT.
Nurses You Move Me 