508 CASE SCENARIO. SMALL BOWEL OBSTRUCTION/ ALCOHOL ABUSE.

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.

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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