509 CASE SCENARIO. ABDOMINAL PAIN/ ETOH WITHDRAWAL.

KINGDOM OF GOD HOSPITAL LOS ANGELES ,CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex : 65years old man.

Account number : Q004215328.

MR # Q00099593422.

Admitted : 09/03/2021.

Status: Inpatient admit.

Attending doctor : Tommy Holbib.

Patient name : Bulley Bathurste.

Location: General Surgery.

Room : 62114.

Resuscitation status: Full Code.

Weight: 198lbs.

Height: 5feet 9inches.

Allergy: NKDA.

Primary diagnosis: Abdominal pain/ Etoh withdrawal.

Secondary diagnosis: Hypertension, high cholesterol, Etoh.

Isolation Status:

Standard Precautions.

Is patient at risk for fall: Yes.

Do you have an advance Directive: No.

Copy of advance Directive on the chart.

Diet: Cadiac Heart health diet.

Transportation: Bed.

Skin intergrity impaired: Yes.

02 2liter NC.

Suicidal risk :No.

Family support. Jenny Moody( mother)

Alert and Oriented ×2.

Noncompliance with plan of care.

Doctor Orders:

CT scan of abdomen ( showed Fatty liver)

CIWA PROTOCOL.

Ativan 1mg iv Q8hours prn agitation.

Ativan 2mg IV Q6hour withdrawal.

Ativan 1mg po Q8hours prn agitation.

Dilaudid0.5mg IVQ3hoursprn pain.

Phenergan 12.5mg IM Q6hours prn Nausea and Vomiting.

Zofran 4mg IV Q4hours prn nausea/Vomiting. Metoprolol 10mg po daily.

Hctz 12.5mg po daily.

Norco 5/325mg 2tablets po Q6hours prn pain. Norco 1tablet po Q4hours prn pain.

BOLUS ×1.0.9NS at 75ml/hour rt forearm. Laboratory tests:

CBC with differential, Chem 7,LFT in am.

Urinal at bedside.

Incontinent of bowel and bladder.

Laboratory results:

K=3.8,WBC=4.8,H/H =14.6/43.5.NA= 138

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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