KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000.INTERDISCIPLINARY KARDEX.
Age/Sex 79years old female.
Account number: Q004634313.
MR #Q00066867541.
Admission date 11/10/2021.
Status: Inpatient admit.
Location: General Surgery.
Room 62115.
Attending doctor: Tommy Holbib.
Patient name: Littlelove Holdme.
Resuscitation Status:Full Code.
Allergy NKDA.
Weight 135lbs.
Height 5feet 3inches.
Alert and oriented ×3.
Primary Diagnosis: Decubitus Ulcer left heel with eschar.
Secondary Diagnosis:Bilateral mastectomy, HTN,DM,Chronic Anemia.
Is patient at risk for fall: Yes.
Suicidal risk: Yes.
Language barrier: No.
Family Support: Daughter at her bedside 24/7.
Do you have an advance Directive: No.
Copy of advance Directive on the chart.
Diet Carb Controlled cardiac diet.
Doctor orders:
Turn and reposition Q2hours and prn.
0.9NS @ 75ml/hour.
Accucheck Qac and Qhs.
Humalog insulin (lispro insulin)per sliding scale: Bs =70 to 200 Zero coverage. 201 to 250 give 2units SubQ. 251 to 300 give 3units.301 to 350 give 4unit .350 to 400 call the doctor. ( Please follow the doctor orders and your hospital policy and procedures)
Vancomycin 1gm IV Q12hours.
Zosyn 3.375gm IV Q8hours.
Myperlex dressing to Buttocks discoloration.
Norco 5/325mg po Q4hours prn pain.
Tylenol 500mg po Q6hours prn fever. ( Patient can swallow a whole pill.Does not want her pills crushed)
Risk for skin breakdown. Keep left heel elevated on the pillows.
Laboratory tests :
CBC with differential and Chem 7 in am.
Continue to monitor vital signs Q4hours. Call MD for temperature 🌡>100.5.
Plan:
Discharge to SNF with Zosyn 3.375gm IV Q8hours.
Nurses You Move Me 