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.


Discharge to SNF with Zosyn 3.375gm IV Q8hours.

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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