513 CASE SCENARIO. AFTER DRINKING, FIGHT ENSUED,RIGHT INDEX FINGER BITE.

KINGDOM OF GOD HOSPITAL LOS ANGELES, CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex 35years male.

Account number V006543293.

MR #Q00068867511.

Admission date 01/02/2022.

Status : Observation.

Attending doctor:Tommy Johnjus.

Patient name: Ohio,Columby.

Location: General Surgery floor.

Room : 62114.

Resuscitation status: Full Code.

Weight : 152.

Height :5feet 3inches.

Alert and oriented x4.

Primary diagnosis: Fight bite.Septic joint. Secondary diagnosis: Ecchymosis throughout the right hand,abrasion right hand,pain, swelling, moves all fingers except the right index finger.Splint apply to right index finger and wrapped up.

Allergy : NKDA.

Is patient at risk for fall: No.

Do patient have advance Directive: No.

Copy of advance Directive on the chart.

Diet : Cardiac heart health diet.

Room air.

Transportation method: Wheelchair .

Risk of skin intergrity impaired:No

.Suicidal risk: No.

Patient belongings: With patient.

0.9NS @50ml/ hour,20guage,patent/clean/dry.

Left forearm.

Zosyn 3.375gm IV Q8hours.

Clindamycin 900mg IV Q8hours.

0.9NS flush 10ml Q8hours.

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

Morphine sulfate 2mg IV Q8hours prn.

Laboratory result:

WBC: 7.5.

H/ H 16.8/ 49.0.

K level :4.0.NA 138.

Vital signs Q4hours.

BP:116/75.

Hr 80.

Respiration:18.

02Saturation: 97% .

Room air.

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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