514 CASE SCENARIO. LEFT LOWER EXTREMITY CELLULITIS.

KINGDOM OF GOD HOSPITAL LOS ANGELES, CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex : 34years Female.

Account number : Q005634374.

MR # : Q00058867522.

Admission date : 09/22/2021.

Status: Inpatient admit.

Location : General Surgery.

Room : 62113.

Attending doctor : Tommy Holbib.

Patient name : Isaac,Jenniferi.

Resuscitation: Full code.

Primary diagnosis: Left leg Cellulitis. Secondary diagnosis: Sunburn left calf.(Cellulitis is a common skin infection caused by bacteria)

Back of leg pain/ redness/ warmth/ swelling.

Whipping left leg.

Weight : 170lbs.

Height: 5feet 6inches.

Isolation Status: Standard Precautions.

Is patient at risk for fall: No.

Suicidal risk: No .

Impaired skin intergrity: Yes.

Language barrier: English.

Do patient have advance Directive: No.

Copy of advance Directive on the chart.

Diet : Cardiac heart health diet.

Allergy: NKDA.

Doctor orders: Vancomycin loading dose 1.5gram x1 now.

Blood culture ×3 before antibiotics stat.

Vancomycin 1gm IV Q8hours × 7days.

0.9NS @ 50ml/hour IV, Right forearm 20guage clean/Patent/Intact.

Norco 1 tablets 5/325mg po prn Q4hours moderate .

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

Colace 200mg po Bid.

Dry dressing change Q8hours and prn.

Morphine 2mg IV Q6hour prn severe pain. Laboratory tests @ 05am.

Laboratory Results:

WBC 8.5.

H/H 11.1/36.0.

NA= 140.

K=4.1.

Discharge plan:

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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