515 CASE SCENARIO. PNEUMONIA.

KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000.INTERDISCIPLINARY KARDEX.

Age/Sex 34years F.

Account number V006543294.

MR #V000058867526.

Admission date:04/09/2021@08am.

Status: Inpatient admit.

Location MedTelemetry.

Room 42121.

Attending doctor: Tomtom Worry.

Patient name: Agitate Woods.

Resuscitation Status: Full code.

Primary diagnosis: Pneumonia.

Secondary diagnosis: Fever, Coughing, generalized body ache and pain,Hypertension. + Amphetamine/ Meth,+ Cannabinoids (THC).Right breast mass.

Allergy : NKDA.

Weight 185lbs.

Height :5feet 8inches.

Isolation Status: Standard Precautions.

Risk for fall: No.

Skin intergrity impaired: No.

Suicidal risk: No.

Patient belongings with the patient.

Do patient have advance Directive: No.

Copy of advance Directive on the chart.

Diet : Regular diet.

Transportation: Wheelchair.

Doctor orders: 02@ 2liter NC.

CT Scan of the chest to r/o Embolus.

Ultrasound right breast .

0.9NS @75ml/hour rt forearm 20guage clean/Patent/Intact.

Levaquin 750mg IV Q24hours.

Flagyl 500mg IV Q8hours.

RT treatment Q6hour with DuoNeb.( Due to bronchospasm) Duoneb is use for the treatment of the narrowing of the airway usually adminster by the respiratory therapists per doctor orders.

Follow your facility policy and procedures.

Lovenox 30mg SubQ Q24hours.

COW protocol Q4hours.

Laboratory results:

WBC 8.5.

H/H:13.0/40.0.

NA:136.

K:3.7.

CA+:11.8.

Urinalysis: Yellow urine,Clarity turbidity:Specific gravity: 1.032.(H)Large blood in the urine ( Due to menstruation)+Bacteria.

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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