518 CASE SCENARIO. UROSEPSIS/ METASTASIC CA WITH METS.

KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000.INTERDISCIPLINARY KARDEX. Age/Sex : 65years old female.

Confused 2:1 sitter.

Account number : Q005634332.

MR # : Q00069593426.

Admitted date : 07/13/2020.

Weight : 201lbs.

Height: 5feet 6inches.

Location : MedTelemetry.

Room : 42110.

Attending doctor: Tomtom Worry.

Patient name: Mangala Georgia.

Primary diagnosis: Urosepsis,metastatic cancer with brain mets.

Secondary diagnosis: Hypertension, chronic Renal disease, lung,uterine cancer .

Allergy: PCN,Albuterol.

Transportation method : Bed.

02 at 4liters NC with Saturation 95%.( per 0730am report)

Resuscitation Status: DNR/ DNI.

Isolation Status: Standard Precautions.

Risk for fall: Yes. ( Fall prevention protocol in place)

Suicidal risk: No.

Do you have advance Directive: No.Copy of advance Directive on the chart.

Diet Cardiac heart health diet.( Poor appetite)

Doctor orders:

Dexamethasone sodium 4mg IVP Q6hours.( Treatment of inflammation such as redness, swelling, heat)

0.9NS @ 75ml/hour left leg patent/ clean/ Intact.

Ciprofloxacin 500mg Bid. 09am,2100.

Depakote 500mg po Bid.

Colace 200mg po Bid.

Fentanyl patch 100mcg Q3days.(chronic pain)

Pantoprazole 40mg po Amac.

Phenytoin extended release 300mg po Daily. ( Treatment of convulsion)

Meclizine Hcl 25mg po QID. (Prevent dizziness, nausea cause by motion sickness)

Heparin 5000units subQ daily.( blood thinner)

Morphine sulfate 4mg IV Q4hours prn pain. Zofran 4mg IV Q4hours prn nausea/Vomiting. Dilaudid 2mg IV Q3hours prn severe pain.

Norco 10/325mg 1tablet Q6hours prn mild to moderate pain.

Norco 10/325mg 2tablets po Q6hours prn severe pain 6/10level.

Acetaminophen 650mg po Q4hours temperature of >100.4.

Keppra 500mg po Bid.( To treat the onset of seizures)

Colostomy left abdomen. (Stool collection) Ileostomy connected to foley bag.( Drains urine)

Laboratory results:

WBC 8.5.

H/H 10.5,32.8.

Rbc 3.9.

K=3.7.

Na 135.

Vital signs: 08am bp 140/82,temperature 96%.Hr 65.Respiration 16.02 saturation 93%.

12noon: 130/84,96.8,Hr 75,02 sat 93%,Respiration 16.

Turn and reposition Q2hours for comfort and pressure redistribution. Bedbath daily and prn.Bedside rails up.

Plans:

Discharge patient home with wife when medically stable.

Discharge home with the following parameters: Home health nurse three times a week. Discharge with home oxygen.Continue with home medications upon discharge home.

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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