Age/Sex : 53years old Female.

Account number :Q005634374.

MR # :Q00058867245.

Admission date: 07/13/2021 @08am.

Status: Inpatient admission.

Location :MedTelemetry.

Room 42114.

Attending doctor: Tommy Holbib.

Patient name: Sunflower Monday.

Alert and oriented x3.

Resuscitation Status :Full code.

Primary diagnosis Multiple Vessel CAD.( Goal of treatment is to reduce Angina snd heart failure symptoms)

Secondary Diagnosis: Hyperkalemia resolved ( K=3.9),Hypertension.

Type 2 Diabetes Mellitus,CHF, CRI.

Height : 5feet 6inches.

Weight: 156lbs.

Isolation Status: Standard Precautions.

Risk for fall: Yes.(Fall prevention protocol)

Do patient have advance Directive: No.

Copy of advance Directive on the chart.

Skin intergrity impaired: Yes.

Turn and reposition Q2hours and prn.

Doctor orders:

Diet : Carb Controlled cardiac heart health diet.

Bilateral lower extremities edema 2+.

Foley catheter to gravity keep for urinary retention.

Accucheck Qac/ Qhs.

Right groin angiogram ordered.Saline lock left orearm 20guage clean/ dry / Patent.

Zosyn 3.375gm IV Q8hours.

Carvedilo 6.25mg po Bid.

Plavix 75mg po Qday.

Lasix 40mg IVP Bid.

Protonix 40mg AMAC Po .

Bactrim 1600mg po daily.

Valsartan 160mg po daily.

Regular insulin per sliding scale.

BS 100 to 150 =0.

151 to 200 give 1uint of regular insulin.

201 to 250 ,give 2units.

251 to 300,give 4units regular insulin.

301 to 350 give 5units.

351 to 400 give 6units.

Call and notify the doctor for blood sugar > 400.

Colace 200mg po Bid.

Morphine sulfate 2mg IV Q3hours prn moderate pain.

Morphine sulfate 4mg IV Q3hours prn severe pain .

Norco 1tablet 5/325mg po Q4hours prn mild pain.

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

Zofran 4mg IV Q4hours prn nausea/Vomiting.

Nitroglycerin 0.4mg sublingual UD/ prn.

Vital sign Q4hours + prn.

Laboratory test in am:

CBC with differential, Comprehensive Metabolic panel, Magnesium level, LFT.

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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