523 CASE SCENARIO.PAIN MANAGEMENT.

Normally pain is relief through medication that will aim at altering sensory transmission to the cerebral cortex. Nonnarcotic is use for mild to moderate pain.Narcotic such as Norco 10/325mg ,morphine, dilaudid are use for moderate to severe pain. Pain pills are often use for chronic pain as in this case scenario. The general principles of pain control for the young and old are the same except in dosages.The older adults have decreased in their metabolism and excretion so when in doubt ask questions.

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

Age/Sex 35years male.

Account number V006543698.

MR # V00058867029.

Admission date 04/01/2022@ 09am.

Status: Inpatient admission.

Attending doctor : Tommy Holbib.

Patient name: Breada,Bacone.

Location: General Surgery.

Room: 62114.

Resuscitation status: Full Code.

Allergy: NKDA.

Weight: 150lbs.

Height : 5feet 7inches.

Alert and oriented x4 .

Primary diagnosis: Pain management.

Secondary diagnosis: Ride side weakness,Hypertension.

Noncompliance to plan of care.

Right side flaccid.

Decreased sensation left side.

Isolation status: Standard Precautions.

Risk for fall: Yes.

Suicidal risk: No.

Do patient have advance Directive: No.

Copy of advance Directive on the chart.Diet Cardiac heart health diet. ( Food consistency regular,iced tea,no nuts)

Transportation method: Bed.

02 saturation: 97% on RA.

Doctor orders: Foley catheter for retention. Use bathroom for bowel movement with assistance. PT/ OT Evaluation and treatment complete.

Saline lock:

left forearm 20guage clean ,intact and patent.

Lovenox 40mg SubQ Q24hours.

Motrin 400mg po Q6hours mild pain.

Norco 1tablet 10/325mg po Q6hours prn severe pain.

Metroprolol 10mg po Qday.

Tylenol 650mg po Q4hours prn temperature. Ativan 1mg po Q8hours prn restlessness.

Laboratory tests:

CBC with differential and Chem in am.

Plan: Discharge to SNF. ( Currently no accepting SNF)

Uninsured ,applied for insurance. Authorization approval pending.

Support system: Parents.

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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