527 CASE SCENARIO, RETINA DETACHMENT.

Retina detachment is the coming apart of the retina from the choroid that is found at the back of the eye.This is due to the hole in the retina that will allow the vitreous humor to leak between the retina and choroid.

The causes can be internal changes in the Vitreous chamber due to old age or it can be due to other causes such as penetrating wound,contusion,severe fall,severe trauma. The end result could be total blindness.It starts gradually and the affected individuals will complain of floating spot that is in front of the eyes.Retina detachment requires surgical intervention to repair the hole and stop the leakage by Retina doctor.So it is very important to see your eye doctor immediately without any delay.

KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000.INTERDISCIPLINARY KARDEX. Age/Sex : 35years male.

Account number :V006243204.

MR # V004543294.

Admission date : 02/16/2022 @08am.

Status: Inpatient.

Attending doctor: Tommy Holbib.

Patient name: Jacob,Abram.

Location: MedTelemetry.

Room # 42114.

Resuscitation status: Full Code.

Weight : 158lbs.

Height: 5feet 6inches.

Allergy: NKDA.

Primary diagnosis:

Left Retina Detachment.

Secondary diagnosis: Hypertension, CVA, Hemiplegia,Chronic respiratory failure.

Risk for fall: Yes.( In sitter room,and siderails up x2)Total care patient.

Do you have an advance Directive: NO.

Copy of advance Directive on the chart. Isolation Status: Standard Precautions. Suicidal risk: No.

02 @ 2liter NC. Saturation 94%.

Respiratory therapist treatment Q6hour.

Transportation method: Bed.

Bilateral heel with myperlex.

Left 👁 redness, swelling, eye patch in place.Right side flaccid. Right side facial droopy.

Diet : NPO.( Possible dysphasia)

Incontinent of bowel and bladder.

Condom catheter in place.

Alert and oriented x2.

No family members at his bedside.

D545NS at 50ml/hour.

Left eye loss of vision.

Total care.peg tube in place.

Nutrition consult for recommendations. Ophthalmology consult.

Case manager consult for discharge plans, Social services consult.

Plans: Discharge to SNF ( Skilled Nursing Facility)

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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