532 Case Scenario. Urinary Retention/ Fall Risk/C02 Retention.


Account number : Q005634362.

MR # :Q00058867594.

Admission date: 03/17/2021@0930am.

Status: Inpatient admission.

Location :MedTelemetry.

Room :42114.

Attending doctor :Tommy Holbib.

Patient name: Cigarette London.

Resuscitation Status: Full Code.

Allergy: NKDA.

Weight : 135lbs.

Height :5feet 6inches.

Primary diagnosis: Urinary Retention/ C02 Retention/Fall risk.

Secondary diagnosis: Hypertension COPD Exacerbation, Home 02,BPH,ETOH Abuse, Frequent flyer, Steroid dependent.

Isolation Status: Standard Precautions.

Is patient at risk for fall: Yes.

Fall prevention protocol in place- yellow gown,yellow armband, yellow socks, fall signs at the door, bed in low position, side rails up,call light within reach. Patient close to nursing station.

Transportation method: Wheelchair.

Suicidal risk: No.

Patient belongings are at his bedside.

Do patient have advance Directive: No.

Copy of advance Directive on the chart.

Diet : Cardiac heart health diet.

Doctor orders:

Discontinue Picc line and start peripheral access.

Saline lock left forearm 20guage clean/Patent/ Intact.

Respiratory treatment Q4hours + prn.

Flomax ( BPH)capsule 0.4mg po 09am scheduled.

Colace 200mg po Bid.

Norco 10/325mg 1tablet po Q4hours prn pain. Tylenol 650mg po Q4hours prn temperature. Zofran 4mg IV Q4hours prn nausea Vomiting. M0rphine sulfate 2mg IV Q6hour prn severe pain.

Metroprolol 10mg po Qday.

Foley catheter placed.

Discontinue Foley catheter 24hours after starting Flomax. Ativan 2mg IV Q6hour withdrawal symptoms.

Ativan 4mg po prn agitation.

Zosyn 3.375gm IV Q8hours.

02 4liter NC with Saturation 93%°F.

Front wheel walker.

Consultations: Pulmonary Consult.

Case manager and social worker consult.

BIPAP by Respiratory therapist .

Nurses note: Patient is Noncompliance with plan of care,a smoker and a drinker.No signs of withdrawal symptoms.

Laboratory tests:

WBC 11.5.

K: 3.7.

Na: 137.


Discharge plan:

Discharge to Skilled Nursing Facility when medically stable.

K placed ×1(20meqkcl)

Laboratory tests CBC in differential, Comprehensive Metabolic panel, liver functionpanel in 05am.

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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