533 Case Scenario.Right Foot Incision and Drainage.


Account number : Q006115328.

MR #Q006115328.

Date of admission 09/21/2020 @03am.

Location MedTelemetry.

Room 42114.

Attending doctor Tommy Holbib.

Patient name: Watera Woods.

Resuscitation Status Full code.

Primary diagnosis Right foot wound.S/P Incision & Drainage.

Secondary diagnosis: Hypertension, DM, Chronic Renal disease.

Allergy: NKDA.

Weight 185lbs.

Height: 5feet 6inches.

Isolation Status: Contact Isolation ( MRSA of wound)

Controlled cardiac diet.

Doctor orders: Heparin 5000units subQ daily. Multivitamin 1tablet po 09am scheduled.

Colace 100mg po Bid.

Asorbic acid 500mg po Bid 09am, 2100 scheduled.

Zinc sulfate 220mg po 09am scheduled. Vitamin A 10000IU 09am scheduled.

Metroprolol 100mg po 09an Daily .

Norvasc 10mg po 09am.

Zocor 1tablet po 09am scheduled.

Vancomycin 1gm IV Q24hours.

Zosyn 3.375gm IV Q8hours.

0.9NS Flush 10ml Q8hours.

0.9NS @ 50ml/hour 20guage clean/ Patent / Intact.

Norco 1tablet po Q4hours prn pain.

Enalapril Maleate 5mg po Bid scheduled.

Morphine sulfate 2mg IV Q6hour prn severe pain.

Insulin Human Lispro 6units SubQ 0630am,and 1130am.

Accucheck Qac + Qhs.

Insulin Human Regular.

50 to 150 = 0unit.

151 to 200 =1unit.

201 to 250 = 2units.

251 to 300 =3units.

301 to 350 =4units.> 400 call the doctor.

Vital signs Q4hours.

Wet to dry dressing Bid.

Case manager consult. Infection disease consult. Discharge plans:

Discharge to Skilled Nursing Facility when medically stable.

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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