KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000.INTERDISCIPLINARY KARDEX.
Age/Sex : 75years years old female.
Account number: Q005634372.
MR #: Q00069593424.
Admitted date : 09/16/2020 @09am.
Status: Inpatient admission.
Location : MedTelemetry.
Room : 42114.
Attending doctor : Tommy Holbib.
Patient name: Glady Rome.
Allergy: NKDA.
Height: 5feet 6inches.
Weight: 166lbs.
Resuscitation Status: Full code.
Primary diagnosis : Osteomylitis/Multiple Pressure ulcers on Coccyx,Right Buttocks,right Ishial.
Etiology: Multiple Pressure injuries.
Secondary diagnosis: Diabetes Type 2, Hypertension.
Isolation Status: Standard Precautions.
Risk for fall : No.Suicidal risk: No.
Do patient have advance Directive : No.
Copy of advance Directive on the chart.
Transportation method Bed.
Bilateral heel with myperlex dressing.
Doctor orders: Wound care consultation. Wound care team to evaluate and treat Wound. Zosyn 3.375gm IV Q8hours.
Reposition Q2hours and prn.
Vancomycin 1gm IV Q12hours.
Norvasc 10mg po 09am scheduled.
Zocor 20mg po 09am scheduled.
Colace 100mg po Bid.
Norco 5/325mg 1tablet po Q4hours prn moderate pain .
Norco 5/325mg 2tablets po Q4hours prn severe pain.
Morphine sulfate 2mg IV Q6hour prn severe pain.
Dilaudid 1mg IV Q8hours prn dressing change.
Zofran 4mg IV Q4hours prn nausea /Vomiting.
Tylenol 650mg po Q4hours prn temperature. 0.9NS @ 75ml/ hour right forearm 18guage clean/Patent/ Intact.
Levemir 10units SubQ 2100 scheduled. Accucheck Qac and Qhs.Sliding scales .
Give Regular insulin.Diet: Carb Controlled cardiac heart health diet.
Glucerna 1can TID.(poor appetite)
100 to 200= Zero insulin.
201 to 250 = 4uints.
251 to 300 = 6units.
301 to 350 = 8units .
351 to 400 = 9units + call the doctor.
Woundcare note : Right Buttocks wound measures 5cm x1.5cm × 1cm.
With 50% pink and 50% yellow sloughs.
10% Sersanganous Drainage ,peri wound area pink,and no wound odor.
Coccyx wound measures 5cm x3.5cmx4cm depth. Undermining present measuring 5.5cmx 7cm.Wound base is 56% non- granular tissue 45% yellow sloughs. Peri wound-pink.Stage 1V Pressure injury.
Right Ishial: Unstageable: Upper part is 100% Eschar.Lower part is 100% sloughs measuring 3cm ×2cm unstageable.Pictures in the chart.
Laboratory tests:
CBC with differential and Chem 7 in am.
Vigns Q4hours.
Follow doctor orders and your hospital policy and procedures.
Consultation:Wound care Consult.
Nutrition Consult.Swallow Evaluation. ( Pocket food in the mouth under her tongue.
Case manager consult for placement in 3days.
Nurses You Move Me 