KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000.INTERDISCIPLINARY KARDEX. Age/Sex 53years old Man.
Account number :Q005634572.
MR #: Q000495934293.
Admitted date :09/12/2020 @0450am.
Status: Inpatient.
Location: Med Telemetry.
Room:42111.
Attending doctor :Hussein Andersona.
Patient name: Banana Yorke.
Resuscitation Status: Full Code.
Weight :152.
Height :5feet 6inches.
Primary diagnosis Multiple Rib Fractures/ Left Chest Tube.(Closed head injury without intracranial Pressure) Clavicle and elbow dislocated, ribs fractures, hemopneumothorax,left rib plating. VATS,left Thoracotomy.
Open Thoracotomy is considered a major surgical intervention use for the treatment of pneumothorax. It requires general anesthesia and the application of endotracheal tube.
It could be single or double insertion and the patient will be under mechanical ventilation for the duration of the procedure. Management of pain is very very important and requires system or epidural analgesia.Patient will be properly positioned and secured in order to provide adequate exposure of the thoracic cavity.
Thoracotomies are performed are performed with patient in lateral Decubitus position.It is important that care should be taken to prevent injuries that might happen during positioning.
VATS: This is a Video assisted Thoracoscopic Surgery.It is a minimally invasive surgical technique used to diagnose and treat problems in your chest.
During the procedure a tiny Camera (thoracoscope)and surgical instruments are inserted into your chest through one or more small incisions in the chest wall.
SCD: Bilateral lowerExtremity,
Left Chest tube)
NWB.
PT/ OT NWB to bilateral lower extremities.
Consultation done.
02 at 3liter NC.
Transportation Method: Bed.
Skin intergrity impaired: Yes.
Suicidal risk: Yes.
Language barrier: No.
Doctor Orders: CBC with differential, Comprehensive Metabolic panel in am.
Norco 10mg/325mg 1tablet po prn moderate pain .
Norco 10/325mg 2tablets PO Q6hours prn severe pain.
Zofran 4mg IV Q4hours prn nausea Vomiting.
Morphine sulfate 2mg IV Q3hours prn moderate pain.
Morphine sulfate 4mg IV Q3hours prn severe pain.
Colace 100mg po Bid.
Zosyn 3.375gm IV Q8hours.
Secondary diagnosis:
Hypertension
Isolation Status: Standard Precautions.
Is patient at high risk for falls: No.
Language Barrier: No.
Do you have Advance Directive: No.
Copy of advance Directive on the chart.
Diet Cardiac heart health diet.
Discharge plans:
Discharge home to wife in 48hours with home health nurse if medically stable.
Nurses You Move Me 