Age/Sex 60years old man.

Account number: Q006115328.MR #Q00058867522.

Admission date 09/21/2022@06am.

Status : Inpatient admission.

Location Orthopedic Department.

Room # 52113.

Attending doctor Tommy Holbib.

Patient name Mohammede, Ismealle.

Resuscitation: Full Code.

Weight 158lbs.

Height 5feet 6inches.

Allergy NKDA.

Primary diagnosis MVA/ CONCUSSION FIBULAR FRACTURE. (He was crossing the street to get back to his car.Left fibular fracture none operable ,head laceration sutures removed, scab head,scrab right elbow,scab right knee.Right thrumb fracture is bent,thumb splint applied. Abrasion face,abrasion posterior elbow

Facial laceration

Surgery for right thumb will be at outpatient. Left L2 to L4 Transverse fracture). Doctor orders:

Case manager consult for placement.

Social worker consult.

Physical therapy/Occupational therapy. Ambulate with Physical therapy with Platform walker.

Secondary diagnosis: Hypertension, Hernia repair, hx of alcohol specifically red 🍷. Isolation Status: Standard Precautions.

Risk for fall:No.

Suicidal risk: No.

Patient belongings are at his bedside.

Do patient have advance Directive: No.

Copy of advance Directive on the chart.

Diet: Carb Controlled Diabetes diet.

Discharge plans:

Patient to be discharged to Skilled Nursing Facility.

Case manager faxed documents and awaiting acceptance.

Medications Reconciliation done.

Medications :

Tylenol 650mg po Q4hours prn temperature. Norco 1tablet 10/325mg po Q4hours prn moderate pain.

Morphine sulfate 4mg IV Q4hours prn severe pain.

Morphine sulfate 2mg IV Q3hours prn moderate pain.

Zofran 4mg IV Q4hours prn nausea/vomting.

Merem 1gm IV Q8hours.

Ancef 2gm IV Q8hours.

Carvedilo 6.25mg po at bedtime.

Colace 100mg po Bid.

Triamt/Hctz tablet 37.5/25mg (Generic for Maxzide-25mg Tablet)

Accucheck Qac/Qhs.

Insulin sliding scale. Humalog SubQ.

BS 0 to 150 zero insulin.

151 to 200 give 2units SubQ.

201 to 250 4units.251 to 300 give 6units.

301 to 350 give 8units.

351 to 400 give 10units SubQ of Humalog and call the doctor.

Skin intergrity impaired: yes.

Provide Frequent Reposition.

1.If your patient is in sitting position,reposition atleast every hour(Q1hour) so that the point under pressure will be shifted and pressure redistribution. As a healthcare professional you must consider posture alignment, weight distribution, stability and pressure relief while positioning.

2.Avoid Donut-type devices during sitting positions because donut device will cause more pressure on the patient. You should select a cushion based on a required needs of the patient who needed pressure reduction when in a sitting position. If this cannot be achieved place the patient back in bed.Encourage the patient to redistribute their weight if they can be shifting their weight every 15minutes.

3.Keep the head of bed 🛌at the level ordered by the doctor ( lowest position)or contraindicated by the doctor. You should use overhead Trapeze to help reposition patient in bed or other devices such as the draw sheet.

4.Keep patient leg active but please do not massage.

5. Provide adequate nutrition. Patient should eat plenty of nutritious meals and drink plenty of water and other fluids to keep patient hydrated. 6.Monitor intake and output. Keeping track of what the patient eat and patient ability to control urination and bowel movements.

7.Keep patient clean at all times. Give regular sponge bedbath, bathtub or shower if possible. Follow doctor orders.

8.Avoid rubbing reddened areas over the bony prominence

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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