A 65years old female comes in to Emergency room with CVA with deficit, alert and oriented x 2.Urinary track infection, cellulitis around the G Tube.Transaminis. Weight 160lbs,Height 5feet 6inches.High risk for fall. Side rail up x2,patient close to nursing station. Contact Isolation.Full code, no suicidal risk .02 at 2liter nasal canula. Skin integrity impaired. Transportation method bed.Strict NPO.G Tube to be replaced in two days.Allergy to vancomycin. D5NS at 100ml/hr.Zosyn 3.378gm IV Q8hours.Zyvox 600mg IV Q24HOURS. Motrin 400mg po Q6hours prn temperature. Morphine sulfate 2mg IV Q4hours prn severe pain. Pantoprazole 40mg IV QAMAC. Norvasc 10mg po Qdaily. Laboratory results Hgb 12,Hct 39.WBC 10.5,K level 3.4 replaced.Na 138.Magnesium 1.8.Ca+ 9.0.Raise the head of bed up.Do not keep it lowered. Keep the patient comfortable. Raise side rail for patient safety. Place the call light within patient reach and also patient belongings within reach. Patient is given bedbath as ordered. Make sure that the bath water is changed frequently as it gets cooler or soapy.Patient is reposition frequently for comfort and pressure redistribution. Some of these patient care can be delegated to the certified Nursing assistant working with the Registered nurse.
GOALS DURING HOSPITALIZATION.
The Goal will be patient joint and strength mobility maintenaned during hospitalization. Cellulitis around the G Tube healed clean and dry.Patient willing and ready to learn new skills to help herself to independent.
Discharge plans.
Discharge home with home health when medically stable.
Nurses You Move Me 