Admission Orders Template For Primary Diagnosis Hospital-Acq

Question

Admission Orders Templateprimary Diagnosishospital Acquired Pneumonia Admission Orders Templateprimary Diagnosishospital Acquired Pneumonia Primary Diagnosis: Hospital Acquired Pneumonia Status/Condition: Hemodynamically stable Code Status: Full Code Allergies: NKA Admit to Unit: Telemetry Diet: Cardiac diet IV Fluids: Sodium Chloride 0.9% 1,000 ml IV continuous at 100 ml/hr Critical Drips: No critical drips at this time Respiratory: 4L nasal cannula to maintain oxygen saturation above 96% continuously; oxygen saturation monitoring (oxymetry) Medications: Discontinue Ciprofloxacin Start Piperacillin/Tazobactam 4.5 mg IV every 6 hours Tobramycin 5 mg/kg IV every 24 hours Vancomycin 15 mg/kg IV every 12 hours Continue lisinopril 10 mg orally twice daily (home dose) Lovenox 40 mg subcutaneously daily Laboratory and Microbiology: After culture results, blood and sputum reports with sensitivity to piperacillin/tazobactam will determine further management. If sensitivities confirm activity, discontinue Tobramycin and Vancomycin, and continue piperacillin/tazobactam to complete a 10-day course. Nursing Orders Vital signs every 4 hours; pulse oximetry continuous; weigh patient upon admission; reorient PRN; intake and output every shift; assess IV site every shift; cardiac monitoring on telemetry for 24 hours with re-assessment; obtain consent for procedures as needed; implement bleeding precautions; fall precautions; bathroom privileges with assistance; repeat blood cultures and sputum specimens; placement of PICC line; consult case management and social work for potential discharge home with Home Health services to complete the antibiotic course. Follow-Up Laboratory Tests Chest X-ray Chest CT Complete Blood Count (CBC) Comprehensive Metabolic Panel (CMP) Repeat blood and sputum cultures Consultations Infectious Disease specialist for antibiotic management Physical Therapy Endocrinology for management of hypothyroidism, as patient is not taking medication at home Patient E

Dr. Jack HW Helper · Accepted Answer

Admission Orders Templateprimary Diagnosishospital Acquired Pneumonia Admission Orders Templateprimary Diagnosishospital Acquired Pneumonia Primary Diagnosis: Hospital Acquired Pneumonia Status/Condition: Hemodynamically stable Code Status: Full Code Allergies: NKA Admit to Unit: Telemetry Diet: Cardiac diet IV Fluids: Sodium Chloride 0.9% 1,000 ml IV continuous at 100 ml/hr Critical Drips: No critical drips at this time Respiratory: 4L nasal cannula to maintain oxygen saturation above 96% continuously; oxygen saturation monitoring (oxymetry) Medications: Discontinue Ciprofloxacin Start Piperacillin/Tazobactam 4.5 mg IV every 6 hours Tobramycin 5 mg/kg IV every 24 hours Vancomycin 15 mg/kg IV every 12 hours Continue lisinopril 10 mg orally twice daily (home dose) Lovenox 40 mg subcutaneously daily Laboratory and Microbiology: After culture results, blood and sputum reports with sensitivity to piperacillin/tazobactam will determine further management. If sensitivities confirm activity, discontinue Tobramycin and Vancomycin, and continue piperacillin/tazobactam to complete a 10-day course. Nursing Orders Vital signs every 4 hours; pulse oximetry continuous; weigh patient upon admission; reorient PRN; intake and output every shift; assess IV site every shift; cardiac monitoring on telemetry for 24 hours with re-assessment; obtain consent for procedures as needed; implement bleeding precautions; fall precautions; bathroom privileges with assistance; repeat blood cultures and sputum specimens; placement of PICC line; consult case management and social work for potential discharge home with Home Health services to complete the antibiotic course. Follow-Up Laboratory Tests Chest X-ray Chest CT Complete Blood Count (CBC) Comprehensive Metabolic Panel (CMP) Repeat blood and sputum cultures Consultations Infectious Disease specialist for antibiotic management Physical Therapy Endocrinology for management of hypothyroidism, as patient is not taking medication at home Patient E

Admission Orders Template For Primary Diagnosis Hospital-Acq

Admission Orders Templateprimary Diagnosishospital Acquired Pneumonia

Nursing Orders

Follow-Up Laboratory Tests

Consultations

Patient Education and Health Promotion

Discharge Planning and Follow-Up Care

References