Admission Orders Template

 

 

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 100 ml / hr

 

· Critical Drips : No critical drips at this time

 

Respiratory: 4L nasal cannula to maintain O2 above 96% continuous Oxymetry

 

Medications:

Discontinue Ciprofloxin

Start piperacillin/ tazobactam 4,5 mg IV every 6 hours

Tobramycin 5 mg/ kg IV every 24 hours

Vancomycin 15 mg/kg every 12 hours

Continue lisinopril 10 mg oral twice a day home dose

Lovenox 40 mg daily subcutaneously

 

After culture receiving, blood and sputum report with sensitivity to piperacillin/ tazobactam:

Discontinue:

Tobramycin 5 mg/ kg IV every 24 hours

Vancomycin 15 mg/kg every 12 hours

Continue piperacillin/ tazobactam 4,5 mg IV every 6 hours to complete 10 day treatment.

 

 

 

Nursing Orders : Vital Signs every 4 hours, Pulse Oximetry continuous, Weigh patient once upon admission, reorient PRN, Intake and Output every shift, Assess IV site every shift, Cardiac monitoring in telemetry floor for 24 hours and re- assess, Consent for treatment as needed, bleeding precautions, fall precautions, bathroom privileges with assistance times 1. Repeat blood cultures and sputum, PICC line placement, consult case management and social worker for possible discharge home with Home Health for completion of the 10-day course antibiotics.

 

 

Follow-Up Lab Tests:

 

· Diagnostic testing : Chest X-ray, Chest CT, CBC , CMP, Blood and sputum cultures

Consults: Infection Disease for antibiotic management , Physical therapy, Endocrinologist for hypothyroidism as patient is not taking medication at home.

 

Patient Education and Health Promotion (address age-appropriate patient education. if applicable): Cardiac diet due to hypertension, antibiotic management at home.

 

Discharge Planning and Required Follow-Up Care: Primary care Provider within one week after discharge

 

References (minimum of three timely references that prove this plan follows current standards of care):