10/1/2010
1548
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Admit to medical unit, diagnosis pneumonia
condition fair
nkda
VS q4 hr, I&O
BR with BRP
Dietary consult - diet as tolerated
Blood Cultures x 2
CBC
BMP
Sputum - Gram stain, C&S
UA
CXR - PA/Lat
EKG
SpO2 q shift
O2 to keep O2 sat greater than 90% per O2 protocal
Xopenex 1.25mg by HHN q4 hrs PRN difficulty breathing, wheezing, or desaturation
Azithromycin 500 mg IV q24 hrs
ceftriaxone 1 gm IV q24 hrs
Zofran 4mg IV q6 hrs PRN nausea or vomiting
SL - routine and prn flushes
Resume home med - Protonix 40 mg PO daily
Tylenol gr. X q4 hrs prn temp. > 101
guafenesin 2 teaspoons q4 hrs PRN cough
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10/1/2010
1654 |
DVT
Prophylaxis Protocal - Lovenox 30mg SQ q24 hrs
PATIENT CATEGORY / RISK FACTORS:
Patient is >40 years old & no additional risk factor -
Mod risk
CBC, PT/INR, PTT before starting
Influenza vaccine: per Influenza Vaccination Screening & Administration Protocol
Pneumonia vaccine: per Pneumococcal Vaccination Screening & Administration Protocol
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