Pt. name:  Dale Mayman                        Admitting Physician:   Dr. S Phillips       
Age: 51                                           DOB: 11/13/xx                             Bed: ER Bed 2
Admitting diagnosis: Confusion bleeding gums
Pt. ID # 542768                                                Med Rec #:  78543
Wt. lbs: 172  kg: 78                 Ht.: 71 inches                                 Race:Caucasian
Major Support:  Wife                                                                      Religion:Not stated

Immunizations: current
Allergies: Ace inhibitors (angioedema)

 
Nursing Map of Care
Complete Patient Assessment
Physician Orders
date/time

orders

8/01/2013
1548

Physician’s Orders

  1. Begin Morphine Sulfate 2mg. SL every four hours for pain and dyspnea.
  2. Begin breakthrough dose of Morphine Sulfate 1mg, SL hourly as needed for pain and dyspnea.
  3. Begin Colace 200mg. PO daily at hour of sleep for prevention of constipation.
  4. May use Dulcolax 10mg. suppository rectally every three days as needed for constipation.
  5. Begin supplemental O2 at 2L/minute via nasal cannula as needed for dyspnea or shortness of breath.
  6. Begin Atropine ophthalmic drops 2 drops SL every four hours as needed for increased secretions/pharyngeal rales.
  7.  May use Atrovent inhaler 2 inhalations four times daily as needed for shortness of breath.