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

     

ER Orders

     

     

     

Lab:  CMP, Pt/INR, Ammonia, CBC with diff, Blood Cultures x 2 separate sites, UA and Urine Culture, Sputum Culture, Serum ETOH level, Urine Tox Screen

     

Permit for paracentesis

     

     

     

Gram stain, C & S on paracentesis fluid

 

 

 

 

 

 


date/time

orders

     

Discharge Orders

     

     

     

Discharge home in stable condition

     

Home health for assist with Medications, diet, and IV antibiotics administration

     

2 g sodium diet

     

discharge medications:
Aldactone 100 mg PO Daily
Lasix 40 mg PO Daily
Inderal 10 mg PO BID - hold if HR < 60, SBP < 100
MVI table PO Daily
Lactulose 30 mL PO Daily
Vancomycin 1 gram IVPB every 12 hours
Zosyn 3.375 grams IVPB every 6 hours

 

 

 

 

 

 

 

 

 

date/time

Physician’s Orders