Pneumonia

Please note the template added is almost complete Please add supporting literature with 4 references/ Citations APA styleUsing the Required Admission Orders Template, write a full set of admission orders for the patient in the branching exercise. MY ORDERS ARE ENTERED IN THE TEMPLATE ANY RATIONALE MUST BE ENTERRED AFTER MY ORDERS

  • Be sure to address each aspect of the order template
  • Write the orders as you would in the patient’s chart
  • Make sure the order is complete and applicable to the patient
  • Any rationale you feel the need to supply should be done at the end of the order set – not included with the order
  • Please do not write per protocol. We do not know what your protocol is and you need to demonstrate what is appropriate standard of care for this patient.
  • A minimum of four current, evidenced based references are required – no older than 5 yearsAdmission 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):

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