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PNEUMONIA ORDERS
Page 1 of 2

DATE _________________________________________________ Time _____________________________________
1. Admit to Service of ______________________________________________________________
2. Allergies: ____________________________________________________________________________________
3. Admit to:
4. Diagnosis:
Additional Diagnoses: ___________________________________________________________________________ 5. Condition:
6. Code Status:
7. Nursing Documentation:
Other______________________________________ Daily Weights (kg) / I&O and record on admission and daily. Saline lock or IV fluids: ____________________________________________________________________ 9. Activity:
10. Diet:
11. Fluids:
Fluid Restriction _________________ml/day 12. Medication Choices:
Pharmacy to dose all medication for creatinine clearance. Ceftriaxone (Rocephin) 1 gram IV every 24 hours and Doxycycline 100mg every 12 hours
Other ________________________________________________________________ Other ________________________________________________________________ Acetaminophen 650 mg orally every 4 hours prn temp greater than 100.5 F or mild pain / headache not to Other______________________________________________________________________ Milk of Magnesia 1-4 tablespoons orally every day – titrate to soft stools Other__________________________________________________________ Other_________________________________________ Other_________________________________________ Continued on page 2
8761-EH03 (12-16-08)


PATIENT LABEL
PNEUMONIA ORDERS
Page 2 of 2
Other : _______________________________________________________________________________________ Other : _______________________________________________________________________________________ Other : _______________________________________________________________________________________ Other : _______________________________________________________________________________________ Other : _______________________________________________________________________________________ Other : ________________________________________________________________________________-______
14. Diagnostic Studies:
15. Admit Lab:
Blood Cultures x2, 15 minutes apart from different sites, prior to antibiotics Sputum gram stain and culture. If patient not able to provide sample within 15 minutes, RT to induce with 2.5 mg Albuterol in 2.5cc normal saline. If patient cannot provide a sample within 30 minutes, consider nasal Other ____________________________________________________________________________ 16. Lab in AM: _______________________________________________________________________________________

17. Respiratory:
O2 __________________________________________________________ SVN with Albuterol + 2.5 mg QID / PRN or
SVN with/2.5 mg Albuterol + 0.5 mg Atrovent QID / PRN Advair 100/50 1 click every am or
Other: ________________________________________________________________________________________
18. Assessments/Consultations:
Other ___________________________________________ Smoking cessation counseling/education if patient smoked in last year 19. Discharge planning:
_______________________________________________________________________________________ Physician’s Signature PATIENT LABEL

Source: http://www.carsontahoe.com/imgUpload/PDF/8761-EH03PneumoniaOrders12-16-08.pdf

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