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INFLUENZA-LIKE ILLNESS - PROTOCOL ORDER FORM
PHYSICIAN ORDER
PATIENTS SEEN IN EMERGENCY DEPARTMENT WITH INFLUENZA-LIKE ILLNESS
DIAGNOSTIC TESTS
___ Pulse oximetry
___ Chest x-ray
___ Complete blood count with differential
___ Blood cultures: Gram stain, culture and susceptibility testing
___ Multivalent immunofluorescent antibody testing or PCR of nasopharyngeal aspirates or swabs
for common viral respiratory pathogens, such as influenza A and B, adenovirus,
___ Children: PCR of parainfluenza viruses, and respiratory syncytial virus
___ Adults with radiographic evidence of pneumonia: Legionella and pneumococcal urinary
antigen testing
___ Adults and children <5 yrs with radiographic pneumonia:
PCR for M. pneumoniae and Chlamydia Pneumoniae
___ Comprehensive serum chemistry panel, if metabolic derangement or other end-organ
involvement, such as liver or renal failure, is suspected
___ All of the following respiratory specimens should be collected for novel influenza A virus
testing: nasopharyngeal swab; nasal swab, wash, or aspirate; throat swab; and tracheal aspirate
(for intubated patients), stored at 4°C in viral transport media; and acute and convalescent serum
samples.
Admission Orders
___ Standard Precautions + Droplet Precautions.
IV solution:____________________________
Vital signs: ____________________________
O2: __________________________________
Activity: ________________________________
Diet: __________________________________
Medications:
Antivirals:
Antibiotic:
Home Meds:
Antipyretic:
Nurse Signature: _______________________________________
Date: __________________________________________
Fax this order form to Pharmacy.
Developed 10/06
Place Patient Label Here
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