Name:______________________________
DOB:______________________________
Generic equivalents are utilized unless checked.
l CORE MEASURE REQUIREMENTS
Physician Name(s)
Status
Admit to Dr.______________________________
Inpatient
Observation
Code Status
Code Status:________________________________________________________
Location
_________________________________________________________________
ICU
Telemetry
Medical
Other
Old chart to floor with patient.
Diagnosis
Community Acquired Pneumonia ( CAP )
Healthcare Associated Pneumonia ( HAP )
Condition
Good
Serious
Fair
Critical
Nursing Interventions
Vital Signs
Per unit Protocol
Other:_______________________
Activity
Bed Rest
with bedside commode
with bathroom privileges
Out of bed with assistance
Ambulation
Fall Prevention
Monitor
Pulse oximetry per unit routine and record
Interventions
Strict Recording of Intake and Output record
Daily weights (chart results)
Aspiration Precautions
Transcribed
Noted / Acknowledged
Signature
Telephone Order(TOR)
Date / Time
Signature
PHYSICIAN INITIALS
Date / Time
DATE / TIME
Originated 2010
rev Pneumonia Admission Orders Pg 1 of 4 public
Revised 5/12/11
Name:______________________________
DOB:______________________________
Generic equivalents are utilized unless checked.
l CORE MEASURE REQUIREMENTS
Respiratory Therapy
Respiratory Therapy per protocol
Oxygen ______________ Liters
Atrovent 0.5 mg nebulizer every ______ hours
Albuterol 2.5mg nebulizer every ______ hours
Atrovent 0.5 mg nebulizer every ______ hours PRN Shortness of Breath / Wheezing
Albuterol 2.5mg nebulizer every ______ hours PRN Shortness of Breath / Wheezing
Diet
Regular
Nothing by mouth except for medications
Cardiac Diet
American Diabetes Association_________kCal
IV Fluids
Saline lock with 3 mL Normal Saline flush every 12 hours
IVF:________________________ with __________ milliequivalents Potassium
Chloride (KCL) / liter at ___________mL / hour times __________ hours
Any other IV fluids:______________________________________________
Medications
Protocols
l
Smoking Cessation Education Materials
Scheduled
CAP Non - ICU
Antibiotics
PCN allergy:
(may choose one)
l
Rocephin ( cefTRIAXone ) 1 gram IV piggyback every 24 hours PLUS Zithromax
(azithromycin) 500 mg PO every 24 hours
l
Rocephin ( cefTRIAXone ) 1 gram IV piggyback every 24 hours PLUS Doxycycline
100mg PO every 12 hours
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Levaquin ( levofloxacin ) 750 mg IV piggyback every 24 hours ( may change to PO
when tolerating diet )
CAP ICU Admission
(may choose one)
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Rocephin (cefTRIAXone) 1 gram IV piggyback every 24 hours PLUS Zithromax
(azithromycin) 500 mg IV piggyback every 24 hours
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Rocephin (cefTRIAXone) 1 gram IV piggyback every 24 hours PLUS Levaquin
(levofloxacin) 750 mg IV piggyback every 24 hours
Send blood cultures times 2 if not collected in ER
Transcribed
Noted / Acknowledged
Signature
Telephone Order(TOR)
Date / Time
Signature
PHYSICIAN INITIALS
Date / Time
DATE / TIME
Originated 2010
rev Pneumonia Admission Orders Pg 2 of 4 public
Revised 5/12/11
Name:______________________________
Generic equivalents are utilized unless checked.
l CORE MEASURE REQUIREMENTS
Aspiration Pneumonia
DOB:______________________________
(may choose one)
Zosyn ( Piperacillin and Tazobactam ) 3.375 grams IV piggyback every 6 hours
Cleocin ( Clindamycin ) 600mg IV every 6 hours
PCN allergy:
Healthcare Associated Pneumonia (may choose one)
Zosyn ( Piperacillin and Tazobactam ) 4.5 grams IV piggyback every 6 hours PLUS
Levaquin ( Levofloxacin ) 750 mg IV piggyback every 24 hours ( Pharmacy to adjust
renal dosing )
Doripenem ( Doribax ) 500mg IV piggyback every 8 hours PLUS Levaquin
(levofloxacin) 750mg IV piggyback every 24 hours ( Pharmacy to adjust renal dosing )
PCN allergy:
MRSA Suspected
Vancomycin ( Vancocin ) 15mg / kg IV every 12 hours ( Pharmacy to adjust )
VTE Prophylaxis
Lovenox (enoxaparin) 40 mg Subcutaneous every day
OR if Creatinine Clearance less than 30 mL / min
Lovenox (enoxaparin) 30 mg Subcutaneous every day
Anti-embolism Hose (TED) to bilateral lower extremeties
Sequential compression devices to bilateral lower extremeties
Anti-Inflammatory
(may choose one)
Solu-MEDROL (methyIPREDNISolone) _______ mg IV every _________ hours
PredniSONE _________ mg PO every ______ hours
Expectorant
GuaiFENesin 600 mg ______tab(s) PO every 12 hours
Ulcer Prophylaxis
( may choose one )
Pepcid ( famotidine ) 20 mg PO every 12 hours
Protonix ( pantaprazole ) 40 mg PO every 24 hours
Pepcid ( famotidine ) 20 mg IV push every 12 hours
Protonix ( pantaprazole ) 40 mg IV push every 24 hours
Vaccines
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l
Other Medicines
Pneumococcal Vaccine 0.5 mL IM 1 time only ( age 65 and over or high risk: *assess
year-round* )
Influenza Vaccine 0.5 mL IM 1 time only ( age 50 and over or high risk: *assess from
October through end of March flu season* )
Other: ________________________________________________________
________________________________________________________
Transcribed
Noted / Acknowledged
Signature
Telephone Order(TOR)
Date / Time
Signature
PHYSICIAN INITIALS
Date / Time
DATE / TIME
Originated 2010
rev Pneumonia Admission Orders Pg 3 of 4 public
Revised 5/12/11
Name:______________________________
DOB:______________________________
Generic equivalents are utilized unless checked.
l CORE MEASURE REQUIREMENTS
PRN
Adult Insulin Sliding Scale Protocol
Low
High
Pain
Severe ( 7 - 10 )
Morphine Sulphate 2 mg IV push every 2 hours PRN severe pain
Moderate ( 4 - 6 )
HYDROcodone / APAP 5 / 325 mg 2 tabs PO every 6 hours PRN moderate pain
Mild ( 1 - 3 )
HYDROcodone / APAP 5 / 325 mg 1 tab PO every 4 hours PRN mild pain
PRN
Temperature
Constipation
Tylenol (Acetaminophen) 650 mg PO every 4 hours PRN temperature over 101.3
degrees Fahrenheit
Colace (Ducosate Sodium) 100 mg PO two times per day PRN constipation
Milk of Magnesia (magnesium hydroxide) 30 mL PO daily PRN constipation
Nausea
Zofran (ondansetron) 4 mg IV every 3 hours PRN Nausea / Vomiting
Diagnostics
Lab
In AM
Basic Metabolic Panel
Magnesium
Complete Blood Count with differential
Comprehensive Metabolic Panel
Radiology
Chest X-ray _________________________________________
Other
_______________________________________________________________
Consults
Other:
Speech Therapy
Notify Physician
Temperature greater than ____________
Heart Rate greater than ___________ or less than _________
Oxygen Saturation less than ____________________________%
Systolic Blood Pressure less than _______________________
Diastolic Blood Pressure greater than _____________________
Change of patient condition
Transcribed
Noted / Acknowledged
Signature
Telephone Order(TOR)
Date / Time
Signature
PHYSICIAN SIGNATURE
Date / Time
DATE / TIME
Originated 2010
rev Pneumonia Admission Orders Pg 4 of 4 public
Revised 5/12/11