Inpatient Observation Bed Type: Med/Surg PHYSICIAN S ORDERS Page 1 of 5 Satellite Telemetry Telemetry ICU Resuscitation (Code)Status: Admit to: Diagnosis: Pneumonia Other: Consult: Condition: Stable Guarded Critical Allergies: NKDA Diet: NPO, strict NPO after midnight, except medications Clear liquids Full liquids Regular Consistent Carb (ADA 1800 cal) Cardiac (low cholesterol, low fat, 2 g Na with salt substitute PRN) (also see Nursing Orders) Activity: Bedrest Up with assistance Up ad lib Labs: In AM: CBC with differential BMP INR Magnesium NOW: Cardiac Enzymes with troponin Q 3 H x 3 IV Solutions Saline lock 50 ml per H * See IV Fluid Availability List 75 ml per H * Currently NaCl 0.9% is reserved for Sepsis 100 ml per H 125 ml per H Nursing Orders Vital signs: x Per unit routine Cardiac monitor x weight on admission and daily height on admission x measure intake and output Q 8 H strict I & O x Identify allergies and list in HHS x List home medications in HHS and confirm with the Attending Physician to continue Point of Care Blood Glucose Q 2 H x 2. Notify Physician if above 180 mg/dl. ICU only. Obtain record from any other healthcare facility, if admitted within last 3 weeks. Interventions Elevate head of bed 30 degrees 45 degrees Patient oral care protocol Q 8 H PRN chapped lips or dry mouth Urinary catheter initiation/management Complete the Immunization/Vaccine Protocol VTE Prophylaxis/Treatment x SCD hose enoxaparin (LOVENOX) 40 mg SUBQ daily Contingency Notify provider Fi O 2 need is greater than 50% Notify provider If new temperature greater than 101º F or 38.3º C PH PNEU 0317PH Date Printed: PHY00237pg1
PHYSICIAN S ORDERS Page 2 of 5 Respiratory Pulse oximetry now once On room air On supplemental O 2 routine once a day and record, in the morning On room air On supplemental O continuous Q 4 H Q 8 H Supplemental oxygen titration x Start at 2 L per minute and titrate to maintain oxygen saturation 92% or greater x Assess for home oxygen therapy if SpO 2 is less than 87% on room air Biphasic positive airway pressure (BIPAP) ABG with lytes (IS 7) ABG with lactate (IS 4) ABG with lactate (IS 4) and ABG with lytes (IS 7) Pulmonary function tests Other: 2 Medications Antibiotics Give ALL first doses of antibiotics STAT! Community Acquired Pneumonia Give TWO antibiotics below, if not allergic to cephalosporins or penicillin: ceftriaxone (ROCEPHIN) 1 g IV NOW and every 24 H for a total of 5 days. May give first dose IM if difficulty starting an IV PLUS azithromycin (ZITHROMAX) 500 mg PO NOW and daily for a total of 3 days. May give IV if patient is unable to tolerate oral intake. MD aware of penicillin allergy Patient previously tolerated cephalosporins * If failed outpatient therapy escalate to HCAP treatment options. If patient has a life threatening penicillin/cephalosporin allergy, use: levofloxacin (LEVAQUIN) 750 mg PO NOW and daily for a total of 5 days. May give IV if patient is unable to tolerate oral intake. If patient has a life threatening penicillin/cephalosporin allergy AND failed outpatient levofloxacin choose: meropenem (MERREM) 500 mg IV NOW and Q 6 H x 5 days PLUS azithromycin (ZITHROMAX) 500 mg PO NOW and daily x 3 days. May give IV if patient is unable to tolerate oral intake. PHY00237pg2
PHYSICIAN S ORDERS Page 3 of 5 Healthcare Associated Pneumonia (HCAP) (Patient is at Pseudomonas risk.) Option 1: piperacillin/tazobactam (ZOSYN) 4.5 g IV NOW and Q 6 H for a total of 7 days Option 2: (if non life threatening penicillin allergy/previously tolerated cephalosporins): cefepime (MAXIPIME) 1 g IV NOW and Q 6 H for a total of 7 days MD aware of penicillin allergy Patient previously tolerated cephalosporins Option 3: (life threatening penicillin/cephalosporin allergy) Consult Pharmacy for allergy assessment meropenem (MERREM) 500 mg IV NOW and Q 6 H for a total of 7 days. Risk factors present for MRSA (necrotizing pneumonia, recurrent MRSA infections, septic shock, post influenza infection, failure while on broad spectrum gram negative monotherapy, immuno compromised) vancomycin 20 mg per kg IV x 1 dose now (max dose: 2 g), then Pharmacy to dose x 7 days. Hospital Acquired Pneumonia (HAP) or Ventilator Associated Pneumonia (VAP) Option 1: piperacillin/tazobactam [ZOSYN] 4.5 g IV NOW and Q 6 H for a total of 7 days *** OR *** Option 2: cefepime (MAXIPIME) 1 g IV NOW and Q 6 H for a total of 7 days If life threatenting penicillin/cephalosporin allergy choose: Pharmacy Consult: for allergy assessment meropenem (MERREM) 500 mg IV NOW and Q 6 H for a total of 7 days. If risk factors for multi drug resistant organisms: Option 1 or 2 (select above) *** PLUS tobramycin (NEBCIN) 5 mg per kg (use IBW; Pharmacy to dose) x 1 dose NOW Risk factors present for MRSA (necrotizing pneumonia, recurrent MRSA infections, septic shock, post influenza infection, failure while on broad spectrum gram negative monotherapy, immuno compromised) vancomycin 20 mg per kg (max dose: 2 g) IV x 1, then Pharmacy to dose x 7 days. Positive influenza screen/high suspicion for influenza (October March only) oseltamivir (TAMIFLU) 75 mg PO BID x 5 days Bronchodilators albuterol (VENTOLIN) 0.083% 3 ml nebulizer Q H and Q H PRN respiratory distress or SPO 2 below 90%. OR albuterol/ipatropium 2.5 mg/0.5 mg per 3 ml solution (DUONEB) by nebulizer Q H and Q H PRN respiratory distress or SPO below 90%. 2 PHY00237pg3
PHYSICIAN S ORDERS Page 4 of 5 Corticosteroids: Systemic methylprednisolone [SOLUMEDROL] mg IV Q H OR prednisone mg PO daily Convenience Meds HYDROcodone 5 mg and homatropine 1.5 mg per 5 ml oral syrup [HYCODAN] 5 ml to 10 ml PO Q 4 H PRN cough acetaminophen [TYLENOL] 650 mg PO Q 4 H PRN mild pain, discomfort or temperature above 100.5º F. May give rectally if unable to tolerate oral. Note: Max dose for 24 hours is 4000 mg. HYDROcodone 5 mg and acetaminophen 325 mg [NORCO 5] 1 to 2 tablets PO Q 4 H PRN severe pain magnesium hydroxide 400 mg per 5mL oral suspension [MILK OF MAGNESIA] 30 ml PO daily PRN constipation aluminum hydroxide 400 mg, magnesium hydroxide 400 mg, simethicone 40 mg per 5 ml [MAALOX MAX] 30 ml PO Q 4 H PRN dyspepsia Protocols Initiate the ICU/Non ICU Electrolyte Replacement Protocol Initiate the Adult Insulin Sliding Scale Laboratory Chemistry: In AM: CMP Phosphorus LFTs d dimer B type natriuretic peptide (BNP) routine once Cardiac Enzymes with troponin Q 8 H x 3 TSH Free T4 Hematology: In AM: PTT Fibrinogen Type and Screen T & C for units PRBCs Microbiology: In AM Culture, blood x 2 from separate sites prior to starting antibiotics if not done in ED. Culture, sputum with Gram stain. Respiratory Induce/Collect UrineStudies: In AM: Urinalysis with microscopic. Nurse to collect. Routine once Source: Urinalysis without microscopic Culture, urine Radiology X ray, chest, PA and lateral routine once Reason: X ray, chest AP Portable routine once Reason: CT, chest without contrast routine once Reason: CT, chest with contrast routine once Reason: CT, chest, with and without contrast routine once Reason: CT, chest, with contrast PE Protocol NOW Reason: PHY00237pg4
DATE PHYSICIAN S ORDERS Page 5 of 5 Cardiology 12 lead ECG Reason: Echocardiogram, transthoracic. Reason: To Read: Consults Pharmacy to assess pneumococcal vaccine status. Consult to Pulmonary Rehab Consult Care Coordination Consult Fit for Life Education Smoking Cessation Education Education, general education of the use of MDI and nebulizer Reminders Avoid the routine use of chest physiotherapy in patients with acute exacerbation of COPD; for selected patients who need help with clearing sputum, physiotherapy with positive expiratory pressure masks may be beneficial Avoid the routine use of methylxanthines (theophylline) for patients with acute exacerbation of COPD Avoid the routine use of spirometry to diagnose or monitor patients with acute exacerbation of COPD Avoid the routine use of mucolytics in patients with acute exacerbation of COPD Consider the administration of an inhaled anticholinergic For patients with acute exacerbation of COPD, an inhaled short acting beta 2 agonist (eg, albuterol) should be administered as first line therapy Consider starting antimicrobial therapy particularly in patients with worsening dyspnea, increased sputum purulence, and increased sputum volume Consider the administration of systemic corticosteroid For acutley ill patients hospitalized with COPD, VTE prophylaxis should be used; the options include an LMWH, LDUH, or a factor Xa inhibitor; for patients with a contraindication to anticoagulant therapy, use mechanical prophylaxis with IPC or graduated compression stockings RN or PA Signature Date Time Physician s Signature Date Time Developed: February 2007 Revised: January 2017 Revised: March 2017 PH PNEU 0317PH Date Printed: PHY00237pg5