1. Eric Red Leaf: Community Acquired Bacterial Pneumonia
1.1. Medications
1.1.1. Acetaminophen (Analgesic and antipyretic): Had a fever and pain with coughing
1.1.2. Azithromycin (Macrolide antibiotic ): Azithromycin is an effective antibiotic to treat community acquired pneumonia caused by Streptococcus pneumonia.
1.1.3. Albuterol (Bronchodilator): Helps open the airway so he can breathe easier and cough better
1.1.4. Guaifenesin (Expectorant ): Help him expel the mucus
1.1.5. Dextromethorphan (Antitussive): Has a painful cough that may prevent sleep. Only give at night.
1.2. Orders
1.2.1. Labs/Diagnostics: Sputum culture, influenza nasal swab, chest X-ray, CBC daily, peak flow
1.2.2. Nursing Management: Droplet precautions until bacteria is specified, continuous pulse ox, O2 as needed to keep above 93%, incentive spirometer hourly, vitals Q4H, ambulate QID, elevate HOB
1.3. Referrals
1.3.1. Respiratory therapy
1.3.2. Pulmonology follow up
1.3.3. Teach back inhaler education
2. Paula Jones: Diabetic foot soft tissue infection
2.1. Medications
2.1.1. Vancomycin (Glycopeptide antibiotic): Vancomycin is an effective treatment for diabetic food soft tissue infections
2.1.2. BOOSTRIX (Vaccination): She is unaware of where the wound came from and has not received a Tdap booster in over 20 years
2.1.3. Lantus (Antihyperglycemic): Control blood glucose steadily throughout the day
2.1.4. Humulin R (Antihyperglycemic): Control blood glucose during meal times
2.1.5. D50W (Antihypoglycemic): Use if she becomes hypoglycemic and is unable to take anything orally
2.2. Orders
2.2.1. Labs/Diagnostics: CBC, ESR, wound culture, A1C, blood glucose QID
2.2.2. Nursing Management: Up with assistance, VS Q4H, monitor wound drainage, wound assessment daily, dressing change daily
2.3. Referrals
2.3.1. Infectious disease specialist
2.3.2. Podiatrist
2.3.3. Nutritionist
2.3.4. Endocrinologist follow up
2.3.5. Home health
3. Clint Brown: Upper GI Bleed
3.1. Medications
3.1.1. Hydrazine (Non-nitrate vasodilator): History of hypertension and the increase in fluids may increase his BP too much
3.1.2. FFP (Blood Product): Lost blood due to upper GI bleed and has an increased PT/INR and low hit and hgb
3.1.3. PRBC (Blood product): Lost blood due to upper GI bleed and has a low hct and hgb
3.1.4. Pantoprazole (Proton pump inhibitor): Decreasing the acids helps with healing of ulcers and erosions and can decrease the rate of GI bleeding
3.1.5. Sodium Chloride 0.9% NS (Fluid replacement): In need of fluid replacement from blood loss causing dizziness and low BP
3.2. Orders
3.2.1. Labs/Diagnostics: Stool occult, upper endoscopy, blood type and cross, CBC, PT/INR
3.2.2. Nursing Management: Up with assistance, SCDs unless transferring, NPO 8 hrs before endoscopy, telemetry, vitals Q4H, daily weight, I&O
3.3. Referrals
3.3.1. Medication reconciliation
3.3.2. PCP follow up
3.3.3. Regular PT/INR monitoring
4. Stephanie Smith: Increased Intracranial Pressure
4.1. Medications
4.1.1. Mannitol (Osmotic diuretic): Helps promote diuresis and decreases fluid in the brain to decrease ICP
4.1.2. Diazepam (Benzodiazepine): Helps decease anxiety and agitation, which increases ICP.
4.1.3. Acetaminophen (Analgesic and antipyretic): Increased temperature can increase cerebral metabolic rate, which increases ICP
4.1.4. Phenytoin (Anticonvulsant ): Used for seizure prophylaxis, seizures are common in patients with increased ICP
4.1.5. Lithium (Mood stabilizer): She is in manic phase of bipolar disorder and has not been taking her lithium, it heeds to get back to a therapeutic level
4.2. Orders
4.2.1. Labs/Diagnostics: Neurological assessment, Glasgow Coma Scale, CT, serum electrolytes, ICP monitoring via intraventricular catheter, Lithium levels
4.2.2. Nursing Management: I&O, VS Q2H, reduce stimuli, seizure precautions, elevate HOB, monitor intraventricular catheter insertion site
4.3. Referrals
4.3.1. Psychiatry
4.3.2. Medication reconciliation
4.3.3. Neurology follow up