Asthma
Asthma
| |
|Date and time: |Name: |
| |Age: |
|Allergies: |DOB: |
|1. Admit to: [ ] Acute Care [ ] Day Bed [ ] SCUnit |
|2. Attending Dr: Younger |
|3. Admitting Dx: Asthma |
|4. Contributing Dx: |
|5. Condition: |[ ] Stable [ ] Fair [ ] Serious [ ] Critical |
|6. VS: |Q 1 hr until stable for 4 hr, then Q 4 hr. Daily weights. |
|7. Activity: |Bed rest with bathroom privileges with assistance. |
|8. Nursing: | |
| |Call MD if: P < 50 or > 110; BP < 90/60 or > 160/100; RR > 30; pulse ox < 90%; decreased level of |
| |consciouness; respiratory distress. |
|9. Diet: |Clear liquids x 12 hr and then start a regular diet. |
|10. IV: |Normal saline at 80 ml per hour and then convert to a saline lock and stop the IV fluids. |
|11. Meds: | |
| |Albuterol nebulizer (2.5 mg and atrovent 0.5 mg) Q ___ hr. |
| |Methylprednisolone 125 mg IV Q 6 hr for 4 doses, then decrease to 80 mg IV q 6 hours for 3 doses, then |
| |decrease to 40 mg IV q 6 hours for 3 doses, and then stop it and start c on 7-28-02. |
| |Tylenol 500 mg 1-2 PO Q 4-6 hr prn pain/T > 101(F. |
| |MOM 30 cc PO Q 12 hr prn constipation. |
| |Maalox 30 cc PO Q 2-4 hr prn indigestion. |
| |Ambien 5 mg, one tablet by mouth at bedtime as needed for sleep. |
|12. Other Meds: | |
|13. Labs: |CBC; chem 8; ABG if pulse ox < 90%, respiratory distress or altered consciousness. |
|14. Other: |Consider DVT prophylaxis with: Lovenox 40 mg SQ qd or Heparin 5000 U SQ bid. |
|15 X-rays: | |
|16. Consultations: | |
|17. Respiratory Therapy: |O2 @ [ X ] 2 [ ] 4 [ ] 6 Liters/min via [ X ] NC or [ ] FM. |
| |Albuterol nebulizer (2.5 mg and atrovent 0.5 mg) Q 2 hrs for 2 times, and then qid and prn SOB. |
| |Spot pulse ox on arrival to floor and with nebulizer treatments as needed. |
| |Daily retitrate the oxygen needed to maintain SpO2 levels >90% at rest/walking. |
| |Flovent inhaler 220 mcg, 2 puffs every 12 hours for wheezing and to decrease the inflammation in your airways.|
| |Please wash out her mouth and gargle with water after each usage to prevent a sore mouth and throat from a |
| |fungal infection. |
| |Serevent Inhaler, 2 puffs 30 seconds apart every 12 hours for breathing problems. |
| |Please have her use her inhalers with an Aerochamber spacer, and instruct her in proper inhaler and spacer |
| |usage. |
| |Please do a set of PFTs (before and after bronchodialator treatment) as an outpatient next week. |
|18. H&P: |Please type up the H&P. |
| | |
| |________________________________________________ |
| |Signature |
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