21/JUNE/2020 AT 1:35PM
Admit to: INPATIENT MEDICINE WARD TO THE SERVICES OF DR. NILVERT PEREZ.
Diagnosis: Exacerbation of asthma
Condition: OF CARE; PROGNOSIS GUARDED
Vital signs: q6h. Call physician if P >140; R >30, <10; T >38.5°C; pulse oximeter <90%
Activity: BEDSIDE COMMODE. FALL SAFETY PRECAUTIONS. RAILS UP!
Nursing: Pulse oximeter, bedside peak flow rate before and after bronchodilator treatments.
Diet: MASH AND GROUND, no caffeine.
IV Fluids: D5 ½ NS at 125 cc/h.
Special Medications:
-Oxygen 3 L/min by NC. Keep O2 sat >90%.
-Albuterol (Ventolin) 0.5 mg and ipratropium (Atrovent) 0.5 mg in 2.5 mL NS Q4H.
-Methylprednisolone (Solu-Medrol) 60mg IV q6h x 2, THEN Q24H.
Symptomatic Medications:
-Docusate sodium (Colace) 100 mg PO qhs.
-PEPCID IV 20MG Q12H
LABS/IMAGING: CHEST X-RAY, ECG, pulmonary function tests before and after bronchodilators; echocardiogram. ABG, CBC with DIFF, CMP.
ANY INQUIRIES CONTACT DRA. NILVERT PEREZ STAT!