Monitor for pneumonia, unspecific organism. Monitor for Levofloxacin.
The patient was evaluated today, lying in a hospital bed. Muscle weakness and general condition deterioration were noted During the physical examination. We will continue monitoring the patient's respiratory status. The patient's proper chest dialysis port dressing was intact. Mechanical ventilation setting: high pressure 60, low pressure 10, low min V 2.0, Peep 5, breath rate 10, total volume 450, press control 15, inspiration time 1.0, and press support 10. I didn't see any respiratory distress. S1 and S2 present. The tracheostomy dressing and PEG tube were intact. Amputation of the lower Left leg was noticed, and a stage 4 pressure ulcer on his sacrum and left hip was present. Wound care followed and treated him. Information was obtained from the Patient, Primary nurse, and chart. The patient's chart was reviewed with the nurse. The patient's RN was educated on the importance of complying with the treatment established.
No known allergies
Levofloxacin tablet; 500 mg; amt: 500 mg; oral Special Instructions: levofloxacin tab 500mg(1 tab QD)X 7 DAYS Dx:Pneumonia Once A Day Begin: 03/15/2025 - 03/21/2025
End: 03/21/2025
J18.9 Pneumonia, unspecified organism
Levofloxacin tablet; 500 mg; amt: 500 mg; oral Special Instructions: levofloxacin tab 500mg(1 tab QD)X 7 DAYS Dx:Pneumonia Once A Day Begin: 03/15/2025 - 03/21/2025
End: 03/21/2025
Wound care.
Social worker consult
Careful airway management, infection control, and respiratory support. Ensure proper tracheostomy care by regularly suctioning secretions, maintaining humidification to prevent mucus plugging, and monitoring for signs of respiratory distress or worsening infection. Education was given about the importance of oral care to prevent infection and continue with the antibiotic treatment. Reposition the patient every two hours. Change dressing and assessment on his sacrum area and left hip. Continue wound care treatment.