Follow-up for Pneumonia, an unspecified organism in the context of a patient with chronic illness and poor overall outcomes. Monitor for Ceftriaxone antibiotic.
An 89-year-old female with a history of acute respiratory failure with hypoxia and asthma recently experienced an asthma exacerbation, which has improved following respiratory treatments over the past week. On examination today, she is alert and oriented to person, with no deformities, well-ventilated lungs, equal chest expansion, and no signs of shortness of breath. A comprehensive review of her diagnoses and treatments was conducted to prevent future complications and avoid potential medication interactions. Dressing PEG tube clean and dry. No edema present. Capillary refill less than 2 sec. pulse 2+ equal bilaterally. Her chart was reviewed with the nurse, and both the patient and nurse were educated on the importance of adhering to the prescribed treatment and Plan of Care. The current care plan and medications will be continued.
Ceftriaxone recon soln; 1 gram; amt: 1 gram; intravenous Every 12 Hours. Begin: 03/17/2025 - 03/23/2025
Ending: 03/23/2025
J18.9 Pneumonia, unspecified organism
Ceftriaxone recon soln; 1 gram; amt: 1 gram; intravenous Every 12 Hours. Begin: 03/17/2025 - 03/23/2025
Ending: 03/23/2025
It is recommended that the patient continue her current care plan and medications while maintaining close monitoring for any signs of respiratory distress or exacerbation. Regular follow-ups Should be scheduled to assess her respiratory status and adjust treatment as needed. She should avoid known asthma triggers, adhere to prescribed inhalers and medications, and practice breathing exercises to optimize lung function. Additionally, patient and caregiver education Should be reinforced to ensure compliance with treatment and early recognition of worsening symptoms. If any respiratory symptoms recur or worsen, prompt medical evaluation is advised.