Rivera Viera Noel is a 52cy/o male patient with PMH of Acute respiratory failure with hypoxia, Tracheostomy status, Dependence on respirator [ventilator] status, Pneumonia, unspecified organism, Acute pulmonary edema, Pleural effusion, not elsewhere classified Heart failure, unspecified, Down syndrome, Type 2 diabetes mellitus without complications, Hypothyroidism, Anemia. The patient will be evaluated today for medical needs to avoid future complications. Today, the patient was lying in a hospital bed and followed simple commands. He had decreased respiratory sounds in both lung bases, and no accessory muscle was noted. The patient's right ear was noticed to be bleeding because the patient was itching and scratching the skin outside of the right ear. The patient was with discomfort. I ordered and reported to the RN and the Supervisor that the patient should have Meropenem 1 g iv q12 hour for 7 days and Doxycycline 100 mg po bid for 7 days. The RN cleaned the patient's right ear, and a dressing was applied to prevent more episodes of scratching.
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. Education was given to RN to assess for pain to be able to minimize patient discomfort and administer PRN pain medication. Continue round to evaluate patient condition.