Monitor for pneumonia, unspecific organism. Monitor for Azithromycin.
The patient was evaluated today, lying in a hospital bed. Muscle weakness and general condition deterioration were noted during the physical examination. will continue monitoring the patient's respiratory status. The patient's 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 15. I didn't see any respiratory distress. S1 and S2 present. Tracheostomy dressing and PEG tube were intact. 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. The patient had a decorticate posture.
Azithromycin 03/13- 03/20
J18.9 Pneumonia, unspecified organism
Azithromycin 03/13 -03/20
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.