Pneumonia

2. Diagnosis: Pneumonia

3. Condition:

4. Vital signs: q4-8h. Call physician if BP >160/90, <90/60; P >120, <50; R>25, <10; T >38.5°C or O2 saturation <90%.

5. Activity:

6. Nursing: Pulse oximeter, inputs and outputs, nasotracheal suctioning prn, incentive spirometry.

7. Diet: Regular.

9. Special Medications:

-Oxygen by NC at 2-4 L/min, or 24-50% by Ventimask, or 100% by non-rebreather (reservoir) to maintain O2 saturation >90%. Moderately ill Patients Without Underlying Lung Disease from the Community:

-Cefuroxime (Zinacef) 0.75-1.5 gm IV q8h OR Ampicillin/sulbactam (Unasyn) 1.5 gm IV q6h AND EITHER -Erythromycin 500 mg IV/PO q6h OR Clarithromycin (Biaxin) 500 mg PO bid OR

Azithromycin (Zithromax) 500 mg PO x 1, then 250 mg PO qd x 4 OR Doxycycline (Vibramycin) 100 mg IV/PO q12h. Moderately ill Patients With Recent Hospitalization or Debilitated Nursing Home Patient:

-Ceftazidime (Fortaz) 1-2 gm IV q8h OR

Cefepime (Maxipime) 1-2 gm IV q12h OR

Cefoperazone (Cefobid) 1-2 gm IV q8h AND EITHER

Gentamicin 1.5-2 mg/kg IV, then 1.0-1.5 mg/kg IV q8h or 7 mg/kg in 50 mL

of D5W over 60 min IV q24h OR Ciprofloxacin (Cipro) 400 mg IV q12h or 500 mg PO q12h OR Levofloxacin (Levaquin) 500 mg IV/PO qd. Critically ill Patients:

-Initial treatment should consist of a macrolide with 2 antipseudomonal agents for synergistic activity: -Erythromycin 0.5-1.0 gm IV q6h AND EITHER -Ceftazidime 1-2 gm q8h OR

Piperacillin/tazobactam (Zosyn) 3.75-4.50 gm IV q6h OR Ticarcillin/clavulanate (Timentin) 3.1 gm IV q6h OR Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6h AND EITHER -Levofloxacin (Levaquin) 500 mg IV q24h OR Ciprofloxacin (Cipro) 400 mg IV q12h OR

Tobramycin 2.0 mg/kg IV, then 1.5 mg/kg IV q8h or 7 mg/kg IV q24h OR Trovafloxacin (Trovan) 300 mg IV x 1, then 200 mg IV q24h.

Aspiration Pneumonia (community acquired):

-Clindamycin (Cleocin) 600-900 mg IV q8h (with or without gentamicin or 3rd gen cephalosporin) OR -Ampicillin/sulbactam (Unasyn) 1.5-3 gm IV q6h (with or without gentamicin or 3rd gen cephalosporin)

Aspiration Pneumonia (nosocomial):

-Tobramycin 2 mg/kg IV then 1.5 mg/kg IV q8h or 7 mg/kg in 50 mLs of D5W

over 60 min IV q24h OR Ceftazidime (Fortaz) 1-2 gm IV q8h AND EITHER -Clindamycin (Cleocin) 600-900 mg IV q8h OR

Ampicillin/sulbactam or ticarcillin/clavulanate, or piperacillin/tazobactam or imipenem/cilastatin (see above).

10. Symptomatic Medications:

-Acetaminophen (Tylenol) 650 mg 2 tab PO q4-6h prn temp >38°C or pain. -Docusate sodium (Colace) 100 mg PO qhs. -Ranitidine (Zantac) 150 mg PO bid or 50 mg IV q8h. -Heparin 5000 U SQ q12h.

12. Labs: CBC with differential, SMA 7&12, ABG. Blood C&S x 2. Sputum Gram stain, C&S. Methenamine silver sputum stain (PCP); AFB smear/culture. Aminoglycoside levels peak and trough at 3rd dose. UA, urine culture.

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