Patient Name: John Smith
Ordering Provider: Dr. Kelsey Chambers
Location: Caring Heart Healthcare System – Emergency Department
Airway and Oxygen Support
Oxygen via nasal cannula at 2 L/min to start. Titrate to maintain SpO₂ ≥ 94%.
If oxygen saturation remains <90% or work of breathing increases, escalate to 4–6 L/min NC
IV Access and Fluids
Insert two large-bore IVs (18G or larger)
Normal Saline 500 mL IV bolus over 1 hour. May repeat x1 if BP remains <90/60 mmHg or MAP <65
Laboratory Orders
Complete Blood Count (CBC) with differential
Comprehensive Metabolic Panel (BMP)
Lactate level
Blood cultures x2 (draw from separate sites)
Sputum culture
Urinalysis with reflex culture
Blood glucose
Medications
Levofloxacin 750 mg IV once
Azithromycin 500 mg IV once
Acetaminophen 650 mg PO/PR every 4 hours PRN for fever >101°F
Lisinopril 20 mg PO daily
Monitoring and Nursing Care
Insert Foley catheter for strict I&O monitoring
Monitor urine output hourly; notify provider if output <0.5 mL/kg/hr
Continuous cardiac and pulse oximetry monitoring
Neuro checks every 2 hours
Vital signs every 15 minutes
Imaging
Chest X-ray (completed)
Repeat in 24–48 hours or PRN based on respiratory status