Name
Item
Name of attending physician
text
Phone
Item
Phone number of attending physician
integer
Admitting Diagnosis
Item
Pyelonephritis Associated Diagnoses
text
Diet
Item
Clear liquid
boolean
Diet
Item
AHA step 2
boolean
Diet
Item
ADA___calories
boolean
Diet
Item
If Diet according to ADA, please specify amount of calories
integer
Diet
Item
If Other, please specify
text
Activity
Item
Bed rest with bedside commode
boolean
Activity
Item
bathroom privileges
boolean
Activity
Item
Up ad lib
boolean
Nursing
Item
Vital signs every 4 hrs for 24 hrs then every shift
boolean
Nursing
Item
Notify MD for: T > 101.5, P > 120, BP < 90/60 or > 180/110
boolean
Nursing
Item
Daily weight
boolean
Medications
Item
Levaquin 500 mg IV every 24 hrs
boolean
Medications
Item
Tylenol 650 mg PO every 4 hrs prn temp > 100/pain
boolean
Medications
Item
Phenergan 25 mg IV/IM every 4 hrs prn nausea
boolean
Medications
Item
Demerol 50 mg IM every 4 hrs prn pain
boolean
Medications
Item
If toxic: consider adding Gentamycin (7mg/kg/day) IVP; adjust for renal dose if indicated
boolean
IV
Item
Dextrose 5% in 1/2 normal saline @ 100 mL/hr
boolean
IV
Item
If Other, please specify
text
Lab
Item
Admission: blood cultures x2 prior to antibiotics, CBC, UA, urine culture, basal metabolic profile
boolean
Lab
Item
Daily: CBC
boolean
Other
Item
If history of stones or recurrent pyelo consider IVP or renal ultrasound
boolean
Other
Item
DVT prophylaxis with Lovenox 40 mg sc daily
boolean
Signature
Item
Signature
text
Print Name
Item
Print Name
text
Date and Time
Item
Date and Time
datetime