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Flashcards in Admission Orders Deck (19):
1

Components of admission orders

Admit
Diagnosis
Code status
Vitals
Allergies
Nursing
Diet
Activity
Labs
IV
Special
Medications
Here (House Officer calls)

2

Components of “admit” section of admission orders

Where you are admitting them to (general medical floor, general surgical floor, ICU, etc)

Who you are admitting patient to (include attending’s name and service name)

3

What is included in the vitals section of admission orders?

How often to take vitals, as well as which vitals should be collected (typically include temp, HR, BP, RR)

4

Examples of nursing notes parts of admission orders

Moniter I/Os
Dressing changes
Place/monitor Foley
Place NGT
Turn patient q2 hours
Head of bed at 30 degrees

5

What do you include in diet section of admission orders?

Either what kind of diet — regular, diabetic diet, cardiac diet (low salt/lowcholesterol/low fat), calorie restriction, clear liquids, dysphagia diet, ice chips

OR if they are NPO

6

Where would you include “bedside commode” in the admission orders?

Activity

7

Aside from which labs you want, what else must you include in “labs” section of admission orders?

WHEN you need them by — now, STAT, or specific time

8

What is the main difference between CBC and CBC w/differential?

CBC w/differential includes percentage and absolute differential counts (PMN, lymph, baso, eos, mono, atypical monos)

9

Main differences between BMP and CMP

CMP includes:
Albumin:Globulin ratio
Albumin
Alkaline phsophatase
AST/SGOT
ALT/SGPT
Total bilirubin
Globulin, total
Protein, total

10

What 2 things must you include in the IV section of admission orders?

IVF — normal saline vs. lactated ringers vs. dextrose, etc.

What rate do you want it running at?

11

Term used to describe IVFs that pass readily through a membrane (between intravascular and extravascular/interstitial fluid compartments) — examples include saline or LR

Crystalloid

12

Term used to describe IVFs that do not pass readily through a membrane (between intravascular and extravascular (interstitial) fluid compartments) — examples are albumin, dextran, or hetastarch (Hespan)

Colloids

13

Term used to describe IVFs that are close in composition to plasma

Isotonic

14

Term used to describe IVFs that consist of water not bound by macromolecules

Free water

15

Term used to describe IVFs that have less osmotic pressure than plasma

Hypotonic

16

Term used to describe IVFs that have more osmotic pressure than plasma

Hypertonic

17

What is included in the “special” section of admission orders?

Catch all area —

Radiology/diagnostics, EKGs, echocardiogram, arterial/venous doppler US

Consults such as wound care, respiratory therapy, PT/OT, surgery, cardiology, etc.

[make sure to put “regarding” Re: ______]

18

What are the 2 components to the medications section of admission orders?

Reconcile home medications — which need to be discontinued, held, restarted, continued, changed to IV, etc.

What medications are you going to start?

19

What is included in House Officer section of admission orders?

Notify house officer if: (and include reasons)

Such as: systolic BP <90 or >160, temp >101F, etc.