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Flashcards in Admission Orders Deck (19)
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1
Q

Components of admission orders

A
Admit
Diagnosis
Code status
Vitals
Allergies
Nursing
Diet
Activity
Labs
IV
Special
Medications
Here (House Officer calls)
2
Q

Components of “admit” section of admission orders

A

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
Q

What is included in the vitals section of admission orders?

A

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

4
Q

Examples of nursing notes parts of admission orders

A
Moniter I/Os
Dressing changes
Place/monitor Foley
Place NGT
Turn patient q2 hours
Head of bed at 30 degrees
5
Q

What do you include in diet section of admission orders?

A

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
Q

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

A

Activity

7
Q

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

A

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

8
Q

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

A

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

9
Q

Main differences between BMP and CMP

A
CMP includes:
Albumin:Globulin ratio
Albumin
Alkaline phsophatase
AST/SGOT
ALT/SGPT
Total bilirubin
Globulin, total
Protein, total
10
Q

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

A

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

What rate do you want it running at?

11
Q

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

A

Crystalloid

12
Q

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)

A

Colloids

13
Q

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

A

Isotonic

14
Q

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

A

Free water

15
Q

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

A

Hypotonic

16
Q

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

A

Hypertonic

17
Q

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

A

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
Q

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

A

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

What medications are you going to start?

19
Q

What is included in House Officer section of admission orders?

A

Notify house officer if: (and include reasons)

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