6.1 - Managing Hospital Admissions

Question 1

What is the essential information that should be included in a patient’s history?

Answer 1

1. Identifying data: Include your patient’s name, age, race, gender
2. Chief complaint (CC)
3. HPI
4. PMH (Past medical history)
5. PSH (Past surgical history)
6. Medications
7. Allergies
8. Immunizations
9. FH (family history)
10. SH (social history)
11. ROS

Question 2

What are the essential components of the hospital admission physical exam?

Answer 2

Gauge the extent of your exam on the patients CC:

• General Appearance
• Vital Signs
• Skin
• HEENT
• Neck
• Chest
• Heart
• Breast
• Abdomen
• GU
• Rectal
• MSK
• Peripheral Vascular
• Neuro

Question 3

What are the different parts of an admission order?

Answer 3

• Admit – what service and level of care
• Diagnosis – List your admitting diagnosis. If the patient is postoperative, list the procedure
• Condition – Is the patient stable, guarded, critical
• Vital signs – Should include both your frequency and the parameters to be notified
• Activity – Bedrest, up with assistance, bathroom privileges only. This is important for patients with a history of falls or dementia
• Allergies – Any known or perceived allergies. Can also include drug intolerances if appropriate
• Nursing procedures – tests including preparations needed (enemas, etc.), respiratory care (IS, IPPB) if to be done by nurses alone. Wound care, patient education and specialty requests; “Please document spousal visits in the EMR”
• Diet ordered
• I & O – If required more often than qshift, order it as you want and parameters that you wish to be notified.
• Specific medications – includes patients home meds if continues and treatment meds initiated this admission
• Symptomatic medications – sleep, constipation, pain
• Laboratory/diagnostics – Includes all departments including blood draws for lab, EKG, radiology and other procedures to be done by consultants

Question 4

What are the components of a progress note?

Answer 4

Progress notes should summarize events and occurrences that have occurred, problems that remain active, results of tests or tests that are outstanding, and discharge plans.

1. Date/time/service
2. Subjective data – How does the patient feel today? Document in their words, preferably in quotes
3. Objective data – General appearance, VS, I & O, PE (it is important to emphasize if there has been a change in any physical finding), Lab/diagnostic results (if there is a pertinent change it should be noted: WBC ^12,000 ,
4. Current meds – Indicate days in antibiotic therapy. Day 6 of Levaquin 500 mg IV Q24H
5. Assessment/diagnosis – evaluation of the data, have any conclusions been drawn?
6. Plan – for each problem you are addressing this admission
7. Discharge plan – May indicate if placement is pending, if care manager is involved

Question 5

What are the components of a procedure note?

Answer 5

Any invasive procedure should be documented in a procedure note. These notes are short with pertinent information documented under each category. Do not underestimate the importance of these notes as documentation for the patient’s permanent record.

1. Date/time – specific to the procedure performed
2. Procedure performed – state it as described for billing, with CPT codes
3. Indications for procedure – i.e., patient has poor venous access, CL is needed for 7 weeks of antibiotics
4. Patient consent – it is important to document that you explained risks, benefits and procedure to patient and/or family and procedure indication
5. Lab tests – did you obtain any tests prior to procedure? INR, BUN, Creat? Document them if they are pertinent to the procedure itself
6. Description of procedure – Use detail outlining the preparation (clean, sterile), how you positioned the patient, how you anesthetized or sedated them, devices used (catheters, lines) location of procedure (left lateral chest), drains, outcome
7. Complications and estimated blood loss (EBL) – it’s ok to say minimal or 10 cc or less. If it is a measurable amount, document in CC
8. Disposition – How did the patient tolerate the procedure? What position did you leave them in, supine, HOB elevated, asleep, awake? Did you speak with family? Be brief unless there is a problem.
9. Specimens/findings – Tissue sent to pathology, no specimens obtained. Describe specimens if they were obtained. If an LP or CL is placed and pressures are obtained, document them here.

Question 6

What are the components of a hospital discharge summary?

Answer 6

Hospital discharge summaries are utilized not only for documentation of an inpatient hospital stay; it can be used for billing, teaching and communication with a primary care physician that arranged for admission of their patient.

1. Date of admission
2. Date of discharge
3. Attending MD/ACNP – Also list consulting services
4. Admitting diagnosis – This is the specific reason that the patient was initially admitted to the hospital. Ex: Abdominal pain or Fever, chills. Or Dizziness.
5. Discharge diagnosis – List your primary diagnosis. Include secondary diagnosis, sometimes they occur after admission. (1) NSTEMI (2) Acute renal failure
6. Procedures – Include surgical procedures with dates, procedures the team performed with dates or state None.
7. Brief history – Summarize the patient’s history and what led to the admission. List only the pertinent data.
8. Hospital course – Do this in an orderly and organized fashion. It should be done in chronological order so there is no confusion about the patient stay. Include treatments, medicines given including doses and length especially if antibiotics and patient’s response. If a patient could not tolerate an increased dose of a diuretic, BP med, it is important to say the dose and the intolerance. Potassium increased to 2.5 on Spironolactone 50 mg daily, potassium returned to baseline of 1.5 when spironolactone was decreased to 25 mg daily.
9. Discharge condition – Improved, deteriorated, unchanged
10. Disposition – Where will they return after discharge? Home, SNF, LTAC, transferred to a higher level of care medical facility
11. Discharge medications – List the meds and how you prescribed them, how many pills were in the prescription and if any refills were ordered
12. Instructions and follow up – Describe the provider they are to follow up with including PCP and consultants. If date and time of appt is known, include it. If patient states they will obtain their own appt, document it. This section should also include any dietary restrictions and activity limitations.
13. Problem List – include an updated list. It should include both current and past medical problems.
14. Indicate who you want to receive a copy of this discharge summary. That should include primary care providers and consultants.

Question 7

What are some cardiac reasons to admit a patient to the ICU?

Answer 7

• Acute MI with complications
• Cardiogenic shock
• VT, VF, SVT or hemodynamically compromising atrial arrhythmias
• Acute onset CHF with pulmonary edema and/or respiratory compromise
• HTN emergencies or urgencies with unstable or unpredictable course
• Unstable angina that is accompanied by persistent hypotension or chest pain that is unresponsive to conventional treatment
• All patients that are status post cardiac arrest
• Cardiac tamponade or restriction that results in hemodynamic instability
• Dissecting aortic aneurysm
• Complete heart block requiring any form of pacing (temporary or awaiting permanent pacemaker)

Question 8

What are some pulmonary reasons to admit a patient to the ICU?

Answer 8

• Acute respiratory failure requiring mechanical ventilation or BiPAP in some instances (assess patient stability and tendency to worsen)
• Pulmonary emboli with hemodynamic instability
• Any patient exhibiting a worsening of respiratory stability requiring a more intense level of observation than their current hospital bed
• Massive hemoptysis

Question 9

What are some neurologic reasons to admit a patient to the ICU?

Answer 9

• CVA with AMS
• Coma from any etiology: Metabolic, toxic, anoxic
• Subarachnoid bleed
• Meningitis with AMS or respiratory compromise
• Neuromuscular disorders with decline in pulmonary function
• Status epilepticus
• Patients with severe head injuries, brain damage or brain death (potential organ donors)
• Acute spinal cord injury

Question 10

What are some gastrointestinal reasons to admit a patient to the ICU?

Answer 10

• Massive GI bleeds with hypotension and/or persistent bleeding
• Fulminant liver failure, esophageal bleed or perforation
• Severe pancreatitis

Question 11

What are some endocrine reasons to admit a patient to the ICU?

Answer 11

• DKA with severe acidosis, AMS or respiratory compromise
• Thyroid storm
• Hyperosmolar hyperglycemic nonketotic state
• Symptomatic electrolyte abnormalities, either hypo or hyper states

Question 12

What are some surgical reasons to admit a patient to the ICU?

Answer 12

Any post-operative patient that requires more intense hemodynamic or respiratory monitoring than standard care

Question 13

What are some misc. reasons to admit a patient to the ICU?

Answer 13

Drug Ingestion and drug overdose

• Hemodynamic compromise can be caused by an intentional or unintentional overdose of many drugs, including prescription, OTC and recreational
• Mental status changes, airway protection and close observation of seizure activity with ingestion are ongoing assessments with these ICU patients

Miscellaneous

Any patient that, for any reason, requires frequent hemodynamic monitoring, assessments, and/or procedures. This can include patients on experimental protocols utilizing new therapies with potential or unknown complications. Patients that suffer injuries from lightening, near drowning, hyper or hypothermia should also be monitored initially in an ICU setting.

Question 14

What are the guidelines for patient discharge from the ICU?

Answer 14

• The patient’s physiological status has improved or stabilized and ICU monitoring is no longer indicated
• The patient’s physiological status has worsened or deteriorated but active interventions are no longer panned or aggressive measures will be withdrawn. A lower level of care is now appropriate. If the patient is at end of life, this may also be best for family and friends to be around the patient.

Question 15

When conducting a pre-operative assessment on a patient what factors should you consider?

Answer 15

• When you are asked to do a preoperative assessment on a patient, the primary concern or emphasis is placed on cardiovascular disease
• Approach the patient in the same manner as an admission to your service by evaluating PMH, PSH, FH, SH, Allergies, ROS and meds
• Conduct a full assessment

Question 16

What labs/diagnostic tests should be evaluated pre-operatively?

Answer 16

• Urinalysis – an untreated UTI may progress to urosepsis if not noticed
• CBC – any signs of infection? Most procedures, unless emergent, will need to be postponed if an infection is present. Is the patient anemic? Is it new or chronic, is it explained in the history?
• CXR – PA & lateral. Look for any abnormalities that may be new, any indication of pneumonia or volume overload?
• Patients > 40 years of age – is a cardiac stress test indicated or has it been obtained and results available? Is a cardiology consult indicated for a more thorough clearance? This age group will also need a BMP and stool for occult blood documented in the current or very recent history.
• PFTs – not routine obtained for surgery but if the patient has a heavy smoking history, is undergoing lung surgery or cardiac bypass, these should be obtained to help assess the risk for prolonged mechanical ventilation post operatively and need for pulmonary consult.

Question 17

How do you assess the surgical risk for a patient? What factors should you consider?

Answer 17

1. Nutritional status –​ review the patient’s diet history and intake in the hospital and prior to admission. If you suspect malnutrition, obtain a serum albumin and serum transferrin. If the surgery is extensive and a long recovery is a possibility, these will be key factors. A serum albumin less than 3 gms/dl and/ora serumtransferrin less than 150 mg/dl correlate with botha prolongedrecovery time and increased mortality. If the patient is undergoing surgery and has a chronic illness that has caused an unintentional weight loss of 20%, a prolonged recovery and increased mortality is also a possibility.
2. Immune competence – If there are known disturbances in the immunity such as HIV or prolonged corticosteroid use, healing/recovery may be impaired. Patients with DM and/or renal failure are also at risk for complications, especially if their chronic disease is not well controlled
3. Risk for bleeding – Examine the patients PSH, have they had problems with bleeding in other surgeries? Has anyone in their family had this problem? Are they on blood thinners or antiplatelet therapy that need to be addressed prior to surgery? Aspirin and NSAIDs can also predispose patients to bleeding/bruising post procedure. Does the patient have a moral, ethical or religious contraindication to a blood transfusion? Even if blood loss is not anticipated, this needs to be addressed and a clear plan in place preoperatively.
4. Thromboembolic events – Even if the patient does not have a PMH of a thromboembolic event they are at a higher risk if they have cancer, are obese, are older than 45, use oral contraceptives or have a history of PVD.
5. Coronary Artery Disease – Patients with known CAD should be optimized medically prior to surgery. In all patients, BP should be < 140/90. If the patient is low risk for surgery a stress test should be obtained. If the patient is high risk for surgery, it should be postponed unless it is an emergency, and a cardiology consult requested. As a rule, all patients that have had an MI should wait a minimum of 3 months, preferably 6 as a minimum, before an elective surgical procedure
6. Congestive Heart Failure – A recent assessment of left ventricular function should be obtained, all medications optimized and taken the day of surgery
7. Pulmonary – Patients with lung disease, either obstructive or restrictive are at a higher risk. Patients that continue to smoke and obese patients also pose a higher pulmonary risk.

All risks should be considered before determining a patient “safe” to undergo a surgical procedure. If there is any doubt and the surgery is elective, err on the side of safety and cancel the procedure.

Question 18

How do you manage patients with DM who require insulin in the post-op period?

Answer 18

• One half to two-thirds of their usual dose can be given SQ
• Regular insulin, 5-15 U in 5-10% glucose at 100 cc/hr. You will need to watch serum glucoses closely and maintain them below 200 mg/dl
• Insulin 0.5-1.5 units/hr. continue IV in NS. Infuse glucose separately and maintain glucose below 200 mg/dl
• Portland Protocol – ongoing prospective research study that shows surgical patients have less complications and improved mortality when glucose control is even tighter with levels < 150 mg/dl
• With any management plan chosen, glucoseshould be monitored every 2-4 hours

Question 19

How do you manage patients with DM who do NOT require insulin in the post-op period?

Answer 19

• If diet controlled = avoid glucose solutions on the day of surgery. Monitor glucose every 4-6 hours during surgery
• If on oral agents = discontinue the oral agents on the day of surgery, infuse D5W at 100 ml/hr., monitor glucose every 4-6 hours and maintain < 200 mg/dl with sub q insulin

Question 20

How do you manage patients with CAD in the post-op period?

Answer 20

• continue aspirin unless risk of uncontrolled bleeding is a concern
• continue patient’s beta blockers
• calcium channel blockers and nitrates

Question 21

How do you manage patients with anemia in the post-op period?

Answer 21

Patients have fewer complications if Hgb is at least 8mg/dl. Transfusions may be necessary particularly if cardiovascular complications are a high concern

Question 22

How do you manage patients with renal disease in the post-op period?

Answer 22

• if not yet on dialysis, make sure you review the BMP and CBC immediately prior to surgery to determine if any interventions are indicated to correct electrolytes or normalize Hgb.
• Dialysis patients should be dialyzed the morning of surgery if possible.
• Hct optimally should be at 32 ml/dl. If not discuss the need for transfusion.
• Patients on the kidney transplant waiting list need to avoid transfusions whenever possible to avoid development of antibodies that would precipitate rejection of a transplant.

Question 23

How do you manage patients with pulmonary disease in the post-op period?

Answer 23

All smoking should cease. Antibiotics may be indicated if the patient has purulent sputum. Bronchodilators should be administered pre anesthesia and intra operatively by IV if the patient has severe disease.

Question 24

How do you determine a patient’s physical readiness for surgery?

Answer 24

The patient’s physical readiness for surgery should include optimization and/or normalization of the nutritional status, fluid and electrolyte status, acid base balance and psychological status. Medium acting benzodiazepine may be needed to reduce anxiety and allow sleep the day before surgery.

Question 25

How do you manage the patient’s fluid and electrolytes in the post-op period?

Answer 25

• Post-operative fluid choices are D5NS or lactated ringers.
• Maintenance requirements: 1500-2000 ml/24 hours. More may be administered if there are losses from drains, consider third space losses. Potassium should not be added to fluids for the first 24 hours because an intracellular shift occurs during this time. An exception is large amounts of fluid lost through NG tubes or gastric drainage.
• General rule: replace 20 mEq for every liter of fluid lost

Question 26

What pulmonary care is given to the patient in the post-op period?

Answer 26

DB, IS every 1-2 hours. OOB on POD #1, walking on POD #2 or as soon as tolerated by patient

Question 27

What wound care is given to the patient in the post-op period?

Answer 27

• Aseptic care for the first 24.
• No dressings needed on dry wounds.
• Most surgical services set their own time frame and designated person for wound care and staple and suture removal.
• Most staples can come out on day 5 or 6 (generally done in the outpatient setting) if the patient is still in the hospital.
• Assess the wound daily for any subtle or overt signs of infection

Question 28

What drain care is given to the patient in the post-op period?

Answer 28

• Aseptic technique for external portion of drain.
• If more than 50 ml of drainage is anticipated in an 8 hour period, a bag is generally placed.
• Penrose drains should not be left in place longer than 2 weeks (if they last that long).
• All invasive lines should be removed as soon as possible, including Foley, central line A line, chest tube)

Question 29

What DVT prophylaxis is given to patients in the post-op period?

Answer 29

• Anticoagulation is indicated by procedure.
• Review hospital policy where you are for recommendations.
• Add anti thromboembolic stockings unless contraindicated, or sequential boots. Early ambulation is key!

Question 30

How are fevers managed in the post-op period?

Answer 30

• Most post-operative fever is noninfectious but needs to be addressed.
• Increase pulmonary toilet and assure adequate hydration.
• Watch the patient closely. If they begin to feel “sick” and are not meeting their expected mile stones post operatively (ambulation, pain improvement, appetite) suspect infection.
• Check CBC, culture any purulent drainage and obtain blood cultures. Consider empiric antibiotic therapy.

Question 31

How is bleeding managed in the post-op period?

Answer 31

• If internal bleeding is suspected, evaluate vital signs closely for a possible trend.
• Is there persistent increase in heart rate and decrease in blood pressure? Is there specific and localized pain (e.g. abdomen), a change in mental status? Is there a decrease in hemoglobin not explained by the procedure or possible over hydration with IVF?
• Some instances of internal bleeding require transfusion or reoperation. Alternately if there is a large hematoma accessible to percutaneous drainage, this may be attempted.

Question 32

How is infection managed in the post-op period?

Answer 32

Infection: Locate source, organisms (if possible) and treat according to guidelines

Question 33

How is pain managed in the post-op period?

Answer 33

• Post-operative pain should be managed aggressively to avoid limitation of movement by the patient.
  
  • This can lead to venous stasis, thrombosis and atelectasis/pneumonia.
• Patient’s with poorly controlled pain release stress hormones that can lead to vasospasm or hypertension.
• There are a variety of pharmacological methods to control pain and can include oral, IV and patient controlled analgesia.
• The goal of pain management should also include transitioning the patient successfully from IV forms to PO forms of medications as soon as safely possible.