Admission Orders Flashcards
Components of admission orders
Admit Diagnosis Code status Vitals Allergies Nursing Diet Activity Labs IV Special Medications Here (House Officer calls)
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)
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)
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
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
Where would you include “bedside commode” in the admission orders?
Activity
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
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)
Main differences between BMP and CMP
CMP includes: Albumin:Globulin ratio Albumin Alkaline phsophatase AST/SGOT ALT/SGPT Total bilirubin Globulin, total Protein, total
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?
Term used to describe IVFs that pass readily through a membrane (between intravascular and extravascular/interstitial fluid compartments) — examples include saline or LR
Crystalloid
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
Term used to describe IVFs that are close in composition to plasma
Isotonic
Term used to describe IVFs that consist of water not bound by macromolecules
Free water
Term used to describe IVFs that have less osmotic pressure than plasma
Hypotonic
