Admission orders Flashcards
When do you write admission orders for inpatient?
Someone expected to stay more than 2 midnights due to their clinical presentation
When do you write admission orders for outpatient?
Occurs within one day, no overnight stay, usually occurs in a surgery center, eye center, or special procedures
When do you write admission orders for observation admission?
Needs hospital care but expected to stay only 1 midnight to observe progress
When do you write admission orders for stand-alone surgery centers?
Various procedural or diagnostic encounters
What does ADC VANDALISM stand for? This mnemonic is used to write complete admit orders.
Admit Diagnosis Condition Vitals Activity Nursing Diet Allergies Lab and Diagnostics IV fluids Specialists/consultations Medication Monitoring
When admitting, what do you call it if pt will require cardiac monitoring?
Telemetry
What are some admission criteria for the ICU?
Pts requiring or likely to require advanced respiratory support
Pts requiring support of two or more organ systems
Pts with chronic impairment of one or more organ systems who also require support for an acute reversible failure of another organ
What should you not list as a primary dx?
Signs and sxs. May be a working dx; biggest concern you have for the pt.
Into what two groups do you break the admission dx?
First: new/acute problems
Second: chronic problems
What are the condition categories?
Stable, fair/ill-appearing, and guarded/toxic, critical, expectant
When do you describe the condition as guarded?
A pt with a need to be monitored closely
Describe “critical” condition
These pts typically are going to intensive care as they are either potentially unstable or have been unstable prior to the admission and effectively stabilized enough to be transitioned to a medical unit
Describe “expectant” condition
Most on palliative care or pending hospice consultation, presentation deems them likely to die within 72 hours. Needs inpatient care in order to achieve sx control, which cannot be done at home. May be called “poor prognosis” or “actively dying”.
What do you write under the vitals part of admission orders?
Frequency of vital signs you prefer. Usually every 4 or 8 hours.
Parameters for notifying physician can be placed here as well.
What are some of the options you can record under activity?
Up a lib Bedrest with assistance Bathroom privileges Bedrest (after surgery) No weight bearing to...LE
