Admissions Orders Flashcards
Purpose of admission orders:
outline an intitial treatment plan for patients that enter a medical facility for specialized care as a means to communicate
–Someone expected to stay more than 2 midnights due to their clinical presentation.
Inpatient
Occurs within one day, no overnight stay, usually occurs in a surgery center, eye center, or special procedures
Outpatient
–Needs hospital care but expected to stay only 1 midnight to observe progress. Can transition to an inpatient admission if meets criteria.
Observation admissions
What is Skilled Nursing Care?
Where does it occur?
•Often patients have surgery or illnesses that cause significant debilitation where they are not ready to go home within 3-4 days, so they are transitioned to a Skilled Nursing Facility (“SNiF”) until such time as they can safely go home.
- occurs in a nursing home, where some beds are set-aside for “post-acute care”
what are the 2 types of home environment?
- Hospice care: palliative care at a hospice for end- of life patients
- Home health: needs skilled care at home
What is the structure of admission orders?
1. Written
2. Template
3. Electronic
How do we write admissions orders?
ADC VANDALISMM
- Admit
- diagnosis
- condition
- Vitals
- Activity
- Nursing
- Diet
- Allergies
- Labs and diagnostics
- IV fluids
- Specialists/consulations
- Medication
- Monitoring
What should we write under “admit”
Specifies the service (ICU, med, PCU) and the attending.
Should also specifiy a particular unit and whether the patient will need cardiac monitoring (telemetry)
Who is admitted into the ICU?
Patients
- that need, or will need advanced respiratory support
- that need support of 2 or more organ systems
- that have chronic impariment of 1 more organ systems + also need support for an acute reversible failure of another organ
- Support/care that cannot be addressed on another unit due to medication intensensity, need for close motnitoring or high risk of decline in condition
What should your write under dianogisis?
What should you not write?
How can you organize them?
- Primary diagnosis (biggest concern), even if working diagnosis.
- NOT signs and symptoms.
- In order of priority and break into 2 groups (acute – main concer– vs chronic)
Which is breaking down a diagnosis into 2 groups helpful?
Can let those processing orders to know chronic conditions that contribute to admission, like DB, CAD, HTN, MDD.
what do we write for condition?
1. stable/ “good”
2. Fair
3. Guarded
4. Critical
5. Expectant
“Stable”/good
-stable vital signs and no life-threatening duress
fair= _______.
What is it?
ill-appearing
- Pt is not doing well and needs to be monitored d.t pain or mild circum, but there is minimal impairment of the patients safety.
guarded
patient needs to be monitored closely bc change in vital signs, mentation is altered.
Ex. “toxic” due to sepsis or trauma that caused multiple injuries
patients are going to intensive care bc fear they could become unstable or were unstable before being admitted, but stable enough to go to a medical unit aprop for diagnosis and care
critical
expectant= _______
poor/poor prognosis or actively dying/expantant
- patients who are admitted and seem like they are most likely to die within 72 hours
- Often on palliative care or waiting to be put on.
Expectant patients likely needs ________ palliative care, in order to do what?
inpatient.
control symptoms that cannot be done at home
What symptoms are experienced in actively dying or expectant patients?
Signs that they’re going to die
- low BP
- bradycardia
- agonal respiration
- Hypoxia
- comatose states
Expectant patients do not need _____ therapy, they need _________.
- curative
- need: intense therapy for comfort
how often do you take vitals, usually?
- every 4 or 8 hours.
- if pt is in bad condition, take every 2 hours for 8 hours and then move to 4.
- make sure you note frequency.
what do you write for activity?
the activity that the patient is allowed to do; bed-rest w, water ad-lib (water as desired),
What are Nursing orders?
Orders for nurses “turn, cough, breather exercises ever 2 hrs, wound care” but usually not needed any longer bc they develop are plans for patients.
Diet is assigned based on the patients situation.
Describe the type of patients often assigned
- -regular
- -carb consistent
- -clear liquid
- -full liquid
- -NPO
- Regular: pt can w/e
- Carb consistent: DB pts
- Clear liquid: pre-procedure pts or who face persistent N/V
- Full liquid: slow advance to regular diets after surgery or other illness (creams)
-
NPO: nothing by mouth assx to midnnight b4 surgery or at least 6 hours b4 proecedure. often assx with bedrest
- persis N/V
- acute pancreatitis
- Bowel obstruction
What does Dr. Tyler think is the MOST IMPORTANT FEATURES of admission orders?
-
Medications
- write all meds and doses, those for reconcilation
- specific to admission
how do you write medications?
name, dose, route and schedule
– Docusate Na 100 mg PO BID
what do we write under monitoring
- safety,
- discharge plan,
- patient education
