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Patient Assessment > Hospital Admission Orders > Flashcards

Hospital Admission Orders Flashcards

1
Q

what word should not be in your orders

A

“Unknown”

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2
Q

How to list medications in orders?

A

one medication per

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3
Q

what does AADC VAAN DISSLS stand for?

A

Admit
Attending
Diagnosis
Condition/Code

Vitals
Activity
Allergies
Nursing Procedures

Diet
Ins/outs
Specific meds
Symptomatic meds
Labs/imaging/consults
Special

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4
Q

What features should be part of the admit and attending

A

admit service
attending physician
floor/room
Special needs (telemetry, bed near nursing)
POA

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5
Q

what does POA stand for?

A

power of attorney

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6
Q

if a diagnosis has not been established, how should it be written

A

list the cheif complaint and condition that is most likely as a R/O (rule out)

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7
Q

How specific should you be when writing the diagnosis

A

very!

Include: side of body, exact location

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8
Q

What are the 4 types of condition?

A
  1. good
  2. fair (satisfactory or stable)
  3. serious (poor or gaurded)
  4. critical
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9
Q
A
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10
Q

what does good condition mean

A

VS are stable and within normal limits
pt is conscious and comfortable

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11
Q

what does fair condition mean

A

VS are stable and within normal limits
patient is conscious but may be uncomfortable

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12
Q

what does serious condition mean

A

VS may be unstable and not within normal limts
indicators/outlook is questionable

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13
Q

what does critical condition mean

A

VS are unstable and not within normal limits
pt may be unconcious
indicators/outlook is unfavorable

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14
Q

DNR stands for

A

do not resuscitate

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15
Q

DNI stands for

A

do not intubate

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16
Q

what 2 things do you need to list for vital signs

A
  1. frequency
  2. criterira for when to alert/who to call
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17
Q
A
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17
Q

What does “activity” indicate

A
  • bedrest, OOB, Up ad lib, ambulate QID, bathroom privilages
  • fall risk?
  • alarms for bed or chair?
  • sitter?
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18
Q

Dont forget to document this when documenting allergies

A

the reaction

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19
Q

List the 4 types of nursing procedures

A
  1. Bed position
  2. Preps
  3. dressing changes/ wound care
  4. toileting
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20
Q

what does bed position mean?

A

head of the bed @ ____

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21
Q

when should preps be ordered in nursing procedures

A

for planned procedures or surgeries

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22
Q

what types of things can be ordered for preps?

A
  • enemas
  • scrubs
  • showers
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23
Q

How should dressing changes be documented

A

change, location, time, who to call if something is abnormal

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24
Q

what should be ordered for toileting

A

bathroom privileges
ex. OOB to bedside commode
ex. bedpan

25
Q

What 3 things should be considered for diet

A
  1. does the diet fit patients condition/preference
  2. does the patient need to be fed
  3. daily fluid goals
26
Q

Can diet orders be combined?

A

yes!
ex. clear liquid diet for 24 hrs and advances as tolerated

27
Q

NPO

A

nothing by mouth

28
Q

IVF

A

intravenous fluids

29
Q

what are the names of normal saline?

A

0.9% Normal saline
0.9% NS
0.9% NaCl
ns

30
Q

3 types of isotonic fluids

A
  1. normal saline
  2. Lactated ringer’s solution
  3. 5% dextrose in Water
31
Q

what does lactated ringer’s solution contain?

LR

A
  • water
  • sodium
  • potassium
  • calcium
  • chloride
  • lactate
32
Q

What does D5W start as and then turn into

A

starts as isotonic and then changes to hypotonic when dextrose is metabolized

33
Q

what are the two types of hypotonic fluids

A
  • 0.45% normal saline
  • D5W after its metabolized
34
Q

what are the three names of hypotonic normal saline

A
  • 0.45% ns
  • 0.45% NaCl
  • 1/2 NS
35
Q

what are the 4 types of hypertonic fluids

A
  • 3% normal saline
  • 5% Dextrose + 0.45% NS
  • 5% dextrose and lactated ringer
  • 10% dextrose in water
36
Q

names for 5% dextrose + 0.45% normal saline

A
  • D5 0.45% NS
  • D5 0.45% NaCl
  • D5 1/2 NS
36
Q

D5LR

A

5% dextrose and lactated ringer

37
Q

D10W

A

10% dextrose with water

38
Q

How is a bolus IV given

A

rapidly
wide open line
over 15 minutes or less

39
Q

when is a bolus IV indicated

A
  • dehydration
  • hypotension
  • shock
  • active bleeding + unstable vitals
40
Q

for what comorbidities should be caution be taken when giving bolus IV

A
  • heart failure
  • chronic renal failure
41
Q

standard adult dosing IVF bolus

A

500-1000 ml NS

42
Q

how to dose IV bolus in pedatric patients

A

weight based dosing
20ml/kg

43
Q

what is the dosage for typical maintenance dosage of IVF

A

30ml/kg/24 hrs

43
Q

for what pts is maintenance IVF administered?

A

NPO, restricted oral intake, vomiting, hypotension requiring fluid resus.

44
Q

what is the maintenance dosage for obese patients

A

24ml/kg/24 hours

45
Q

when should a maintenance dose of 20-25ml/kg/24hrs be considered

A
  • elderly
  • renal impairment
  • cardiac Failure
  • malnourished pts
46
Q

IV NS at KVO

A

IV normal saline keep vein open
* IVF given at minimal drip rate to maintain access.

47
Q

IV SL

A

IV saline lock
IV catheter in place in pt but not hooked up

48
Q

Record In’s

A

volume of any fluids fluids given to Pt IV or orally

49
Q

record out’s

A

record volume of urine output measured in a hat, urinal, foley cath

50
Q

Drain types

list 3

A
  1. NG tube
  2. Foley to gravity
  3. JP drain
51
Q

what is a JP drain

A

jackson pratt drain

52
Q

Medication list order

A

name, dose, route, frequency

53
Q

what three types of medication lists should be included

A
  • meds to treat diagnosis
  • meds to continue from home
  • PRN meds for the admission
54
Q

what should be included in lab/imaging orders

A
  1. study to be done
  2. time of day
  3. reason
55
Q

what should be included in a consultatino request?

A
  1. name of consult
  2. reason for consultation
56
Q

what are three types of special tests could be ordered

A
  1. DVT prophylaxis
  2. respiratory therapy
  3. oxygen
57
Q

how should DVT prophylaxis be ordered?

A

name, dose, route, frequency

58
Q

how should respiratory therapy be ordered?

A

name, dose, frequency of neb trx

59
Q

how should oxygen be ordered?

A
  • specific amount of O2
  • method of delivery
  • instructions for titration

Patient Assessment (20 decks)

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