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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
what should be ordered for toileting
bathroom privileges ex. OOB to bedside commode ex. bedpan
25
What 3 things should be considered for diet
1. does the diet fit patients condition/preference 2. does the patient need to be fed 3. daily fluid goals
26
Can diet orders be combined?
yes! ex. clear liquid diet for 24 hrs and advances as tolerated
27
NPO
nothing by mouth
28
IVF
intravenous fluids
29
what are the names of normal saline?
0.9% Normal saline 0.9% NS 0.9% NaCl ns
30
3 types of isotonic fluids
1. normal saline 2. Lactated ringer's solution 3. 5% dextrose in Water
31
what does lactated ringer's solution contain? | LR
* water * sodium * potassium * calcium * chloride * lactate
32
What does D5W start as and then turn into
starts as isotonic and then changes to hypotonic when dextrose is metabolized
33
what are the two types of hypotonic fluids
* 0.45% normal saline * D5W after its metabolized
34
what are the three names of hypotonic normal saline
* 0.45% ns * 0.45% NaCl * 1/2 NS
35
what are the 4 types of hypertonic fluids
* 3% normal saline * 5% Dextrose + 0.45% NS * 5% dextrose and lactated ringer * 10% dextrose in water
36
names for 5% dextrose + 0.45% normal saline
* D5 0.45% NS * D5 0.45% NaCl * D5 1/2 NS
36
D5LR
5% dextrose and lactated ringer
37
D10W
10% dextrose with water
38
How is a bolus IV given
rapidly wide open line over 15 minutes or less
39
when is a bolus IV indicated
* dehydration * hypotension * shock * active bleeding + unstable vitals
40
for what comorbidities should be caution be taken when giving bolus IV
* heart failure * chronic renal failure
41
standard adult dosing IVF bolus
500-1000 ml NS
42
how to dose IV bolus in pedatric patients
weight based dosing 20ml/kg
43
what is the dosage for typical maintenance dosage of IVF
30ml/kg/24 hrs
43
for what pts is maintenance IVF administered?
NPO, restricted oral intake, vomiting, hypotension requiring fluid resus.
44
what is the maintenance dosage for obese patients
24ml/kg/24 hours
45
when should a maintenance dose of 20-25ml/kg/24hrs be considered
* elderly * renal impairment * cardiac Failure * malnourished pts
46
IV NS at KVO
IV normal saline keep vein open * IVF given at minimal drip rate to maintain access.
47
IV SL
IV saline lock IV catheter in place in pt but not hooked up
48
Record In's
volume of any fluids fluids given to Pt IV or orally
49
record out's
record volume of urine output measured in a hat, urinal, foley cath
50
Drain types | list 3
1. NG tube 2. Foley to gravity 3. JP drain
51
what is a JP drain
jackson pratt drain
52
Medication list order
name, dose, route, frequency
53
what three types of medication lists should be included
* meds to treat diagnosis * meds to continue from home * PRN meds for the admission
54
what should be included in lab/imaging orders
1. study to be done 2. time of day 3. reason
55
what should be included in a consultatino request?
1. name of consult 2. reason for consultation
56
what are three types of special tests could be ordered
1. DVT prophylaxis 2. respiratory therapy 3. oxygen
57
how should DVT prophylaxis be ordered?
name, dose, route, frequency
58
how should respiratory therapy be ordered?
name, dose, frequency of neb trx
59
how should oxygen be ordered?
* specific amount of O2 * method of delivery * instructions for titration

Patient Assessment (20 decks)

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