Introduction to admission orders Flashcards
ADC VANDALISM Here
admit diagnosis condition vitals allergies nursing diet activity labs IV special medications house officer
where are you admitting the pt
general med floor gen surgical floor med/surg ICU (cardiac, medical, surgical, neuro) acute telemetry
who are you admitting the pt to
attending name
service name
diagnosis
whats the reason they are being admitted
list in order of priority (most concerning thing first)
not the place to put diff diagnosis
-why in hospital and not sending home
condition
stable
guarded
poor
critical
stable
vitals look good, doesn’t look distressed
guarded
not really sure, may get better or worse
poor
not doing well but not to critical point
code status: recussatation status
full code
DNR
DNI
full code: do everything needed to save them
DNR: allow nature to take its course
DNI: do not intubate
vitals:
how often
typical
and others like O2 and daily weight
allergies
what allergic to and what is reaction
nursing
nursing orders
activity
are you going to let your pt move around
up ad lib (can walk around as much as they like) up with assistance bedside commode up to chair TID fall precuations bedrest ambulate 3 times a day
labs
what kind of tests and when do you need them now (get done today) stat (get done ASAP) in AM ( tomorrow early around 4 am)
IV/meds
normal saline
lactated ringers
D5 1/2 NS
