Others titles

  • Nursing Admission Orders
  • Nursing Inpatient Admission Order Sets

Keywords

  • Hospital Admission
  • Inpatient Care
  • Nursing Order Sets
  • Patient Care Plan
  • Admission Orders
  • Discharge Plan

Standardized Hospital Admission Orders

This dataset consists of 29 standardized hospital admission orders. These admission orders are developed by the family medicine department of the Scott & White Clinic at College Station, Texas. These orders are updated every two years.

Log in to download
Complexity

Get The Data

For getting access to data download links please read and accept the end-user license agreement.
Your Data License
  • Research
    Non-Commercial, Share-Alike, Attribution Free Forever
  • Commercial
    Commercial Use, Remix & Adapt, White Label Log in to download

John Snow Labs Standard End User License Agreement

Last updated:January 20, 2021

This Data Library End User License Agreement (“EULA”) applies to academic researchers, educators, and students using any product of John Snow Labs in John Snow Labs’ Data Library as defined below (hereinafter referred to “you”). This EULA is between you and John Snow Labs Inc., a Delaware corporation (“John Snow Labs”, “we” or “us”).

By downloading and/or using (as applicable) Data Library of John Snow Labs (as defined below), you automatically agree to be bound by, and use it in compliance with, this EULA. This EULA, together with additional terms and conditions and/or policies referenced herein or located on https://www.johnsnowlabs.com and/or conveyed to you by John Snow Labs, is a legally binding contract between you and John Snow Labs.

PLEASE READ THIS EULA CAREFULLY BEFORE DOWNLOADING OR USING DATA LIBRARY.

We may make changes to this EULA from time to time. When we do so, we will revise the “last updated” date given above. The then-current version of this EULA will supersede all earlier versions. You agree that your continued use of Data Library after such changes have been published to our EULA will constitute your acceptance of such revised EULA.

Definitions

“Data Library” means a data library provided by John Snow Labs and located at https://www.johnsnowlabs.com/marketplace/;

“Website” means https://www.johnsnowlabs.com being owned and operated by John Snow Labs.

Important Notice

By downloading and using any product from the Data Library, you acknowledge that the use of Data Library can be subject to the restrictions and controls imposed by United States export regulations.

You represent and warrant that you do not intend to use Data Library for any purpose prohibited by United States export regulations, including, without limitation, terrorism, cyber-attacks, cyber-crimes, money-laundering, industrial espionage, or nuclear, chemical or biological weapons proliferation. Further, you represent and warrant that you are not listed as a denied party on any list governing United States exports.

Eligibility

Our Data Library can be used by an individual.

In the event you have entered into a separate written agreement with John Snow Labs regarding Data Library that contemplates terms that are inconsistent with this EULA, the written agreement shall control and this EULA will not apply to you to the extent inconsistent with such written agreement, or, if such written agreement is contemplated to be in lieu of this EULA, then this EULA shall not apply at all

License Granted

Subject to your compliance with this EULA, as well as any other applicable policies, John Snow Labs grants you non-exclusive, non-transferable, revocable, license to download, access to, modify, and use of, Data Library worldwide (subject to applicable export laws) during the term of this EULA (as described below) under the following conditions:

  • The license can be used solely for research, private study and personal use of Data Library for unlimited period, or unless terminated under this EULA.were made;
  • This license is personal to you and is limited by all terms and conditions set forth in this EULA;
  • The license is granted as a non-commercial, attribution, share-alike and no-derivate-work license as more detailed below;
  • Under the attribution license, you must give the appropriate name of the creator and a copyright notice of John Snow Labs, provide link to this license and indicate if changes
  • Under the share-alike license, you can distribute modified works only under a license identical to this EULA;
  • Under the no-derivate-work license, you can perform only verbatim copies of Data Library, not derivate works or remixes based on it;
  • If the license is used for academic research purpose, the publication shall be made under the open-access, open-source and open-data license.

You can download any dataset from the Data Library from the Website.

Except for your pre-existing rights and this license granted to you, we and our licensors retain all rights, titles and interests in and to our Data Library, all related intellectual property rights, including trademarks (whether registered or pending), domain and business names. Our Data Library is protected by applicable intellectual property laws, including United States copyright law and international treaties.

John Snow Labs is entitled to revoke the license granted at any time at its sole discretion.

License Restrictions

You will be deemed to have taken any action that you permit, assist or facilitate any person or entity to take related to this EULA, your content or use of Data Library. You are responsible for end users’ use of your content and Data Library. You will ensure that all end users comply with your obligations under this EULA and that the terms of your agreement with each end user are consistent with this EULA. If you become aware of any violation of your obligations under this EULA caused by an end user, you will immediately suspend access to your content and Data Library by such end user.

License Restrictions

You will access or use our Data Library solely via John Snow Labs’ Data Library.

Except as otherwise explicitly provided in this EULA or as may be expressly permitted by applicable law, you will not, and will not permit or authorize any third party to:

  1. you cannot reproduce, translate, enhance, decompile, disassemble, reverse engineer or create derivative works of Data Library or its technological features or measures;
  2. you cannot rent, lease, sell, resell, loan, distribute, or sublicense access to any of Data Library;
  3. you cannot circumvent or disable any security or technological features or measures of Data Library;
  4. you cannot use our intellectual property rights without our express prior written authorization or in violation of this EULA;
  5. you cannot use Data Library with an intent to build a competitive product or service, or copy or substantially copy any ideas, features, functions, organization, structure, application program interface, graphics, or user interface of Data Library;
  6. you cannot copy, distribute, or resell any of the information; audio, visual, and audiovisual works, or other content made available on Data Library (collectively, “Content”) or compile or collect any Content as part of a database or other work;
  7. you cannot use any automated tool (e.g., robots, spiders) to access or use Data Library, or to store, copy, modify, distribute, or resell any Content;
  8. you cannot circumvent or disable any rights management, usage rules, or other security features of Data Library;
  9. you cannot use Data Library in a manner that overburdens, or that threatens the integrity, performance, or availability of, Data Library; or
  10. you cannot remove, alter, or obscure any proprietary notices (including copyright and trademark notices) on any portion of Data Library or any Content.

If you breach any of this EULA, the above license will terminate automatically.

Fees and Taxes

This license is for non-commercial use. If you wish to use our Data Library for commercial use, please contact us at support@JohnSnowLabs.com.

Support and Updates

Under this EULA, support services are excluded.

From time to time John Snow Labs can perform updates to our software. If available, such updates may include bug fixes, new features and/or enhancements. You are solely responsible for deploying such updates at your own risk and liability.

Term and Termination

This EULA will become effective as of the date of your order of Data Library and shall be in effect until terminated.

John Snow Labs may suspend or terminate your right to use Data Library, if you or your end user’s use of Data Library:

  1. is in breach of this EULA;
  2. poses a security risk to Data Library;
  3. could adversely impact our systems, Data Library or other customers;
  4. could subject us, our affiliates, or any third party to liability; or
  5. could be fraudulent.

We may also suspend or terminate your right to use Data Library, if you have ceased to operate in the ordinary course, made an assignment for the benefit of creditors or similar disposition of your assets, or become the subject of any bankruptcy, reorganization, liquidation, dissolution or similar proceeding.

You will cease use of Data Library during any period of suspension, or upon termination of this EULA.

All provisions which by their nature are intended to survive termination shall survive termination of this EULA.

Access to Data Library

We do not provide you with the equipment to access Data Library. You are responsible for all fees charged by third parties related to your access and use of Data Library (e.g., charges by Internet service providers).

You are responsible for monitoring your use of Data Library, including payment of all fees and/or taxes related to such access and use. You agree that John Snow Labs is permitted to request and you hereby consent to provide John Snow Labs information related to your use of Data Library for auditing purposes.

You also certify that you are legally permitted to use Data Library, and take full responsibility for the selection and use of Data Library. This EULA is void where prohibited by law, and the right to use Data Library is revoked in such jurisdictions. John Snow Labs makes no claim that Data Library may be lawfully used outside of the United States. If you use Data Library from outside of the United States, you do so at your own risk and you are responsible for compliance with the laws of jurisdiction.

Privacy Policy

We may collect, store and receive personal and other information about you through our Products. Our collection and use of this information is governed by our Privacy Policy available at https://www.JohnSnowLabs.com/privacy/ which may be amended from time to time.

Links and Third Party Content

Data Library may display, or contain links to, third party products, services, and websites. Any opinions, advice, statements, services, offers, or other information that constitutes part of the content expressed, authored, or made available by other users or other third parties, or which is accessible through or may be located using Data Library (collectively, “Third Party Content”) are those of the respective authors or producers and not of us or our shareholders, directors, officers, employees, agents, or representatives.

We do not control Third Party Content and do not guarantee the accuracy, integrity or quality of such Third Party Content. We are not responsible for the performance of, we do not endorse, and we are not responsible or liable for, any Third Party Content or any information or materials advertised in any Third Party Content. By using Data Library, you may be exposed to content that is offensive, indecent, or objectionable. We are not responsible or liable, directly or indirectly, for any damage or loss caused to you by your use of or reliance on any goods, services, or information available on or through any third party service or Third Party Content. It is your responsibility to evaluate the information, opinion, advice, or other content available on and through our Products.

Proprietary Rights

John Snow Labs will not obtain any rights under this EULA from you (or your licensors) to your content.

Data Library is and remains the exclusive property of John Snow Labs and its licensors. Except for the access and use rights expressly set forth in this EULA, no license or other rights in or to Data Library or John Snow Labs trademark(s) and other intellectual property rights therein, are granted to you, and all such licenses and rights are expressly reserved. You will not remove, alter, or obscure any proprietary notices (including copyright and trademark notices) on any portion of Data Library or any Content.

Trademarks

“John Snow Labs,” the John Snow Labs logo, and any other product, business or service name or slogan, whether registered or pending, displayed on Data Library are trademarks of John Snow Labs, Inc. or its suppliers or licensors, and may not be copied, imitated or used, in whole or in part, without the prior written permission of John Snow Labs or the applicable trademark holder. You may not use any metatags or any other “hidden text” utilizing “John Snow Labs” or any other name, trademark or product, business or service name of John Snow Labs without our prior written permission. In addition, the look and feel of Data Library, including all page headers, custom graphics, button icons and scripts, is the service mark, trademark and/or trade dress of John Snow Labs may not be copied, imitated or used, in whole or in part, without our prior written permission. All other trademarks, pending trademarks, registered trademarks, product names and company names or logos mentioned in Data Library are the property of John Snow Labs Inc. and/or their respective owners. Reference to any products, services, processes or other information, by trade name, trademark, manufacturer, supplier, or otherwise does not constitute or imply endorsement, sponsorship, or recommendation thereof by us.

Disclaimer of Warranties

YOUR USE OF DATA LIBRARY IS AT YOUR SOLE RISK. THE PRODUCTS AND CONTENT EACH ARE PROVIDED ON AN “AS IS” AND “AS AVAILABLE” BASIS. WE AND OUR SUPPLIERS AND LICENSORS EXPRESSLY DISCLAIM ALL WARRANTIES OF ANY KIND, WHETHER EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, TITLE, AND NON-INFRINGEMENT. WE DO NOT GUARANTEE THE ACCURACY, COMPLETENESS, OR USEFULNESS OF THE PRODUCTS OR ANY CONTENT, AND YOU RELY ON THE PRODUCTS AND CONTENT AT YOUR OWN RISK. ANY MATERIAL THAT YOU ACCESS OR OBTAIN THROUGH OUR PRODUCTS IS DONE AT YOUR OWN DISCRETION AND RISK AND YOU WILL BE SOLELY RESPONSIBLE FOR ANY DAMAGE TO YOUR COMPUTER OR LOSS OF DATA THAT RESULTS FROM THE DOWNLOAD OF ANY MATERIAL THROUGH OUR PRODUCTS. NO ADVICE OR INFORMATION, WHETHER ORAL OR WRITTEN, OBTAINED BY YOU FROM US OR THROUGH OR FROM OUR PRODUCTS WILL CREATE ANY WARRANTY NOT EXPRESSLY STATED IN THIS EULA. SOME STATES MAY PROHIBIT A DISCLAIMER OF WARRANTIES AND YOU MAY HAVE OTHER RIGHTS THAT VARY FROM STATE TO STATE.

Limitation of Liability

WE AND OUR SUPPLIERS AND LICENSORS WILL NOT BE LIABLE FOR ANY DIRECT, INDIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL, OR EXEMPLARY DAMAGES, INCLUDING BUT NOT LIMITED TO, DAMAGES FOR LOSS OF PROFITS, GOODWILL, USE, DATA, OR OTHER INTANGIBLE LOSSES (EVEN IF WE HAVE BEEN ADVISED OF THE POSSIBILITY OF THESE DAMAGES), RESULTING FROM YOUR USE OF OUR PRODUCTS AND CONTENT. UNDER NO CIRCUMSTANCES WILL THE TOTAL LIABILITY OF US AND OUR SUPPLIERS AND LICENSORS OF ALL KINDS ARISING OUT OF OR RELATED TO YOUR USE OF THE PRODUCTS AND CONTENT (INCLUDING BUT NOT LIMITED TO WARRANTY CLAIMS), REGARDLESS OF THE FORUM AND REGARDLESS OF WHETHER ANY ACTION OR CLAIM IS BASED ON CONTRACT, TORT, OR OTHERWISE, EXCEED THE AMOUNTS, IF ANY, THAT YOU HAVE PAID FOR YOUR USE OF THE PRODUCTS AND CONTENT. BECAUSE SOME STATES DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, THE ABOVE LIMITATION MAY NOT APPLY TO YOU.

Indemnity

To the full extent permitted by applicable law, you shall defend, indemnify and hold harmless John Snow Labs, its affiliates and its licensors, and each of their respective employees, officers, directors, and representatives from and against any claims, damages, losses, liabilities, costs, and expenses (including reasonable attorney’s fees) arising out of or relating to any third party claim concerning: (a) your use of Data Library; (b) breach of this EULA or violation of applicable law by you; (c) any content or the combination of such content with other software, content or processes, including any claim involving alleged infringement or misappropriation of third-party rights by such content or combination; or (d) breach of any obligation or duty you owe to a third party.

Legal Notices

Enforcement of this EULA will be governed by the laws of the State of Delaware, excluding its conflict and choice of law principles. The exclusive jurisdiction and venue for any claims arising out of or related to this EULA or your use of Data Library will lie in the state and federal courts located in Sussex County, within the State of Delaware, and you irrevocably agree to submit to the jurisdiction of such courts. Our failure to enforce any right or provision in this EULA will not constitute a waiver of such right or provision unless acknowledged and agreed by us in writing. In the event that a court of competent jurisdiction finds any provision of this EULA to be illegal, invalid, or unenforceable, the remaining provisions will remain in full force and effect.

Notifications

We may use your contact information to notify you if we have any legitimate interest or if we need to notify you on any important information related to your use of Data Library. We will not send you newsletters unless you expressly consented to such notifications.

Contacting Us

If you have any questions or concerns about Data Library or this EULA, you may contact us by email at support@JohnSnowLabs.com.

Description

The purpose of the Standardized Admission Orders is to reduce variability, simplify work processes and improve the quality of patient care services, especially for family physicians because the scope of their specialty is vast. During a typical day, it is normal for them to encounter a wide variety of patient problems, and nowhere is it as difficult – or important – for them to strive for consistency, efficiency and accuracy in patient care as in the hospital setting.

When standardized admission orders were first developed seven years ago, there were 27 conditions that were thought to be most useful. There are currently 29 admission orders that cover the conditions that the family physicians most frequently encounter in the hospital. It has been observed that this order set covers more than 90 percent of hospital admissions. These order sets are updated every two years.

The admission orders cover the following conditions: Acute Mental Status Change, Acute Myocardial Infarction, Acute Pancreatitis, ASA Overdose, Asthma, Chest Pain, Childhood Bacterial Meningitis, Community Acquired Pneumonia, Congestive Heart Failure, Croup, CVA, Diabetic Ketoacidosis, DVT Lovenox Therapy, DVT Discharge, Endometritis, HIV Pneumonia, Hyperkalemia, Hypernatremia, Hypokalemia, Hyponatremia, Lower GI Bleed, Intractable Headache, Neutropenic Fever, Partial Small Bowel Obstruction, Pediatric Vomiting-Diarrhea-Dehydration, Pelvic Inflammatory Disease, Pyelonephritis, Seizures, Upper GI Bleed

About this Dataset

Data Info

Date Created

2001-10-01

Last Modified

2006-09-13

Version

2006-09-13

Update Frequency

Biennial

Temporal Coverage

N/A

Spatial Coverage

United States

Source

John Snow Labs; American Academy of Family Physicians, Family Medicine Department of the Scott & White Clinic at College Station Texas;

Source License URL

Source License Requirements

N/A

Source Citation

N/A

Keywords

Hospital Admission, Inpatient Care, Nursing Order Sets, Patient Care Plan, Admission Orders, Discharge Plan

Other Titles

Nursing Admission Orders, Nursing Inpatient Admission Order Sets

Data Fields

Name Description Type Constraints
Admission_Order_NameName of admission orderstringrequired : 1
Patient_NameName of the patientstring-
Patient_AgePatient's agestring-
Patient_Date_of_Birthpatient's date of birthstring-
Medical_Record_NumberMedical record numberstring-
StatusStatus of admission. "____" specifies that a value needs to be filled by physicians/nurses in these blanks.stringrequired : 1
Attending_Doctor_NameName of attending physicianstring-
Attending_Doctor_PhonePhone number of attending physicianstring-
Admitting_DiagnosisDiagnosis at the time of admission. "____" specifies that a value needs to be filled by physicians/nurses in these blanks.stringrequired : 1
ICD_10_CM_CodesICD-10-CM codes for Admitting_Diagnosisstringrequired : 1
ICD_10_CM_Codes_DescriptionDescription of ICD-10-CM codes for Admitting_Diagnosisstringrequired : 1
Associated_or_Contributing_DiagnosisAssociated/accompanying diagnosesstring-
Patient_ConditionCondition of patient at the time of admissionstringrequired : 1
Code_StatusValue: Full Code, DNR (Do-Not-Resuscitate order)string-
AllergiesAllergies, if anystring-
DietRecommended diet. "____" specifies that a value needs to be filled by physicians/nurses in these blanks.string-
ActivityAtivity restrcition, if anystring-
Nursing_ResponsibilitiesNursing Orders. "____" specifies that a value needs to be filled by physicians/nurses in these blanks.string-
MedicationsList of Medications prescribed for the treatment. "____" specifies that a value needs to be filled by physicians/nurses in these blanks.string-
IV_AdministrationIV given for the treatment. "____" specifies that a value needs to be filled by physicians/nurses in these blanks.string-
Laboratory_TestsLab tests performed. "____" specifies that a value needs to be filled by physicians/nurses in these blanks.string-
Radiology_ProceduresRadiology procedures performedstring-
Nursing_ConsiderationsMedications or tests to consider, if anystring-
Diagnostic_StudiesDiagnostic studies done on patient's conditionstring-
DecisionDecision made, as part of patient care planstring-
ConsultConsultation recommended to patientstring-
Patient_EducationPatient educationstring-
Follow_UpFollow-up plans, if any. "____" specifies that a value needs to be filled by physicians/nurses in these blanks.string-
ImmunizationsDecision related to immunizationstring-
Other_OrdersMiscellaneous orders, if anystring-
Date_And_TimeDate and time of visit.string-

Data Preview

Admission_Order_NamePatient_NamePatient_AgePatient_Date_of_BirthMedical_Record_NumberStatusAttending_Doctor_NameAttending_Doctor_PhoneAdmitting_DiagnosisICD_10_CM_CodesICD_10_CM_Codes_DescriptionAssociated_or_Contributing_DiagnosisPatient_ConditionCode_StatusAllergiesDietActivityNursing_ResponsibilitiesMedicationsIV_AdministrationLaboratory_TestsRadiology_ProceduresNursing_ConsiderationsDiagnostic_StudiesDecisionConsultPatient_EducationFollow_UpImmunizationsOther_OrdersDate_And_Time
Intractable Headache 23 hr observationIntractable HeadacheG43.911Migraine, unspecified, intractable, with status migrainosusStable; Fair; Serious; CriticalRegular; but no caffeineNotify MD for: T > 100, P < 60 or > 120, BP < 90/60 or > 170/110No analgesics; No narcotics; Reglan 10 mg IV followed by DHE 0.5 mg IV; Then every 8 hrs give Reglan 10 mg IV followed by DHE 1 mg IV until patient is 100% HA free X 24-48 hrs (HA scores = 0); Other: _____HeplockHemogram, basal metabolic profile
Hypernatremia Observation; Admission; Monitored bed; ICUHypernatremiaE87.0Hyperosmolality and hypernatremiaStable; Fair; Serious; CriticalBed rest and up in chair as tolerated Notify MD for T > 101, BP > 190/100 or < 90/60, neuro changesHypovolemic: _____ normal saline IV @ 500 mL/hr until orthostasis resolves, then Dextrose 5% in water (if hyperosmolar) or Dextrose 5% in 1/2 normal saline (if not Hyperosmolar) IV @_____ mL/hr; Hypervolemic: Lasix 80 mg IV/PO daily; Dextrose 5% in water @ ______ mL/hr Comp met profile; UA ; Urine NA; TSH; Urine OSM
ASA Overdose Observation; Admission; Medical floor; Monitored bed; OtherASA overdoseT39.014Poisoning by aspirin, undetermined, initial encounterStable; Fair; Serious; CriticalFull Code; DNRNPO; Clear Liquid; AHA step 2; ADA; OtherBed rest with bathroom privilegesVital signs every 4 hrs for 24 hrs then every 4 hrs if stable; Suicide precautions; Gastric lavage in ER with activated charcoal; Consider dialysis if serum salicylate greater than 70 mg/dlVitamin K 10 mg IM now; Guaiac all stools; OtherDextrose 5% in 1/2 normal saline with 44 mEq bicarbonate/L @ 300 mL/hr (forced alkaline diuresis)ABGs; Hemogram; Lytes; Glucose; Salicylate level, if not done in ERPsych; Social services; MHMR
Lower Gi Bleed Medical; Telemetry; ICULower GI BleedK92.2Gastrointestinal hemorrhageStable; Fair; Serious; CriticalNPO except meds; OtherBed rest with bedside commode; Bathroom privileges with assistanceICU: per routine; Medical: every 1 hr until stable X4, then every 2 hrs until stable X4, then every 4 hrs; Notify MD for: BP < 90/60 or > 180/110, P < 60 or > 120, urine output < 30 cc/hr over 4 hrs, all H/H resultsBolus normal saline _____cc over _____; Dextrose 5% normal saline with 20 mEq KCl/L @ _____mL/hr totalHemogram, comp met profile, PT/PTT/INR on admission; HH every 6 hrs X24 hrs; Type and screen for _____units PRBCHave patient sign informed consent form for blood transfusion.
Upper GI Bleed Observation; Admission; Medical Floor; Telemetry; ICUUpper GI BleedK92.2Gastrointestinal hemorrhageStable; Fair; Serious; CriticalNPO except meds, NPO including medsBed rest with bedside commode; Bathroom privileges with assistanceICU: per routine; Telemetry or medical: every 1 hr until stable X4, then every 2 hrs until stable X4, then every 4 hrs; Notify MD for: BP < 90/60 or > 170/110, P < 60 or > 120, Urine output < 30 cc/hr over 4 hrs, all H/H results; If NG to suction, replace NG fluid cc for cc with NG with 20 mEq KCl every 12 hrsProtonix 40 mg PO/IV every 12 hrs; Other: ___Bolus normal saline _____cc over ______; Dextrose 5% normal saline with 20mEq KCl/l @ _____mL/hr totalHemogram, comp met profile, PT/PTT/INR on admission; HH every 4 hrs X3; Type and screen for _____units PRBC
Pediatric Vomiting/Diarrhea/Dehydration Pediatric Floor: Observation; AdmissionPediatric vomiting/diarrhea/dehydrationR11.10; R19.7; E86.0Vomiting unspecified; Diarrhea unspecified; DehydrationStable; Fair; Serious; CriticalNPO; Formula/Breast; Age appropriate diet as toleratedCrib; Bassinet; BedVital signs: every 4 hrsTylenol (10 mg/kg) _____ PO/PR every 4 hrs prn T > 101; Phenergan 12.5-25 mg PR 1 6-8 hrs prn n/vReplacement (mls) = % X wt (kg): Replacement 1/3 over first 4 hrs with Dextrose 5% in 1/2 normal saline; Replacement 1/3 over second 8 hrs with Dextrose 5% in 1/2 or 1/4 normal saline; Replacement 1/3 over third 12 hrs with D5.2 normal saline; Replace in addition to maintenanceBasal metabolic profile, CBC UA on admission; basal metabolic profile in a.m.; Stool for rotazyme, routine culture, O&P, yersinia
Partial Small Bowel Obstruction Surgical; Medical Floor; Observation; AdmissionPartial Small Bowel ObstructionK56.60Unspecified intestinal obstructionStable; Fair; Serious; CriticalNPO Bed rest with bathroom privileges with assistanceVital signs: every 4 hrs for 24 hrs then every shift; Notify MD for: T > 101.5, P > 120, BP < 90/60 or > 180/110; NG tube to low continuous suction; I&ODemerol 25-50 mg slow IVP every 3-4 hrs prn pain; Phenergan 12.5 mg slow IVP every 3-4 hrs Dextrose 5% normal saline with 20 mEq KCl @ 125 mL/hr; Bolus _____; Replace NG output mL per mL with ______ normal saline every 12 hrsDaily hemogram, basal metabolic profile in a.m.X-ray: acute abdominal series if not done in ER/clinicSurgical consult as indicated (complete obstruction); Consider DVT prophylaxis with Lovenox 40 mg sq daily; Consider gastrografin UGI with small bowel follow-through after 24-26 hrs of NG suction
Hyponatremia Observation; Admission; Medical bed; Telemetry; ICUHyponatremiaE87.1Hypo-osmolality and hyponatremiaStable; Fair; Serious; CriticalFull Code; DNRNPO; Clear liquid; AHA step 2; ADA ______ calories; OtherBed rest with bathroom privileges with assistanceOrthostatic VS every 4 hrs until stable x4, then every shift; Notify MD for: T > 101, BP < 90/60 or > 190/100, neuro changesHypovolemic: ______ normal saline IV @ 500 mL/hr until orthostasis resolves, then; Dextrose 5% normal saline (if hyperosmolar) at ______ mL/hr, OR; Dextrose 5% in 1/2 normal saline (if not hyperosmolar) at _____ mL/hr; Hypervolemic: Lasix 80 mg IV/PO daily; Dextrose 5% in water at _____mL/hrCMP, UA, urine Na+, TSH, urine OSM, plasma osmolality and CXR on arrival daily BMPDVT prophylaxis with Lovenox 40 mg SQ daily; D/C medications that could contribute to hyponatremia (i.e., diuretics, Tegretol, SSRI, amiodarone, theophylline)
Pyelonephritis Observation; Admission; Medical Floor; Monitored bed; OtherPyelonephritisN10Acute pyelonephritisStable; Fair; Serious; CriticalFull Code; DNRNPO; Clear liquid; AHA step 2; ADA ______ calories; OtherBed rest with beside commode; Bathroom privileges; Up ad libVital signs every 4 hrs for 24 hrs then every shift; Notify MD for: T > 101.5, P > 120, BP < 90/60 or > 180/110; Daily weight; I&OLevaquin 500 mg IV every 24 hrs; Tylenol 650 mg PO every 4 hrs prn temp > 100/pain; Phenergan 25 mg IV/IM every 4 hrs prn nausea; Demerol 50 mg IM every 4 hrs prn pain; If toxic: consider adding Gentamycin (7mg/kg/day) IVP; adjust for renal dose if indicatedDextrose 5% in 1/2 normal saline @ 100 mL/hr; Other _____Admission: blood cultures x2 prior to antibiotics, CBC, UA, urine culture, basal metabolic profile; Daily: CBCIf history of stones or recurrent pyelo consider IVP or renal ultrasound; DVT prophylaxis with Lovenox 40 mg sc daily
Seizure Disorder Observation; Admission; Medical Floor; Telemetry; ICUSeizure DisorderG40.89Other seizuresStable; Fair; Serious; CriticalBed rest with seizure precautionsVital signs: every 2 hrs with neuro checks until stable X4, then every 4 hrs; Notify MD for: T > 100, BP < 90/60 or > 170/110, seizures, Glasgow coma scale < 15Dilantin loading options:; PO Dilantin _____mg (15 mg/kg) every 4 hrs X3 doses, OR; IV Dilantin 50 mg/min; IVP to total of _____mg (18 mg/kg) then begin Dilantin 300 mg PO daily, OR; Fosphenytoin-load (10-20 PE/kg); Ativan 2-4 mg slow IVP over 10 min prn active seizures lasting more than 3 min; Tylenol 650 mg PO every 4-6 hrs prn fever or pain; MOM 30 mL PO every 12 hrs prn constipation; Other ______Hemogram; Comp met profile; VDRL; Urine Toxicology screen for “drugs of abuse”MRI of head with and without contrast for “new onset seizures, R/O mass, lesion”; EEG for “new onset seizures” to be read by neurologist