USMLE Forum Archives - USMLE Step 3 - Standard Admit Orders
Standard Admit Orders
meduploader - 06-01-09 13:23
1. Admit to (Service), Medical floor, Telemetry, CCU or ICU
2. Diagnosis: Asthma or Chest Pain – R/O MI
Contributing Dx: DM, Dementia ....
3. Condition: (Stable, Fair, Serious, Critical) 4. Vitals: (Routine/Q shift/Q4 hours) or Q 1 hr until stable for 4 hr, then Q 4 hr. 5. Allergies: (NKDA)
6. Nurses instructions:
Spot pulse ox on arrival to floor and with nebulizer treatments.PEFR pre and post nebulizer treatments; record on chart.Call MD if: P < 50 or > 110; BP < 90/60 or > 160/100; RR > 30; pulse ox < 90%; decreased LOC; respiratory distress. STAT EKG for significant chest pain
ASA Overdose:
Suicide precautions.
Gastric lavage in ER with activated charcoal.
Consider dialysis if serum salicylate level greater than 70 mg/dl
Replace NG output cc per cc with 1/2 normal saline Q shift
7. Diet: (Regular, 1800 ADA, 2gm or 4gm Na+) or Clear liquids x 12 hr.
8. Activity: Bed rest with/without bathroom privileges with assistance.
9. Lab: (CBC c d & p, A-8, SMA, PT/PTT, CXR, U/A, EKG, DXT's, Ca-Mg-PO4). ABG if pulse ox < 90%, respiratory distress or altered consciousness. Total CK, monoclonal CK-MB, troponin I on admission (if not done in ER) for MI
CXR (portable) if not done in ER for Angina/MI.
CT of head without contrast if not previously done in ER for CVA
EEG: New onset seizures.
10. Meds: (Drug, dose, frequency): O2 @ 2, 4, 6 Liters/min via NC or FM.Albuterol nebulizer (2.5 mg in 3 cc NaCl) Q 8 hr.Methylprednisolone 125 mg IV bolus followed by 80 mg IVPS Q 6 hr.MSO4 2-10 mg SIVP Q 30 min prn severe chest pain.
Heparin 5000 U SQ Q 12 hr.
Coumadin 10 mg PO Q day x 3 days, then 5 mg PO Q 5 pm starting day four.
If both magnesium and PO4 are low, supplement magnesium first.
Lactulose 30 mL/ PO TID for Hepatic encephalopathy.
Acetaminophen level: If toxic range: begin N-acetylcysteine (mucomyst) 140 mg/kg PO followed by 70 mg/kg PO Q 4 hr for 68 hr.
11. PRN Meds:
Tylenol 500 mg 1-2 PO Q 4-6 hr prn pain/T > 101°F.MOM 30 cc PO Q 12 hr prn constipation.
Maalox 30 cc PO Q 2-4 hr prn indigestion.Benadryl 50 mg PO @ bedtime prn insomnia.
Ambien 10 mg PO QHS prn insomnia. Haldol 1-2 mg PO Q hr prn agitation.
Ativan 1 mg 1/2 - 1 PO Q 8 hr prn anxiety.
Phenergan suppl 25 mg pr Q 4 hr prn n/v.
Demerol 25-50 mg slow IVP Q 3-4 hr prn pain
12. IV:
#1 – 1000 mL normal saline at 1000mL/hr.
#2 – 1000 mL normal saline with 20 mEq KCl at 500mL/hr.
#3 – 1000 mL normal saline with 20 mEq KCl at 500mL/hr.
#4 – 1000 mL 1/2 normal saline with 20 mEq KCl at 250mL/hr.
#5 – 1000 mL D5-1/2 NS with 20 mEq KCl at 250mL/hr when glucose < 250 mg per dL.
ASA Overdose: D5 1/2 normal saline with 44 mEq bicarbonate/L @ 300 cc/hr (forced alkaline diuresis).
D5 1/2 normal saline @ 125cc/hr. HIV patient.
If esophageal variceal bleeding is suspected, consider Sandostatin 50ug bolus, then 50 ug/lhr continuous infusion.
For Hyperkalemia: Calcium gluconate: 10% 5-10 cc IV over 2-5 min; second dose may be given in 5 min; may repeat Q 1 hr prn Sx. If dig toxicity suspected, give over 30 min or omit.
Furosemide: 40-80 mg IV Q day.
Hypovolemic: normal saline IV @ 500 cc/hr until orthostasis resolves, then D5W (if hyperosmolar) or D5 1/2 normal saline (if not hyperosmolar) IV @ _____ cc/hr.
13. Additional Orders: IV orders: (Type at cc/hr or hr rate) DXT (AC and HS, Q4 hours, Q6 hours) Consider DVT prophylaxis with Lovenox 40 mg SQ Qd or Heparin 5000 u SQ bid.
14. Alcohol (DT) Precautions:B12 1000ug IM now & in M Vit. K 10mg IM now & qAM x3 Folate 1mg PO qday x4 MVI 1 PO qday Thiamine 100mg IM qday x3 Librium 25mg Po q6hrs PRN agitation Lab: Mg, ETOH level, PTT/PT
15. Sliding Scale Regular Humulin:BS <200 do nothing BS 200-300 5u SQ BS 300-400 10u SQ BS > 400 call MD
meduploader - 06-01-09 13:23
1. Admit to (Service), Medical floor, Telemetry, CCU or ICU
2. Diagnosis: Asthma or Chest Pain – R/O MI
Contributing Dx: DM, Dementia ....
3. Condition: (Stable, Fair, Serious, Critical) 4. Vitals: (Routine/Q shift/Q4 hours) or Q 1 hr until stable for 4 hr, then Q 4 hr. 5. Allergies: (NKDA)
6. Nurses instructions:
Spot pulse ox on arrival to floor and with nebulizer treatments.PEFR pre and post nebulizer treatments; record on chart.Call MD if: P < 50 or > 110; BP < 90/60 or > 160/100; RR > 30; pulse ox < 90%; decreased LOC; respiratory distress. STAT EKG for significant chest pain
ASA Overdose:
Suicide precautions.
Gastric lavage in ER with activated charcoal.
Consider dialysis if serum salicylate level greater than 70 mg/dl
Replace NG output cc per cc with 1/2 normal saline Q shift
7. Diet: (Regular, 1800 ADA, 2gm or 4gm Na+) or Clear liquids x 12 hr.
8. Activity: Bed rest with/without bathroom privileges with assistance.
9. Lab: (CBC c d & p, A-8, SMA, PT/PTT, CXR, U/A, EKG, DXT's, Ca-Mg-PO4). ABG if pulse ox < 90%, respiratory distress or altered consciousness. Total CK, monoclonal CK-MB, troponin I on admission (if not done in ER) for MI
CXR (portable) if not done in ER for Angina/MI.
CT of head without contrast if not previously done in ER for CVA
EEG: New onset seizures.
10. Meds: (Drug, dose, frequency): O2 @ 2, 4, 6 Liters/min via NC or FM.Albuterol nebulizer (2.5 mg in 3 cc NaCl) Q 8 hr.Methylprednisolone 125 mg IV bolus followed by 80 mg IVPS Q 6 hr.MSO4 2-10 mg SIVP Q 30 min prn severe chest pain.
Heparin 5000 U SQ Q 12 hr.
Coumadin 10 mg PO Q day x 3 days, then 5 mg PO Q 5 pm starting day four.
If both magnesium and PO4 are low, supplement magnesium first.
Lactulose 30 mL/ PO TID for Hepatic encephalopathy.
Acetaminophen level: If toxic range: begin N-acetylcysteine (mucomyst) 140 mg/kg PO followed by 70 mg/kg PO Q 4 hr for 68 hr.
11. PRN Meds:
Tylenol 500 mg 1-2 PO Q 4-6 hr prn pain/T > 101°F.MOM 30 cc PO Q 12 hr prn constipation.
Maalox 30 cc PO Q 2-4 hr prn indigestion.Benadryl 50 mg PO @ bedtime prn insomnia.
Ambien 10 mg PO QHS prn insomnia. Haldol 1-2 mg PO Q hr prn agitation.
Ativan 1 mg 1/2 - 1 PO Q 8 hr prn anxiety.
Phenergan suppl 25 mg pr Q 4 hr prn n/v.
Demerol 25-50 mg slow IVP Q 3-4 hr prn pain
12. IV:
#1 – 1000 mL normal saline at 1000mL/hr.
#2 – 1000 mL normal saline with 20 mEq KCl at 500mL/hr.
#3 – 1000 mL normal saline with 20 mEq KCl at 500mL/hr.
#4 – 1000 mL 1/2 normal saline with 20 mEq KCl at 250mL/hr.
#5 – 1000 mL D5-1/2 NS with 20 mEq KCl at 250mL/hr when glucose < 250 mg per dL.
ASA Overdose: D5 1/2 normal saline with 44 mEq bicarbonate/L @ 300 cc/hr (forced alkaline diuresis).
D5 1/2 normal saline @ 125cc/hr. HIV patient.
If esophageal variceal bleeding is suspected, consider Sandostatin 50ug bolus, then 50 ug/lhr continuous infusion.
For Hyperkalemia: Calcium gluconate: 10% 5-10 cc IV over 2-5 min; second dose may be given in 5 min; may repeat Q 1 hr prn Sx. If dig toxicity suspected, give over 30 min or omit.
Furosemide: 40-80 mg IV Q day.
Hypovolemic: normal saline IV @ 500 cc/hr until orthostasis resolves, then D5W (if hyperosmolar) or D5 1/2 normal saline (if not hyperosmolar) IV @ _____ cc/hr.
13. Additional Orders: IV orders: (Type at cc/hr or hr rate) DXT (AC and HS, Q4 hours, Q6 hours) Consider DVT prophylaxis with Lovenox 40 mg SQ Qd or Heparin 5000 u SQ bid.
14. Alcohol (DT) Precautions:B12 1000ug IM now & in M Vit. K 10mg IM now & qAM x3 Folate 1mg PO qday x4 MVI 1 PO qday Thiamine 100mg IM qday x3 Librium 25mg Po q6hrs PRN agitation Lab: Mg, ETOH level, PTT/PT
15. Sliding Scale Regular Humulin:BS <200 do nothing BS 200-300 5u SQ BS 300-400 10u SQ BS > 400 call MD
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