Term
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Definition
• Name of attending
• Location or level of care
REMEMBER TO DATE AND TIME ALL ORDERS! and
REMEMBER TO DATE AND TIME ALL ORDERS! |
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Term
Mnemonic
• ADC VANDALISM(C) • ADC VAAN DIML
ADC VANDIMLS |
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Definition
| Now, there are a number of mnemonics for doing admission orders. I like ADC VAAN DIML, because A stands for "admit," D stands for "diagnosis," C stands for "condition." And what I'm going to do now is we're going to go through each one of those things in the mnemonic. |
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Term
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Definition
• List admitting diagnosis or procedure if post-op note
• It is better to put a positive diagnosis than a negative diagnosis
• Diagnosis: Abdominal pain not
• Diagnosis: Rule out appendicitis |
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Term
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Definition
• Here you justify the level of care needed. • If ICU, write “critical.”
• General or observation, write “fair.”
• Avoid “good” and “stable.”
• “Stable” for ICU is different than “stable” for general floor.
• Patient in ICU could be on a vent and be stable
• Then you may put “stable with critical/guarded/fair” |
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Term
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Definition
• How often do you want vitals taken?
• T/BP/P/RR
• May not include oxygen saturation (check with facility)
• Typical is q shift on a general medicine floor
• Match the frequency with how sick the patient is and if the results will change the care of the patient |
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Term
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Definition
• List or write NKDA (no known drug allergies) • If the patient has an allergy, list the type of
reaction if known
• Allergies: PCN—hives and SOB
• Also note allergies to environmental items • E.g., latex |
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Term
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Definition
• What do you want nursing to do? If not listed, it will not be done.
• Examples: • I&O
• NG to LIS
• Continuous pulse oximetry
• Bedside blood glucose AC & HS • Turn patient every 2 hours
• Dressing changes
• HOB at 45 degrees |
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Term
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Definition
• If you don’t order a diet, the patient does not eat
• Describe what you want the patient to have or not have
• NPO
• Clear liquids and advance as tolerated • Regular
• 1800 cal ADA
• Writing “as tolerated” is not sufficient |
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Term
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Definition
• What do you want the patient’s limits to be? • Up in halls TID
• Bed rest
• Bathroom with assistance
• Bedside commode with assistance • “Up in arms” ad lib for pediatrics |
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Term
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Definition
• List all the labs and frequency or timing
• CBC q AM
• Gentamycin level 1⁄2 hour before next dose
• BMP q 8 hours
• CMP in AM
• Blood cultures times 3 at least 15 minutes apart
• Bring all stat requests to nursing attention right away. |
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Term
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Definition
• List the type of fluid and rate • 0.9 NS at 85 cc/hour
• D5 NS with KCl 20 mEq at 100 cc/hour
• Rates and daily intake
• 50 cc/hour = 1200 cc/day • 83 cc/hour = 2000 cc/day • 100 cc/hour = 2400 cc/day
• Normal daily intake is 100 cc/hour • 150 cc/hour = 3600 cc/day |
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Term
| Composition of Common Crystalloid Solutions |
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Definition
D5W- 5% Dextrose--- 252 Glucose
Half-normal saline 0.45% NaCl--- 77 Na, 77Cl
Normal saline- 0.9% NaCl--- 154 Na, 154Cl
Ringer's lactate, lactated ringer- 130Na, 109 Cl and 28mmol/L lactate, 4 mmol/L K+, 3 mmol/L Ca2+ |
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Term
| effect of adding one liter of different crystalloid solutions |
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Definition
D5W- 333mL change in ECF, 667mL change in ICF
half-normal saline 667mL change in ECF, 333mL change in ICF
normal saline- 1,000mL change in ECF, 0 mL change in ICF
ringer's lactate- 900 mL change in ECF, 100 mL change in ICF |
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Term
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Definition
• List special tests like radiology: • CT scan
• X-ray
• MRI, etc.
• Make sure you give location of what you want x-rayed and why
• (E.g., PA/lateral CXR—history of hemoptysis)
• Do you want a wet reading and called back to you |
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Term
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Definition
• Specify which consultant (may want a specific MD) and why.
• E.g., consult and comanagement with Dr. Bone for right hip pain
• If at all possible, call the consultant yourself to discuss the case. |
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Term
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Definition
• List the following
• Med, dose, interval, route, and duration if applicable
• E.g., Lasix 20 mg PO q12 hours
• Don’t forget prn meds with dose, interval, route
• Sleep, e.g., Ambiem
• Nausea, e.g., phenergan • Pain, e.g., ibuprofen
• Fever, e.g., Tylenol
Writing for these saves middle-of-the-night phone calls |
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Term
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Definition
• Parameters for when you want to be notified of any change:
• Call house officer if:
• O2 sat <92%
• Temp > 101.5°F
• Pulse <60 or >100 per minute • RR <6 or >24 per minute
• SBP <80 or >180 mm Hg
• Urine output < 100 cc/8 hours |
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Term
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Definition
• Respiratory precautions
• Strict isolation
• Suicide precautions
• Seizure precautions |
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