Admit to: observation

Admission Order Set
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Status: OUTPATIENT OBSERVATION & SERVICES
Level of Care: Med Surg (3 South 4 North) IMC/DOU (2 North 2 South) Tele (2 North 2 South)  ICU  CCU Can be
transported w/o RN unless otherwise stated Needs to be transported w/ RN Respiratory isolation (place in neg pressure room)
DIAGNOSIS : _____________________________________________________________________
CONDITION: Stable Fair Guarded Critical Case Management Eval Social Worker Eval Financial Counselor Eval
Vitals: Per protocol Orthostaticx1 Neuro checks Q____H
Activity: Up adlib Bed rest Bed rest with bathroom privileges Pt. eval and treat Ot eval and treat Speech eval and
treat Swal ow eval and treat
Precautions: Fal Seizure Aspiration Suicide Sitter 1 to one 1 Sitter (for suicidal pt admitted to floor)
Allergies: NKDA Latex Sulfa PCN _______________________
Code status: Full code DNR (fil Blue DNR form) limited resuscitation (fil Blue DNR form)
Diet: Regular AHA Renal Consistent carbohydrate Clear Liquids NPO except med NPO ________________
IVF: Saline Lock 0,9 NS AT KVO 0,9 NS AT________ml/hr ___________________
NURSING: Spo2 on ra after ambulation Strict I&Os Daily weight Foley catheter with care Diabetic teaching Peg site
care (if applicable) Smoking cessation if indicated Pneumococcal and influenza vaccine per hospital protocol
Notify MD if: Temp: below 36.1 above 38.5 SBP below 95 above 180 DBP below 35 above 110 Pulse below 50 above 110
SPO2 below 90 on RA Urine output less than 30 ml in 2 hours
RESPIRATORY: IS Q1 While awake Notify MD if SPO2 below 90 on RA ___________________
DVT Prophylaxis: Heparin 5000 units subcutaneously Q8hrs Enoxoparin (Lovenox) 40mg subcutaneous daily (decrease to 30 mg if
Creatinine clearance less than 30mL/min) SCDs to BLE SCDs to BLE if dopplers negative (BLE venous dopplers notify md if abnormal order venous dopplers only if box SCDs to BLE if dopplers negative is checked) Ambulate tid GI Prophylaxis: Pantaprazole (Protonix) 40 mg PO daily Pepcid 20mg PO bid
HTN: Hydralazine 5mg IV Push Q4Hrs prn SBP above 180 or DBP above 110
Nausea:  Ondansetron (Zofran) 4mg IV Push Q4Hrs prn nausea vomiting  Reglan 5mg IV Push Q6Hrs prn nausea vomiting
Insomnia: Zolpidem (Ambien) 5mg po Qhs prn Insomnia, may repeatx1 Restoril 7.5mg po Qhs prn Insomnia, may repeatx1
Temperature: Acetaminophen 650 mg po q4h prn temperature over 101 Cooling blanket PRN fever Bear hugger (heating
blanket) for hypothermia
PAIN: Acetaminophen 650 mg po q4h prn mild pain ______________________________Q4HPRN for moderate pain
______________________________Q4HPRN for severe pain
Admission Order (08/30/12)
Admission Order Set
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GI: Docusate (Colace) 100mg po daily bid (Hold for diarrhea) Dulcolax supp 10mg pr daily prn constipation
Miralax 17 gm po daily (hold for diarrhea) Lactulose 30ml po daily prn constipation Loperamide (Imodium) 2mg po prn diarrhea after each loose stool up to 16mgday Aluminum/Magnesium/Simethicone (Maalox) 10 ml po Q4h prn heart burn Simethicone 80mg po Q6h prn flatulence Calcium Carbonate Chewable (Tums) 1000mg po Q4h prn heart burn max 15 tablets/day ANXIETY: ____________________________________________________________________ Q6h prn for anxiety prn for anxiety
Diagnostics:
Morning Labs: cbc bmp chem12 renal panel BCP lipid panel TSH HgbA1C CK&troponin
Point of care glucose testing AC&HS with lispro insulin supplemental scale as below If Glucose <60 Dextrose 50%, 50mL (25Gms) IV Push x1 & notify MD 61 – 70: if able to take PO give juice/snack, if unable to take PO, Dextrose 50%, 25mL (12.5Gms) IV Push x1 & notify MD Please choose below scale or order custom  Blood glucose (mg/dL)
Lispro Insulin subcut.
 Blood glucose (mg/dL)
Lispro Insulin subcut.
Notify MD if glucose above 300mg/dL on 2 consecutive readings if pt has AMS, respiratory depression do stat point of care glucose test and notify MD TO/VO: _______________________________ Print MD Name: _____________________________
Required read back completed: MD Signature: ______________________________
Date: __________ Time: __________ Date: __________ Time: __________
Admission Order (08/30/12)

Source: https://communicate.chw-interactive.org/cm/media/documents/admisson_order_set.pdf