Admission Orders Template

Admission Orders Template: Please note the template added is almost complete Please add supporting literature with 4 references/ Citations APA style using the Required Admission Orders Template, and write a full set of admission orders for the patient in the branching exercise. MY ORDERS ARE ENTERED IN THE TEMPLATE ANY RATIONALE MUST BE ENTERED AFTER MY ORDERS 

  • Be sure to address each aspect of the order template
  • Write the orders as you would in the patient’s chart
  • Make sure the order is complete and applicable to the patient
  • Any rationale you feel the need to supply should be done at the end of the order set – not included with the order
  • Please do not write per protocol. We do not know what your protocol is and you need to demonstrate what is the appropriate standard of care for this patient.
  • A minimum of four current, evidenced based references are required – no older than 5 years 

Admission Orders Template

Primary Diagnosis: UTI / Septic shock

Status/Condition Guarded

Code Status: Full Code

Allergies: NKA

Admit to Unit: Stepdown Telemetry

Diet: Diabetic diet

IV Fluids: Sodium Chloride 0.9 % 1,000 ml IV continuous 100 ml / hr

· Critical Drips: No critical drips at this time

Respiratory: 2L nasal cannula to maintain O2 above 94% continuous Oxymetry

Medications:

Rocephin 1 g, 100 ml/h Every 24 hours IV push

Metoprolol 25 mg PO daily – Do not administer if Systolic Blood pressure below 110 and Diastolic below 70

Insulin Lispro subcutaneously as per sliding scale – before meals

Lantus 10 Units subcutaneously daily before bed

See also  10 Inspiring Reflective Essay Examples

Aspiring 81 mg oral daily

Nursing Orders: Vital Signs every 4 hours, Pulse Oximetry continuous, Weigh patient once upon admission, reorient PRN, Intake and Output every shift, Assess IV site every shift, Cardiac monitoring in telemetry floor for 24 hours and re-assess, Consent for treatment as needed, notify the provider if there is any change in cardiac rhythm, bleeding precautions, fall precautions, bathroom privileges with assistance times 1.

Follow-Up Lab Tests:

· Diagnostic testing: 12 Lead ekg ( to assess myocardial function ), CBC ( to assess WBC and potential Anemia), BMP – for electrolytes and possible DKA, Urinalysis for UTI, Chest X-ray for potential infection, Blood cultures, Urine cultures

/

Consults: Infection Disease for antibiotic management, Nephrology for Renal function, Physical therapy, Endocrinologist for diabetes management.

Patient Education and Health Promotion (address age-appropriate patient education. if applicable): Diabetes education

Discharge Planning and Required Follow-Up Care: Primary care Provider within one week after discharge

References (minimum of three timely references that prove this plan follows current standards of care):

Table of Contents