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 â Do not administer if Systolic Blood pressure below 110 and Diastolic below 70
Insulin Lispro subcutaneously as per sliding scale â before meals
Lantus 10 Units subcutaneously daily before bed
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 â 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):
