Syncope Admission

Patient Name: HEOTEST, TOMMY

Age: 34 years Gender: M Location: 2WB W235 01 Height: 185.4 cm Weight: 79.5 kgs BMI: 23.1 Serum Creatinine: ?? Date Drawn: 09/09/2011 06:35am
Ordering Clinician: PATERSON

Admission

Admit to provider:
Patient status:
Location or specify in blank: (specify):
Telemetry monitoring:
Condition:
Provider must sign paper Resuscitation Status Order Set for DNR
Code Status:
Isolation precautions:

Diagnosis

Diagnosis:

Consents and Consults

Consult physician or specialty Reason: Specify physici or group:
Consult physician or specialty Reason: Specify physician or group:

Vital Signs

Vital signs
Orthostatic blood pressure
Neuro checks

Allergies

Add allergy:
Remove allergy:

Activity

Up ad lib
Ambulate in hall
Ambulate with assist
Up to chair
Ambulate and up to chair
Out of bed with assist
Bedrest with bathroom privileges
Bedrest with bedside commode
Bedrest

Nursing Orders

Assess and document mental status

Launch DVT Prophylaxis iForm
Document immunization status for pneumococcal and flu vaccine
Fluzone: Influenza vaccine per CDC guidelines if not contraindicated 0.5 ML IM ONCE
Pneumovax: Pneumococcal vaccine per CDC guidelines if not contraindicated 0.5 ML IM ONCE
Measure weight and record in kilograms
Record height
Launch blood glucose management iForm for ordering insulin and finger stick blood sugar
Measure intake and output
Insert IV with site care management
Insert INT with site care management
Insert urinary cath with cath care management
Straight cath
Reposition and turn Q2H
Elevate HOB greater than or equal to 30 degrees

Respiratory

RT will manage Oxygen via Oxygen Protocol if RT Evaluate and Treat Protocol is selected

Initiate respiratory therapy to evaluate and treat protocol
Initiate oxygen protocol
Oxygen via nasal cannula, adjust to keep oxygen saturation greater than 90 percent
CPAP/BIPAP via home settings
Launch respiratory iForm

Diet

NPO NOW
NPO after midnight
Clear liquid
Full liquid
Regular
Diabetic
Cardiac, includes low sodium, low cholesterol
Launch diet iForm for additional diets including tube feeding

IV Fluids

None
NS
1/2 NS
D5W
D5W NS
D5W 1/2 NS
LR
Choose rate: ML/HR Other: ML/HR
Add 20 MEQ potassium chloride to each liter
Launch IV fluid iForm for additional IV fluid choices

Special Studies

Avoid routine laboratory or diagnostic testing

General Radiology

Chest single view, portable Reason:
Chest single view, portable Reason:
Chest PA and lateral Reason:
Chest PA and lateral Reason:
Abdominal single view (KUB)
Abdominal single view (KUB) NEXT AM
Reason for abdominal exam:

Computed Tomography

Creatinine with eGFR for patients 60 years and older with history of diabetes and /or patients at risk for contrast induced nephropathy CIP

CT brain or head Reason:
CT brain or head NEXT AM Reason:

Echo

2 D Echo Reason:
2 D Echo NEXT AM Reason:

Ultrasound

Carotid Doppler Reason:

Carotid Doppler NEXT AM Reason:

Cardiology

12-lead EKG
12-lead EKG
Reason for EKG:
12-lead EKG PRN CHEST PAIN

Other

EEG routine Reason:
EEG routine NEXT AM Reason:

Medications

Give oral medications via NG tube when available

PRN Medications

Maximum dose of acetaminophen is 4 GM in 24 hours. When selecting dose of HYDROcodone or oxyCODONE choose a higher dose rather than increasing number of tablets to prevent acetaminophen toxicity.

Analgesics: Mild Pain (Pain Scale 1 to 3)

acetaminophen [TYLENOL] 650 MG ORAL EVERY 6 HRS PRN for mild pain or fever
acetaminophen supp [TYLENOL] 650 MG RECTAL EVERY 6 HRS PRN for mild pain or fever
ibuprofen [MOTRIN] ORAL for mild pain
ibuprofen [MOTRIN] ORAL EVERY 8 HRS PRN for mild pain
traMADol [ULTRAM] 50 MG ORAL EVERY 8 HRS PRN for mild pain

Analgesics: Moderate Pain (Pain Scale 4 to 6)

ketorolac [TORADOL] IV EVERY 6 HRS PRN for moderate pain for a maximum of 8 doses; maximum of 15 MG in patients greater than 65 years
HYDROcodone-acetaminophen [NORCO] ORAL for moderate pain
HYDROcodone 7.5 MG-acetaminophen 500 MG /15 ML elixir [LORTAB] for moderate pain

Analgesics: Severe Pain (Pain Scale 7 to 10)

Launch PCA iForm

HYDROcodone-acetaminophen [NORCO] ORAL for severe pain
oxyCODONE [ROXICODONE] ORAL for severe pain
oxyCODONE-acetaminophen [PERCOCET] ORAL for severe pain
morphine IV for severe pain
HYDROmorphone [DILAUDID] IV for severe pain; ATTENTION: 1 MG of HYDROmorphone [DILAUDID] is equal to 7 MG of morphine

Antidotes and Rescue Agents

naloxone [NARCAN] 0.2 MG IV ONCE AS NEEDED for opiate reversal; the dose may be repeated at 2 minute intervals, start O2 at 2 L per nasal cannula, titrate to keep O2 sats greater than 90, and call the physician for respiratory rate less than 8 per minute or patient is in respiratory distress

Antiemetics

ondansetron [ZOFRAN] IV EVERY 8 HRS PRN for nausea/vomiting
promethazine [PHENERGAN] ORAL EVERY 4 HRS PRN for nausea/vomiting
promethazine supp [PHENERGAN] RECTAL EVERY 4 HRS PRN for nausea/vomiting
promethazine [PHENERGAN] IM EVERY 4 HRS PRN for nausea/vomiting
metoclopramide [REGLAN] EVERY 6 HOURS for nausea/vomiting

Laxatives

magnesium hydroxide 400 MG/5 ML oral suspension [MILK OF MAGNESIA] 30 ML ORAL for constipation
bisacodyl [DULCOLAX] ORAL DAILY PRN for constipation
bisacodyl [DULCOLAX] 10 MG RECTAL DAILY PRN for constipation
docusate sodium [COLACE] 100 MG ORAL BID
magnesium citrate 300 ML ORAL ONCE PRN for constipation
polyethylene glycol 3350 MG oral powder [MIRALAX] 17 GM ORAL DAILY for constipation, in 8 ounces of water
mineral oil enema [FLEET] 1 ENEMA RECTAL ONCE PRN for constipation

Sedatives and Antihistamines

diazepam [VALIUM] EVERY 4 HRS PRN for agitation or anxiety
LORazepam [ATIVAN] EVERY 4 HRS PRN for agitation
ALPRAZolam [XANAX] ORAL for anxiety
temazepam [RESTORIL] ORAL AT BEDTIME PRN for insomnia
zolpidem [AMBIEN] ORAL AT BEDTIME PRN for insomnia, maximum of 5 MG in patients greater than 65 years old, may repeat 1 time before 2 AM as needed
hydrOXYzine pamoate [VISTARIL] 25 MG ORAL AT BEDTIME PRN for insomnia
diphenhydrAMINE [BENADRYL] AT BEDTIME PRN for insomnia; not for use in patients greater than 65 years old
diphenhydrAMINE [BENADRYL] EVERY 6 HRS PRN for itching

Stress Ulcer Prophylaxis Agents

famotidine [PEPCID] 20 MG EVERY 12 HOURS
pantoprazole [PROTONIX] 40 MG DAILY
aluminum-magnesium-simethicone suspension [MAALOX/MYLANTA] 30 ML ORAL EVERY 4 HRS PRN for dyspepsia

Additional Medications

nicotine patch [NICODERM] TDERMAL DAILY for smoking cessation (remove for insomnia)

Laboratory

Cardiac Markers

CK with CKMB Q6H x 3
CK with CKMB Q6H x 2 if first cardiac marker is performed in the ED TIMED Q6H
Troponin Q6H x 3
Troponin x 2 if first cardiac marker is performed in the ED TIMED Q6H

Panels

Comprehensive metabolic panel (CMP)
Comprehensive metabolic panel (CMP)
Basic metabolic panel (BMP)
Basic metabolic panel (BMP)
Basic metabolic panel plus Mg and PO4 (BMP with Mg and PO4)
Basic metabolic panel plus Mg and PO4 (BMP with Mg and PO4)
Hepatic panel
Hepatic panel

Hematology

Complete blood cell count without differential
Complete blood cell count without differential
Complete blood cell count with automated differential
Complete blood cell count with automated differential
Prothrombin time (PT) with international normalized ratio (INR)
Prothrombin time (PT) with international normalized ratio (INR)
Partial thromboplastin time (PTT), activated
Partial thromboplastin time (PTT), activated

Chemistry

B-type natriuretic peptide
B-type natriuretic peptide
Creatine phosphokinase CPK
Creatine phosphokinase CPK
Glucose, serum, random
Glucose, serum, random
Lactate dehydrogenase (LDH), serum
Lactate dehydrogenase (LDH), serum
Lipase level, serum
Lipase level, serum
Magnesium (Mg) level, serum
Magnesium (Mg) level, serum
Phosphorus level, serum
Phosphorus level, serum
Protein level, total, serum
Protein level, total, serum
Digoxin level
Digoxin level
Alcohol, ethyl (EtOH) medical
Alcohol, ethyl (EtOH) medical

Microbiology

Blood culture Q15MIN x 2

Urine Studies

Drug screen comprehensive urine STAT
Urinalysis with reflex culture
Urinalysis with reflex culture NEXT AM