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
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 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):