Admission Orders Template

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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, write a full set of admission orders for the patient in the branching exercise.

  • 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 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

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Primary Diagnosis: Atrial Fibrillation with Rapid ventricular Response

 

Status/Condition : Hemodynamically stable

 

Code Status: Full code

 

Allergies: NKA

 

Admit to Unit: Telemetry Unit

 

Activity Level: Ambulate with assistance if necessary, Bedrest with Bathroom privileges, Fall risk in place

 

Diet: 2 Gram Sodium Diet, Low fat

 

IV Fluids: Sodium Chloride 0.9  % solution 1000 ml – IV continuous, Order rate: 50 ml/h, Administer over 20 hours

 

  • Critical Drips: None at this time will reevaluate after initial dose of Beta Bloker is given

Respiratory: Nasal Cannula 2L to maintain SPO2 above 93 %

 

  • Medications : Metoprolol tartrate 2,5 mg IV bolus administer over 2 min once, for Atrial Fibribilation with Rapid ventricular response – re evaluate for possible initiation of Metoprolol Oral as initial treatment.

 

 

 

Nursing Orders : Vital Signs every 4 hours, Pulse Oximetry continuous, Weigh patient once upon admission, Educate for Cardiac Disease, Cardiac Arrythmias 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. Admission Orders Template

 

 

Follow-Up Lab Tests: 12 lead EKG, THS, CBC. CMP, PT , PTT

 

  • Diagnostic testing : TEE, ECHO Doppler

 

Consults: Cardiologist consult for New Onset of Atrial fibrillation with Rapid ventricular response

 

Patient Education and Health Promotion: Educate patient in regards Cardiac disease, diet , medication compliance and proper specialist follow up. Admission Orders Template

 

Discharge Planning and Required Follow-Up Care: Plan to discharge home with primary care and cardiologist follow up within one week.

 

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