Inpatient Pocket Card Set

Updated February 27th, 2021

Satya Patel, MD, Kelley Chuang, MD,
Jennifer Fulcher, MD, PhD, Simon Wu, MD,
Pamela Tsing, MD, Tyler Larsen, MD,
Michael Spiker, MD, Michael F. Ayoub, MD,
Antonio Pessegueiro, MD Digital copy, note templates, A/P guide

Pre-Rounding Guide
Overnight Events Night float signout, nursing notes
Interdisciplinary
Review original note and any addendum
notes
Vital signs Trends and ranges (min and max) values
Input: Oral, IV
I/O and Output: Urine, stool, drains, ostomy, hemodialysis
weights (include last bowel movement)
Weight trends
Include trends
Labs Review pending/send-out labs
Consider which ones are truly needed on daily basis
Review images yourself
Radiology
Note if interpretation is preliminary or final
Bacterial culture not considered “negative” until at least
Microbiology
48 hours (does not finalize until day 5)
IV fluids and drips
Missed doses of medications
Review medications that have expired/“fallen off”
Review medications that need to be discontinued
Medication Overnight medications that were not written as PRN by
Administration primary team
Record (MAR) Pain medications
Insulin requirements (and glucose ranges)
Antibiotics received and start/end dates
Review if held/modified home meds can be
restarted/returned back to home dose
Cardiac Review telemetry
monitoring Consider if it needs to be continued
Review dates of when these were placed
Tubes, Lines,
Review indications for removal and/or replacement on
Drains
daily basis
 Daily Checklist
Indications for NPO
o Upcoming procedure
o PET scan (also avoid dextrose-containing fluids –
review all IV meds)
FEN/GI o Concern for aspiration of all PO intake (including
medications)
o Avoid caffeine prior to regadenoson stress testinga
o IV fluids (always put end-time/total amount and review
daily)
o SCDs
o Enoxaparin subQ if CrCl >30 (hold 24 hours before
most procedures)
DVT
o Heparin subQ if CrCl <30 (hold 6 hours before most
prophylaxisb
procedures)
o Contraindications: active bleeding, low platelet count,
upcoming procedures
Indications (for critically ill patients)
o On mechanical ventilator for >48 hours
Stress ulcer
o Coagulopathy (INR >1.5, plt <50)
prophylaxisc
o High-dose/chronic steroid or NSAID use
o Recent GI bleed
Code Options include: Full, DNR/never intubate, DNR/okay to
statusd intubate, compressions okay/never intubate
Disposition Checklist
o Update family/DPOA on status of patient
o Fill out/update POLST form (if indicated)
o Post-hospitalization living situation
o Insurance for meds (prior authorization) and nursing homes
o Post-discharge transportation
o Equipment at home for safety/function
o Outpatient referrals and appointments
o Consider need for prescriptions (new medications, refills)
o Discharge medication education
o Discharge summary (include pending inpatient labs that require
outpatient follow-up)
o Outpatient labs if needed
o Handoff communication to accepting provider (PCP, SNFist, etc.)
a. Some centers require patients to be NPO prior to stress test simply due to policy
b. The FDA has approved some DOACs and fondaparinux as options as well
c. If a patient is on longstanding PPI or H2-blocker therapy which cannot be
discontinued due to symptoms or specific medical indication, this will suffice as
stress ulcer prophylaxis
d. At the VA, patients cannot legally have mixed code status (patients must be Full
Code or DNR/never intubate)
 Anti-Emetic Regimen Guide
QT-
Class Medication Route Common Side Effects
Prolongation
Ondansetron PO, IVP, IM,
✓
Serotonin (Zofran) sublingual
Headache, constipation, drowsiness, diarrhea
antagonists Granisetron (Kytril, PO, IV,
✓
Sancuso) transdermal
Metoclopramide
PO, IVP, IM Drowsiness, EPS, do not use if increased GI motility ✓
(Reglan)
Olanzapine PO, IM,
EPS, hyperglycemia ✓
(Zyprexa) sublingual
Dopamine (DA) Prochlorperazine
PO, IVP, PR EPS, NMS ✓
antagonists (Compazine)
EPS, constipation, dry mouth, blurred vision,
Haloperidol (Haldol) PO, IM ✓
somnolence
Chlorpromazine
IM, IV EPS, dry mouth ✓
(Thorazine)
Histamine Diphenhydramine PO, IVPB,
Dizziness, drowsiness, paradoxical excitation ✓
antagonists (Benadryl) IVP
PO, IVP, IM, Bradycardia, flushing, thirst, xerostomia, urinary
ACh antagonists Scopolamine ✓
transdermal retention
DA/Histamine/ACh Promethazine PO, PR, EPS, NMS, drowsiness, sedation, leukopenia,
✓
antagonist (Phenergan) IVP, IM thrombocytopenia
Neurokinin-1 Aprepitant (Emend) PO Hiccups, bradycardia, neutropenia
receptor Fosaprepitant
IV Angioedema, bradycardia, neutropenia
antagonists (Ivemend)
Leukocytosis, mood changes, adrenal suppression,
Dexamethasone PO, IVP, IM
hyperglycemia
Trimethobenzamide
Centrally acting PO, IM EPS, disorientation, seizure
(Tigan)
THC, dronabinol PO Hyperemesis, tachycardia, nystagmus, ataxia
Lorazepam (Ativan) PO, IVP, IM Respiratory depression
When using multiple agents, avoid choosing from the same class
 Bowel Regimen Guide
Class (Mechanism) Medication Side Effects
Polyethylene
Nausea, bloating, cramping
glycol
Lactulose Abdominal bloating,
Osmotic agents (draws water into bowel, Sorbitol flatulence
thereby loosening stool and promoting
Glycerin Rectal irritation
evacuation)
Magnesium
sulfate PO
Watery stools and urgency
Magnesium
citrate
Bisacodyl Rectal irritation
Stimulant laxatives
Senna Melanosis coli
Impaction above strictures,
Bulk-forming laxatives (fiber absorbs
Psyllium fluid overload, gas, and
excess water and stimulates elimination)
bloating
Discomfort during
Rectal distension Tap water enema
procedure
 Pharmacologic Pain Management Options
Class Options
Acetaminophen (24 hours: < 3-4g in healthy adults, <3g in CKD, <2g in liver disease or cirrhosis)
Anti-inflammatory Oral NSAIDs or IV ketorolac (avoid NSAIDs if CKD or >2 of the following risk factors: history of GI ulcer,
age >60, on steroids, on ASA/anticoagulation)
Opioid Hydrocodone, morphine, oxycodone, hydromorphone, fentanyl, tramadol, codeine
Topical Lidocaine patch, menthol cream, lidocaine/prilocaine cream, capsaicin cream
Neuropathic
Gabapentin, pregabalin, SNRIs, TCAs
agents
Anti-spasmodic Baclofen, cyclobenzaprine, tizanidine

Opioid Conversion Tablea,b,c

Equianelgesic dosing (mg)
Opioid Onset Peak Duration t1/2 Considerations
IV, SC, IM PO
IV: 5-10m IV: 10-15m Caution in renal failure, active
Morphine 10 25 3-4h 2-4h
PO: 30m PO: 60m metabolites
Morphine ER 25 4h 8-12h
IV: 5m IV: 15m Reduce dosing in hepatic
Hydromorphone 2 5 4-5h 2-3h
PO: 30m PO: 60m dysfunction
Oxycodone N/A 20 10-30m 1-2h 3-4h 3-4h Caution in hepatic dysfunction
Oxycodone ER --- 20 8-12h ---
Hydrocodone N/A 25 10-30m 1-2h 4-6h 4h Caution in hepatic dysfunction
Prodrug metabolized to morphine
Codeine 100 200 4h
in liver, variable metabolism
Fentanyld,e 0.15 N/A 2h Preferred for hepatic/renal failure
Avoid if MAOI used in last 14d
Tramadol 100 120 1h 2h 4-6h 6-8h
Can ↓ seizure threshold
a. Different tables will reference different values – choose one and stick with it
b. When rotating opioids, consider reducing equivalent dose by 25-50% to account for incomplete cross tolerance
c. From Demystifying Opioid Conversion Calculations: A Guide for Effective Dosing, 2nd Edition by Dr. Mary Lynn McPherson PharmD, BCPS, CPE
d. Transdermal fentanyl patch is only used for opioid-tolerant patients and requires pain management/palliative care to titrate. If patients with hepatic and
renal failure, fentanyl is preferred. Time to steady-state for patch is up to 36h. If patch is removed, half-life is 17h
e. If patients with renal failure, consider hydromorphone, oxycodone, fentanyl, or methadone
 Inpatient Blood Pressure Management Guide
Route Frequently Used Effect
Class Relative/Absolute Contraindications
PO IV Agents on ICP
Metoprolol, Bradycardia, heart block, ADHF, COPD
β-blockers ✓ ✓ ↔
Carvedilol, Labetalol exacerbation
Captopril,
Enalaprilat (IV),
ACEI/ARBs ✓ ✓ AKI, hyperkalemia, angioedema ↔
Lisinopril,
Valsartan
α2 agonistsa ✓ ✓ Clonidine Severe bradycardia ↔
Nitratesa ✓ ✓ Isosorbide dinitrate Severe AS, PDE inhibitor use ↑
Nifedipine ER, HFrEF
CCBsb ✓ ✓ Diltiazem, For non-dihydropyridines: Bradycardia, ↔
Amlodipine heart block
Chlorthalidone,
AKI, hypovolemia, difficulty with
Diuretics ✓ ✓ Hydrochlorothiazide, ↓
transferring to urinate
Spironolactone
Vasodilators ✓ ✓ Hydralazine ↑
Can develop severe reflex tachycardia
Non-selective due to the unpredictable drop in SBP
✓ Phentolamine ↓
α blockers
Partial D1
✓ Fenoldopam Glaucoma ↑
agonists

a. Transdermal formulation is available

b. Amlodipine takes approximately 30 hours to become effective
 IV Fluid Timeouta
Step 1: Indication Step: 2 Approach Step 3: Type of fluid Step 4: Amount of fluid
o Colloids are not superior to crystalloids
o Give IV fluids (in 500-1000 mL increments)
Low preload state o LR seems superior to 0.9% NS
and re-assess volume status
leading to vital o You cannot rely on serum lactate levels if
Resuscitation o In sepsis, consider 20-30 mL/kg (use extra
sign changes +/- you give LR to a patient with cirrhosis
caution with heart failure, renal failure and
symptoms o If increased ICP, consider using Plasma-
cirrhosis)
Lyte instead of LR
Disrupted oral
Maintenance 0.45% NS with 5% dextrose Calculate amount using “4-2-1” rule
intake
Electrolyte Repletion Guide
Electrolyte Amount Route Details
Potassium !"#$ & ' ()*+#$ &
x 100 = mEq of KCl Oral, IV (10 mEq/hr peripherally, >4 if acute MI, cardiac conditions
(ref range 3.5-4.5) ,-.#*/0/0. ! 20 mEq/hr centrally) KCl >4.5 if VT
!"#$ 12 ' ()*+#$ 12
x 10 = gm of Oral (MgO causes diarrhea, Mg-
Magnesium ,-.#*/0/0. !
>2 if CAD or active cardiac conditions
protein complex does not cause
(ref range 1.3-1.7)
MgSO4 >2.5 for VT
diarrhea), IV MgSO4
Calcium No need to replete unless symptomatic or
1 gm at a time IV calcium carbonate
(ref range 8-10) if QT prolongation
Phosphate See table below Oral, IV Pay attention to K load
(ref range 2.5-4.5)

Phosphate Repletion Guidec

Dose (based on phosphate level)
Route Formulation Amount of K
Phos <1.5 Phos 1.5-1.9 Phos 2-2.5
Neutra-Phos 2 packets 1-2 packets 1 packet 7.1 mEq per packet
Neutra-Phos-K 2 packets 1-2 packets 1 packet 14.3 mEq per packet
Oral
2 tablets q4h x4 2 tablets q4h x3 2 tablets q4h x2
K-Phos Neutral (Na and K Phos) 1.1 mEq per tablet
doses doses doses
Potassium Phosphate 18-21 mmol 12-15 mmol 9-12 mmol 4.4 mEq per 3 mmol phos
IV
Sodium phosphate 18-21 mmol 12-15 mmol 9-12 mmol 0 mEq
a. Consider aggressive IV fluids for nephroprotection in specific situations (e.g., tumor lysis, hypercalcemia, etc.)
b. If creatinine is <1, just divide by 1
c. If CrCl <30, divide dose by 50%
Antibiotic Spectrum (Jennifer Fulcher, MD, PhD, UCLA Infectious Diseases)

Antimicrobial Stewardship