Admission Orders

ADMIT – Admit to Med-Surg floor, Eskenazi General Surgery Team B, Dr. Ortiz
DIAGNOSIS – cholecystic disease
CODE STATUS – full code
VITALS – Vital signs Q4 hours: HR, BP, SPO2, RR, Temperature
ALLERGIES – sulfa drugs: hives
INTRAVENOUS –
begin peripheral IV, now
begin IV fluid bolus, 0.9% NS, 500mL over 30 minutes, now
begin mIVF, 0.9% NS, 125ml/hr, continuous, begin after fluid bolus
NURSING –
Strict Inputs and Outputs recorded Q8H
Patient in Semi-Fowler’s Position, now
Daily standing weight at 0400
Assess Pain Scale Score Q6H
2L supplemental O2 via NC if SPO2 < 94%
ACTIVITY –
Fall precautions, continuous
Full bathroom privileges, continuous
Ambulate in hallway TID
LABS –
CMP, once, now
CBC with differential, once, now
Amylase, once, now
Lipase, once, now
GGT, once, now
Urinalysis, clean catch midstream, once, now
Urine Pregnancy Test, once, now
SPECIAL –
Transabdominal Ultrasound (cholecystosonogram) to assess for cholelithiasis and cholecystitis,
now
MEDICATION –
Omeprazole 20mg capsule orally daily at 0900 for 3 days.
Indomethacin 25mg capsule orally TID for 3 days
Odansetron 8mg oral tablet Q8H PRN for nausea, available for 3 days
Piperacillin-tazobactam (Zosyn) 3.375 g IV Q6H for 4 days
CALL ORDERS –
Call the on-call resident for General Surgery Team B if any of the following occur:
HR >115 or HR < 60
RR > 20 or RR < 12
SBP > 150 or SBP < 90
DBP > 100 or DBP < 60
SPO2 < 90%
Temperature > 102F or Temperature < 96F (Fever in excess of 102F)
Urine output < 500mL over 12 hours or urine output > 2000mL over 12 hours
Signs of jaundice (yellow eyes, yellow skin)
Clay-colored stools
Dark (brown) colored urine
Hematemesis or Hematochezia
Severe Pain > 9 or 10 within 6 hours of receiving a dose of indomethacin
DIET – NPO except medications
CONDITION - fair