How To Care For A Diabetic Patient
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- Georgiana Johns
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1 Height: cm Weight: kg Allergies: [ ] No known allergies [ ]Medication allergy(s): [ ] Latex allergy [ ]Other: Admission/Transfer/Discharge [ ] Admit Patient T;N to Dr. [ ] Admit Status: [ ] Inpatient [ ] Routine Post Procedure <24hrs [ ] 23 hour OBS [ ] Bed Type: [ ] Med/Surg [ ] Critical Care [ ] Stepdown [ ] Telemetry; Specific Unit Location: [ ] Notify Physician- Once of room number on arrival to unit Primary Diagnosis: Secondary Diagnosis: Vital Signs [ ] Vital signs T;N, Monitor and Record T,P,R,BP, per unit routine [ ] Vital signs T;N, Monitor and Record T,P,R,BP, q4h(std) [ ] Vital signs w/neuro Checks T;N, Monitor and Record T,P,R,BP, per unit routine [ ] Vital signs w/neuro Checks T;N, Monitor and Record T,P,R,BP, q4h(std) Activity [ ] Out Of Bed ( Activity As Tolerated ) T;N, Up ad lib [ ] Ambulate T,N; BID [ ] Ambulate T,N; BID Special Instructions: In room only [ ] Bedrest T;N, Routine [ ] Out Of Bed ( Up To Chair ) T;N, Up Ad Lib Food/Nutrition [ ] NPO T;N [ ] NPO T;2359 [ ] NPO T;2359, Except for Medications [ ] Breastfeed T;N [ ] Formula Per Home Routine T;N [ ] LEB Formula Orders Plan see separate sheet [ ] Regular Pediatric Diet T;N [ ] Clear Liquid Diet T;N Patient Care [ ] Advance Diet as Tolerated T;N, start clear liquids and advance to regular diet as tolerated [ ] Isolation Precautions T;N, Isolation Type: [ ] Seizure Precautions T,N; Routine [ ] Intake and Output Strict ( Strict I/O ) T;N, Routine, q2h(std) [ ] Daily Weights T;N, Routine, q Eve, [ ] Avoid T,N, Avoid Contact with Pregnant Women [ ] O2 Sat-Spot Check (Nsg) T;N, with vital signs [ ] O2 Sat Monitoring NSG T;N [ ] Cardiopulmonary Monitor T;N, Routine, monitor type: CP monitor [ ] Incentive Spirometry NSG T;N,Q2h-Awake, 10 breaths Respiratory Care [ ] Oxygen Delivery T; N, L/min, Titrate to keep O2 sat =/> 92. Wean to room air *065* Page 1 of 6
2 Continuous Infusions [ ] Sodium Chloride 0.9% 1,000mL,IV,Routine,T:N, at ml/hr [ ] D5 1/4 NS 1,000mL,IV,Routine,T:N, at ml/hr [ ] D5 1/4 NS KCl 10 meq/l 500mL,IV,Routine,T:N, at ml/hr [ ] D5 1/4 NS KCl 20 meq/l 1,000mL,IV,Routine,T:N, at ml/hr [ ] D5 1/2NS 1,000mL,IV,Routine,T:N, at ml/hr [ ] D5 1/2 NS KCl 10 meq/l 500mL,IV,Routine,T:N, at ml/hr [ ] D5 1/2 NS KCl 20 meq/l 1,000mL,IV,Routine,T:N, at ml/hr Medications [ ] Heparin 10 unit/ml flush (peds) 5 ml (10units/mL),Ped Injectable, IVPush, prn, PRN Catheter Clearance, routine,t;n, peripheral or central line per nursing policy [ ] acetaminophen mg, Liq, PO, q4h, PRN Pain or Fever, routine,t;n,reference Range: 10 to 15 mg/kg/dose, Max Dose=90/kg/day up to 4 g/day [ ] acetaminophen 80 mg, chew tab, PO, q4h, PRN Pain or Fever, routine, T;N,Max Dose=90 mg/kg/day up to 4 g/day [ ] acetaminophen 325mg, tab, PO, q4h, PRN Pain or Fever, routine,t;n,max Dose=90 mg/kg/day up to 4 g/day [ ] acetaminophen mg, Supp, PR, q4h, PRN Pain or Fever, routine, T;N,Reference Range: 10 to 15 mg/kg/dose, Max Dose=90mg/kg/day up to 4 g/day [ ] acetaminophen-codeine 300 mg-30 mg oral tablet 1 tab, Tab, PO, q4h, prn Pain, Routine, T;N, (1 tab = 30 mg of codeine) [ ] acetaminophen-codeine 120 mg-12 mg/5 ml oral liquid ml, Liq, PO, q4h, prn Pain, Routine, T;N, Reference Range: 0.5 to 1 mg of codeine/kg), (5 ml = 12.5 mg of codeine) [ ] ibuprofen 400 mg, Tab, PO, q8h,prn, Pain/Fever, Routine, T;N [ ] ibuprofen mg, (10 mg/kg), Oral Susp, PO, q8h,prn, Pain/Fever, Routine, T;N, Max dose = 800 mg [ ] ibuprofen 200 mg, Tab, PO, q8h,prn, Pain/Fever, Routine, T;N [ ] ibuprofen 800 mg, Tab, PO, q8h,prn, Pain/Fever, Routine, T;N [ ] ibuprofen 600 mg, Tab, PO, q8h,prn, Pain/Fever, Routine, T;N [ ] ketorolac mg, (0.5 mg/kg), Injection, IV Piggyback, q6h, (for 5 days), Routine, T;N, Max dose = 30 mg [ ] morphine mg, Injection, IV Push, q3h, PRN, Pain, Routine, T;N, Reference Range: 0.05 to 0.1 mg/kg/dose, Max dose = 5 mg [ ] morphine immediate release mg, Oral Soln, PO, q4h, PRN, Pain,Reference Range: 0.1 to 0.2 mg/kg/dose, Routine, T;N [ ] morphine immediate release 15 mg, Tab, PO, q4h, PRN, Pain, Routine, T;N [ ] morphine extended release 30 mg, ER Tablet, PO, q12h, Routine, T;N [ ] morphine extended release 15 mg, ER Tablet, PO, q12h, Routine, T;N [ ] morphine extended release 60 mg, ER Tablet, PO, q12h, Routine, T;N [ ] LEB Morphine PCA see separate sheet [ ] penicillin 125 mg, Oral Susp, PO, bid, Routine, T;N [ ] penicillin 250 mg, Oral Susp, PO, bid, Routine, T;N [ ] penicillin 125 mg, Tab, PO, bid, Routine, T;N [ ] penicillin 250 mg, Tab, PO, bid, Routine, T;N Page 2 of 6
3 Medications continued [ ] erythromycin ethylsuccinate mg, (10 mg/kg), Oral Susp, PO, qid,(14 day),routine, T;N [ ] erythromycin ethylsuccinate mg, (10 mg/kg), Tab, PO, qid, (14 day), Routine, T;N [ ] ceftriaxone mg, (50 mg/kg), Injection, IV Piggyback, q24h, (14 day) Routine, T;N, Max dose = 2 grams [ ] vancomycin mg, (10 mg/kg), Ped Injectable, IV Piggyback, q6h, (14 day) Routine, T;N, Max dose = 1 gram [ ] azithromycin mg, (10 mg/kg), Oral Susp, PO, once, Routine, T;N, Max dose = 500 mg [ ] azithromycin 500 mg,tab, PO,once, Routine, T;N [ ] azithromycin mg, (5 mg/kg), Oral Susp, PO, qday (4 dose), Routine, T+1;N, Max dose = 250 mg [ ] azithromycin 250 mg,tab, PO, qday (4 dose), Routine, T+1;N [ ] clindamycin mg, (10 mg/kg), Injection, IV Piggyback, q8h, (14 day) Routine, T;N, Max dose = 4.8 grams/day [ ] clindamycin mg, (10 mg/kg), Oral Susp, PO, tid, (14 day) T;N, Max dose = 1.8 grams/day [ ] clindamycin 300 mg, Cap, PO, tid, (14 day) Routine, T;N, Max dose = 1.8 grams/day [ ] clindamycin 600 mg, Cap, PO, tid, (14 day) Routine, T;N, Max dose = 1.8 grams/day [ ] levofloxacin mg, (10 mg/kg), Injection, IV Piggyback, q12h, (14 day), Routine, T;N [ ] levofloxacin mg, (10 mg/kg), Tab, PO, bid, (14 day), Routine, T;N [ ] polyethylene glycol grams, powder, PO, qday, Routine, T;N [ ] polyethylene glycol grams, powder, PO, qday, Routine, T;N [ ] docusate mg, (2.5 mg/kg), Liq, po, bid, Routine, T;N [ ] docusate 50 mg, Cap, PO, bid, Routine, T;N [ ] sodium biphosphate-sodium phosphate enema 66 ml, Enema, PR, once, Routine, T;N, 2 to 11 years pediatric [ ] sodium biphosphate-sodium phosphate enema 133 ml, Enema, PR, once, Routine, T;N, greater than or equal to 12 adult years [ ] ondansetron mg,oral Soln,PO,q8h,PRN nausea/vomiting, routine,t;n, Reference range: Age 4-11= 4mg dose, Age greater than 11 = 8mg dose, Maximum 24mg/day [ ] ondansetron 4mg,Orally Disintegrating Tablet,PO,q8h,PRN nausea/vomiting, routine,t;n [ ] ondansetron mg(0.15 mg/kg),injection,ivpush,q8h,prn nausea/vomiting, routine,t;n, Max dose = 8mg Page 3 of 6
4 Medications continued [ ] diphenhydramine mg, (1 mg/kg), Injection, IV, q6h, PRN Itching, Routine, T;N, Max dose = 50 mg [ ] hydroxyurea mg, Cap, PO, qday, Routine, T;N, Max dose = 2000 mg [ ] hydroxyurea mg, Oral Susp, PO, qday, Routine, T;N, (1 ml = 100 mg), Max dose = 2000 mg [ ] Exjade mg, Tab, PO, Qday, Routine, T;N, Max dose = 10 to 40 mg/kg/day, Disperse tablets in water, orange juice, or apple juice (use 3.5 ounces for total doses <1 g; 7 ounces for doses >1 g); stir to form suspension and drink entire contents. Rinse remaining residue with more fluid; drink. Administer at same time each day on an empty stomach, 30 minutes before food. Do not administer simultaneously with aluminum-containing antacids Transfusion Orders [ ] LEB Transfusion Less Than 4 Months of Age see separate sheet Plan [ ] LEB Transfusion-4 Months of Age or Greater see separate sheet Plan [ ] NOTE: LEB Apheresis Pre Procedure Plan must be ordered outside this plan. [ ] RBC Phenotype Ext Ag, Testing T;N, Routine, blood,once [ ] Coombs, Direct T;N, Routine, blood,once Laboratory [ ] Urinalysis w/reflex Microscopic Exam T;N, Routine, T;N, once, Type: Urine, Nurse Collect [ ] Urinalysis w/reflex Microscopic Exam T;N, routine, urine, qam Chemistry [ ] Comprehensive Metabolic Panel ( CMP ) T:N, routine, blood, once [ ] Comprehensive Metabolic Panel ( CMP ) T:N, routine, blood, qam [ ] Uric Acid T:N, routine, blood, once [ ] Amylase level T:N, routine, blood, once [ ] Lipase Level T:N, routine, blood, once [ ] LD (LDH) T:N, routine, blood, once [ ] LD (LDH) T:N, routine, blood, qam Hematology [ ] CBC T;N, Routine, blood,once [ ] CBC T:N, routine, blood, qam [ ] Reticulocyte Count T;N, Routine, blood,once [ ] Reticulocyte Count T:N, routine, blood, qam [ ] Erythrocyte Sedimentation Rate T;N, Routine, blood,once Microbiology [ ] Pregnancy Screen Serum T;N, Routine, blood,once [ ] EBV Profile ( Epstein-Barr Virus Profile ) T;N, Routine, blood,once [ ] Blood Cultures T;N, Routine, once, Specimen source: peripheral blood [ ] Blood Cultures T;N, Routine, once, Specimen source: cental line [ ] Urine Culture T;N, Routine, once, Specimen source: urine, catheterized [ ] Urine Culture T;N, Routine, once, Specimen source: urine, clean catch [ ] Urine Culture T;N, Routine, once, Specimen source: urine, suprapubic [ ] Occult Blood T;N, Routine, once, Type: stool, nurse collect [ ] Stool Culture T;N, Routine, once, Specimen source: stool, nurse collect Page 4 of 6
5 Reference Lab [ ] Hemoglobinopathy Evaluation Routine, T;N, once, Type: Blood ( Abnormal Hemoglobin Analysis(HPLC) [ ] Human Parvovirus B19 Antibody Panel T;N, Routine, blood,once [ ] Hemoglobin F T;N, Routine, blood,once [ ] Hemoglobinopathy Evaluation (Hemoglobin S) T;N, Routine, blood,once Diagnostic Tests [ ] Chest 2VW Frontal & Lat ( Chest PA & Lateral T;N, routine, Reason:, Transport: ) [ ] Chest 1VW Frontal ( Chest 1 VW ) T;N, routine, Reason:, Transport: Portable [ ] Echocardiogram Pediatric (0-18 years) T;N, routine, Reason:, Transport: [ ] Electrocardiogram ( EKG ) T;N, routine, Reason:, Transport: [ ] Abd Sing AP VW ( KUB ) T;N, routine, Reason:, Transport: [ ] CT Brain/Head WO Cont T;N, routine, Reason:, Transport: [ ] MRI Brain & Stem WO Cont T;N, routine, Reason:, Transport: [ ] MRA Head WO Cont T;N, routine, Reason:, Transport: [ ] CT Abdomen WO Cont T;N, routine, Reason:, Transport: [ ] CT Pelvis WO Cont T;N, routine, Reason:, Transport: [ ] US Abd Comp w/delay diet Plan T; N, Routine, Reason For Exam: "measure splenic volume and assess for gallstones", [ ] US Abd Ltd Sing Organ/FU w/delay diet Plan T; N, Routine, Reason For Exam: splenic volume, [ ] US Abd Ltd Sing Organ/FU w/delay diet Plan T; N, Routine, Reason For Exam: gallbladder, [ ] US Abd/ Retroper Dup Art In/Vein Out Ltd( US Abd Limited w/doppler ) T; N, Routine, Reason For Exam:, [ ] Hip Comp 2+VW RT T; N, Routine, Reason For Exam:, [ ] Hip Comp 2+VW LT T; N, Routine, Reason For Exam:, [ ] Hips 2+VW Ea Hip Incl AP Pelvis Bil T; N, Routine, Reason For Exam:, Consults/Followups [ ] Notify Resident - Continuing T;N, For:, Who: [ ] Notify Resident- Once T;N, For:, Who: [ ] Physician Group Consult (Consult MD Group) T;N, Consult Who:,Reason: [ ] Physician Consult ( Consult MD ) T;N, Consult Who:,Reason: [ ] Medical Social Work Consult ( Consult Medical T;N, Reason: Social Work ) [ ] Dietitian Consult T;N, Reason: Page 5 of 6
6 Consults/Followups continued [ ] Consult Child Life T;N, Reason: [ ] Consult Teacher T;N, Reason: [ ] PT Ped Eval & Tx ( Physical Therapy Ped Eval T;N, Reason: & Tx ) [ ] OT Ped Eval & Tx ( Occupational Therapy Ped T;N, Reason: Eval & Tx ) [ ] ST Ped Eval & Tx ( Speech Therapy Ped Eval & Tx ) T;N, Reason: Date Time Physician's Signature MD Number Page 6 of 6
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