Walden UniversityNURS 6550Admit Orders

ACUTE MENTAL STATUS CHANGE admission order Name: ______________________________________________ Age: _______ DOB: ____ /____ /____ Medical record #: _______________ 1. Status: l Observation l Admission l Medical floor ...

ACUTE MENTAL STATUS CHANGE admission order Name: ______________________________________________ Age: _______ DOB: ____ /____ /____ Medical record #: _______________ 1. Status: l Observation l Admission l Medical floor l Monitored bed l Other ______________________ 2. Attending: Dr: __________________________________ phone: ________-_____________ 3. Admitting Diagnosis: Acute Mental Status Change Associated Diagnoses: __________________________________________________________________________ 4. Condition: l Stable l Fair l Serious l Critical Code Status: l Full Code l DNR 5. Allergies: ______________________________________________________________________________________________________________________ 6. Diet: l NPO l Clear liquid l AHA step 2 l ADA ______ calories l Other______________________ 7. Activity: l Bed rest with bedside commode l Bathroom privileges l Up ad lib l Fall precautions 8. Nursing: l Vital signs with neuro every 4 hrs for 24 hrs then every shift l Notify MD for: T > 101.5, HR > 120, BP < 90/60 or > 180/110, decline in neurostatus, O2 sat < 92% l Pulse ox every 8 hrs nasal cannula/face mask to maintain O2 sat > 92% l I&O 9. Medications: For aggressive or psychotic behavior management Acutely agitated and over 200 lbs without renal/hepatic impairment l Haldol 10 mg PO/IM, Ativan 4 mg PO/IM and Cogentin 1 mg PO/IM every 6 hrs prn; hold if BP < 100/60 mmHg, OR l Geodon 20 mg IM every 8 hrs prn; hold if BP < 100/60 mmHg Acutely/moderately agitated and under 200 lbs without renal/hepatic impairment l Risperdal 2 mg and Ativan 2 mg PO every 6 hrs prn, OR l Haldol 5 mg IM and Ativan 2 mg IM and Cogentin 1 mg IM every 4 hrs prn; hold if BP < 100/60 mmHg, OR l Geodon 20 mg IM every 8 hrs prn; hold if BP < 100/60 mmHg Mildly agitated with renal/hepatic impairment l Risperdal 2 mg PO and Ativan 2 mg PO every 8 hrs prn Elderly/Frail l Risperdal 0.5 mg PO and Ativan 0.5 mg PO every 8 hrs prn (not to exceed 3 in 24 hrs), or l Haldol 2 mg IM and Ativan 1 mg every 8 hrs prn; hold if BP < 100/60 mmHg 10. IV: l IV lock; flush per routine l IV __________________________@ mL/hr 11. Lab: l Admission: CBC, sed rate, comp met profile, serum ammonia, HIV, RPR, TSH, urine drug screen l Consider: serum for lead and heavy metals and lumbar puncture l Other labs: ___________________________________________________ 12. Diagnostic Studies: l CT head without contrast l CXR 2 view; reason: rule out bony abnormality/infiltrate l Consider carotid Doppler 13. Consult: _____________________________________________