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Admission orders: Cardiac Case 2 Example

Primary Diagnosis: 

Hypertension is the primary diagnosis. Patient is also known to be diabetic.

Status/Condition (Critical, Guarded, Stable, etc.):

The patient walks in the hospital in a stable condition.

Code Status: 

The patient is of Do-Not-Resuscitate (DNR) status.

Allergies: 

The patient has no known food or drug allergy (NKFDA)

Admit to Unit: 

To be admitted to the medical-surgical unit.

Activity Level:

The patient has no restrictions to activity.

Diet: 

The patient is on carbohydrate-controlled diet and input output control.

IV Fluids: 

• Critical Drips (If ordered, include type and rate. Do not defer to ICU protocol.): 

Maintain patent IV access.

 0.9% sodium chloride 3-10mls flush in every 12 hours.

0.9% sodium chloride 3-10mls flush before and after every IV drug infusion.

Respiratory: Oxygen (If ordered, include type and rate.), pulmonary toilet needs, ventilator settings: 

Oxygen via nasal canula for SPO2 below 92%.

Discontinue for saturation above 93% on RA.

Medications (include ALL, tx of primary condition, underlying conditions, pain, comfort needs, etc., dose and route):

Metoprolol:( 50mg – 400mg/day). 50mg administered twice a day Taken orally after meals. Increase the dose on weekly or longer intervals on need basis.

Insulin: (0.2-0.4 units/kg/day). Administer subcutaneously after measuring the glucose level. Maintain patent IV line for emergency cases. Adjust doses according to blood glucose control.

Aspirin: 162.5mg oral dose once/day. Assess for bleeding disorders and contraindications such as surgery.

Nursing Orders (vital signs, skin care, toileting, ambulation, etc.):

Maintain an input and output record every four hours, blood pressure recording every 4 hours, AC glucose monitoring before every meal and perform daily weight checking (Jian-Hong et al, 2020), prevent falls while in hospital.

Follow-Up Lab Tests:

Perform lipid profile, electrolytes level, kidney function test, BUN, KUB and Creatinine clearance.

Urine protein, urinalysis and urine drug level.

• Diagnostic testing (CXR, US, 2D Echo, etc.):

Cardiac: echocardiogram and EKG.

Consults:

Cardiology consult: hypertensive management

Nutritionist consult: review of diet plan and weight gain

Social worker consult: conducive home-based care before discharge

Pharmacist consult: antihypertensive management

NOTE: (Do not defer management to a specialist. As an ACNP, you must manage the patient’s acute needs for at least a 24-hour period]. Include indication for consult. For example: “Cardiology consult for evaluation of new-onset atrial fibrillation,” or “Nutrition consult for TPN recommendations.”

Patient Education and Health Promotion (address age-appropriate patient education. if applicable):

Diet: the patient needs to reduce on sodium related products such as salt that are likely to increase water retention. She is encouraged to take fruits and vegetables, and lower portions of carbohydrates to manage her glucose levels (Whelton et al, 2017).

Medication: She is discouraged on the use of over-the-counter drugs without review of her regimen by the pharmacist. This will intend to reduce cases of toxicity that could stress the kidney. She is also educated on importance of drug compliance, in presence of the primary caregiver.

Lifestyle: Although she is expected to ambulate while at home, precaution by the patient and the caregiver is needed to avoid any skin injury. This could expose the patient to risks of heavy bleeding due to the use of ASA, and poor wound healing due to diabetes. Prevention of falls is also a priority since her old age relates with weak bones due to bone structure breakdown.

Discharge Planning and Required Follow-Up Care:

The patient must be educated on blood pressure measurement with the help of the caregiver and mode of recording. High blood pressure values should be shared for easy identification by the caregiver. The caregiver and the patient are educated on need for compliance since at her age, she is likely to forget medication regimen frequently. The caregiver should also check with the doctor before using any additional drug to avoid possible detrimental interactions.

The patient should avoid caffeine intake, salt intake, and increase potassium rich diets. The caregiver should be educated on compliance on follow-up clinics as directed by the doctor (Franklin & McCoy, 2017). The caregiver should also be aware of signs that warrant immediate medical checkup such as unresponsiveness, sudden confusion, sweating, skin cut or fall, severe headaches and sudden changes in vision.

References

Franklin, M. & McCoy, M. (2017). A transition of care from hospital to home for patients with hypertension: Wolters Kluwer Health. DOI-10.1097/01.NPR.0000511701.94615.4f

Jian-Hong, M., Hai-Shan W., Na, L. (2020). The evaluation of a nurse-led hypertension management model in an urban community healthcare, Medicine: Volume 99 – Issue 27 – p e20967 doi: 10.1097/MD.0000000000020967

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison Himmelfarb, C., DePalma, S. M., Gidding, S., Jamerson, K. A., Jones, D. W., MacLaughlin, E. J., Muntner, P., Ovbiagele, B., Smith, S. C., Spencer, C. C., Stafford, R. S., Taler, S. J., Thomas, R. J., Williams, K. A., … Wright, J. T. (2017). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary. Hypertension, 71(6), e136-e139. doi:10.1161/HYP.0000000000000066

Rubric Detail

Rubric Detail

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Name: NRNP_6566_Module2_Assignment2_Rubric

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List View
Excellent

Point range: 90–100 Good

Point range: 80–89 Fair

Point range: 70–79 Poor

Point range: 0–69
Using the Admission Orders Template, write a full set of admission orders for the patient in the branching exercise. Be sure to address the following:
· Identify the Correct Diagnosis.
5 (5%) – 5 (5%)
The order set includes an accurate and correct diagnosis.
4 (4%) – 4 (4%)
The order set includes a diagnosis that is an appropriate differential diagnosis.
3 (3%) – 3 (3%)
The order set includes a diagnosis that is incorrect and not supported by patient data.
0 (0%) – 2 (2%)
The order set includes and inaccurate / dangerous diagnosis.
· Identify the ‘Status/Condition’, ‘Code Status’, ‘Admit to Unit’
for the patient in the presenting case.
5 (5%) – 5 (5%)
The order set includes an accurate description / plan for condition, code status, and admission location.
4 (4%) – 4 (4%)
The order set includes an accurate description for 2 of the 3 variables.
3 (3%) – 3 (3%)
The order set includes an accurate description for 1 of the 3 variables.
0 (0%) – 2 (2%)
The order set includes inaccurate, missing, or dangerous descriptions for these variables.
· Describe the “Allergies’, ‘Activity Level’ and “Diet” for the patient in the presenting case.
5 (5%) – 5 (5%)
The order set includes an accurate description / plan for allergies, activity level, and diet.
4 (4%) – 4 (4%)
The order set includes an accurate description for 2 of the 3 variables.
3 (3%) – 3 (3%)
The order set includes an accurate description for 1 of the 3 variables.
0 (0%) – 2 (2%)
The order set includes inaccurate, missing, or dangerous descriptions for these variables.
· Identify any ‘IV Fluids’ needed for the patient in the presenting case.
9 (9%) – 10 (10%)
The order set clearly and accurately identifies a complete order for IV fluid type, flow rate, and administration parameters for the patient in the presenting case.
7 (7%) – 8 (8%)
The order set is missing 1 element of a complete order for IV fluid type, flow rate, and administration parameters for the patient in the presenting case.
5 (5%) – 6 (6%)
The order set is missing 2 elements of a complete order for IV fluid type, flow rate, and administration parameters for the patient in the presenting case.
0 (0%) – 4 (4%)
The order set is incomplete, includes wrong / dangerous fluids or flow rate, incorrect parameters for IV fluid type, flow rate, and administration parameters for the patient in the presenting case.
· Identify any ‘Respiratory’ needs for the patient in the presenting case. Be specific about oxygen (if ordered, include type and rate), pulmonary toilet needs, and ventilator settings.
5 (5%) – 5 (5%)
The order set clearly and accurately identifies a complete order for respiratory care, delivery method, treatments and parameters for the patient in the presenting case.
4 (4%) – 4 (4%)
The order set is missing 1 element of a complete order for respiratory care, delivery method, treatments and parameters for the patient in the presenting case.
3 (3%) – 3 (3%)
The order set is missing 2 elements of a complete order for respiratory care, delivery method, treatments and parameters for the patient in the presenting case.
0 (0%) – 2 (2%)
The order set is incomplete, includes wrong / dangerous orders, or incomplete parameters for respiratory care, delivery method, treatments and parameters for the patient in the presenting case.
· Describe the ‘Medications’ including any IV drips for the patient in the presenting case.

Be specific about medications related to the reason for admission and any chronic medications the patient may be taking (ALL, tx of primary condition, underlying conditions, pain, comfort needs, etc.). Be sure to include name, dose, route of administration, and frequency of each medication.
13 (13%) – 15 (15%)
The order set clearly and accurately identifies a complete set of medication orders for the patient in the presenting case. Orders are complete, account for all conditions, and are appropriate to treat the patient.
10 (10%) – 12 (12%)
The order set clearly and accurately identifies a complete set of medication orders for the patient in the presenting case. There are incomplete orders, missing medications, or missing elements in the orders.
5 (5%) – 9 (9%)
The order set is missing essential elements of a medication order, missing medications, or are inappropriate to treat the patient in the presenting case.
0 (0%) – 4 (4%)
The order set is incomplete, includes wrong / dangerous orders, or inappropriate medications to treat the patient in the presenting case.
· Explain any ‘Nursing Orders’ for the patient in the presenting case. Be specific about vital signs, skin care, toileting, and ambulation.
9 (9%) – 10 (10%)
The order set includes a full set of nursing orders that provide essential direction to provide care, monitor, assess, ensure safety, prevent complications and promote healing.
7 (7%) – 8 (8%)
The order set include inaccurate or is missing 1 or 2 nursing orders essential to direct nursing care, monitor, assess, ensure safety, prevent complications, and promote healing.
5 (5%) – 6 (6%)
The order set include inaccurate or is missing 3 or 4 nursing orders essential to direct nursing care, monitor, assess, ensure safety, prevent complications, and promote healing.
0 (0%) – 4 (4%)
The order set include inaccurate, missing, or provides dangerous nursing orders essential to direct nursing care, monitor, assess, ensure safety, prevent complications, and promote healing.
· Explain the ‘Follow-Up Lab’ tests for the patient in the presenting case. Be specific about diagnostic testing (e.g., CXR, US, 2D Echo, etc.).
9 (9%) – 10 (10%)
The order set includes complete laboratory and diagnostic testing to adequately monitor and assess the presenting patient.
7 (7%) – 8 (8%)
The order set includes most (missing 1 or 2) laboratory and diagnostic testing to adequately monitor and assess the presenting patient.
5 (5%) – 6 (6%)
The order set includes some (missing 3 or 4) complete laboratory and diagnostic testing to adequately monitor and assess the presenting patient.
0 (0%) – 4 (4%)
The order set is missing essential laboratory and diagnostic testing to adequately monitor and assess the presenting patient.
· Explain the ‘Consults’ for the patient in the presenting case. Be specific about how you, as an ACNP, would manage the patient’s acute needs for at least a 24-hour period. Include indication for consult (e.g., “Cardiology consult for evaluation of new-onset atrial fibrillation,” “Nutrition consult for TPN recommendations”).
5 (5%) – 5 (5%)
The order set includes clear, accurate, and essential consults for the patient in the presenting case including complete rationale for the consult.
4 (4%) – 4 (4%)
The order set is missing one of the following: necessary consult, inaccurate information, or inaccurate rationale for consults needed to manage the presenting patient.
3 (3%) – 3 (3%)
The order set is missing 2 or more of the following: necessary consult, inaccurate information, or inaccurate rationale for consults needed to manage the presenting patient.
0 (0%) – 2 (2%)
The order set is missing multiple consults, rations, or accurate descriptions for consults needed to manage the presenting patient.
· Explain the ‘Patient Education and Health Promotion’ for the patient in the presenting case. Be sure to address age-appropriate patient education, if applicable.
9 (9%) – 10 (10%)
The order set provides clear, accurate, and complete patient education and health promotion recommendations for the patient in the presenting case.
7 (7%) – 8 (8%)
The order set is missing 1 or 2 essential elements of patient education and health promotion for the patient in the presenting case.
5 (5%) – 6 (6%)
The order set is missing 3 or 4 essential elements of patient education and health promotion for the patient in the presenting case.
0 (0%) – 4 (4%)
The order set is missing multiple essential elements of patient education and health promotion for the patient in the presenting case.
· Explain the ‘Discharge Planning and Required Follow-Up Care’ for the patient in the presenting case.
5 (5%) – 5 (5%)
The order set provides clear, accurate, and complete discharge planning and necessary follow up care for the patient in the presenting case.
4 (4%) – 4 (4%)
The order set is missing 1 or 2 essential elements of discharge planning and necessary follow up care for the patient in the presenting case.
3 (3%) – 3 (3%)
The order set is missing 3 or 4 essential elements of discharge planning and necessary follow up care for the patient in the presenting case.
0 (0%) – 2 (2%)
The order set is missing multiple essential elements of discharge planning and necessary follow up care for the patient in the presenting case.
· Identify a minimum of three ‘References.’ Be sure that they are timely and support the admission order in following current standards of care.
9 (9%) – 10 (10%)
The order set includes a minimum of three professional level references that are timely and clearly support the admission orders following current standards of care. References are formatted in APA format.
7 (7%) – 8 (8%)
The order set does not include a minimum of three professional level references that are timely and clearly support the admission orders following current standards of care. APA format is incorrect.
5 (5%) – 6 (6%)
The order set does not include a minimum of three references or includes non-professional level resources to support their admission order set. APA format is incorrect.
0 (0%) – 4 (4%)
The order set is missing minimum number of references or includes poor sources that do not reflect professional writing or current standard of care information. APA format is not followed.
Written orders include all elements, address all the needs of the patient, are complete, logical, and meets the complete needs of the patient.
5 (5%) – 5 (5%)
Written order set is complete, addresses all the needs of the patient, and are based on current literature.
4 (4%) – 4 (4%)
Written orders are mostly complete only missing 2 essential elements in addressing the needs of the patient.
3 (3%) – 3 (3%)
Written orders are missing 3 to 4 essential elements are reflect an incorrect standard of care.
0 (0%) – 2 (2%)
Written orders are incomplete, do not address the needs of the patient, or reflect an outdated standard of patient care.
Total Points: 100
Name: NRNP_6566_Module2_Assignment2_Rubric