Reuben Notes

Admission Orders

Date/Time

  • Admit to reg nsg floor per Dr. MD / Dr. POD
  • Dx: cellulitis R foot secondary to infected ulcer
  • Condition: stable
  • Vitals: q shift
  • Activity: CBR c bedpan, strict NWB right foot
  • Nsg: Keep dsg C,D,I, podiatry service to change. Bolster dsg as necessary. Accu check q Q 6h/Q 4h if NPO
  • Diet: High/ Medium or Low CCC Diet
  • I/O :
    • IVF to heplock
    • If dehydrated, orthostatic start NSS @100cc/h unless renal compromise, Then 80cc/h is safe.
  • Labs :
    • CBC-D
    • CMP
    • CRP
    • ESR
    • HgA1C
    • cultures
    • blood Cx
    • PVR's
    • TCOM's - all longstanding wounds, chronic infections, all DM patients over 50 y/o and all patients with DM >10 years.
      • written as - Consult respritory Therapy for Transcutaneous oxygen measurements
      • Specify where you want measurments taken. Keep in mind the plantar foot is not a good location due to thickness of skin.
    • PT/PTT/INR
    • UA
    • CXR and EKG - if to go to OR
  • Meds :
    • all home meds - confirm with admitting MD
    • IV Abx = confirm with attending / ID if already involved
    • Lovenox 40mg SQ daily
    • Ambien 5mg po qhs prn insomnia
    • Multivitamins, arginate, zinc if nutritional status is low.
  • X-rays: 3 views
    • MRI, bone scan when indicated.
  • Consult : Infectious disease consult
    • Medical clearance, Cardiology clearance if to OR
    • Vascular consult if needed
    • Dietary consult if needed.
    • Social services for SNF placement if anticipated or Medicaid pending number if no insurance.

Admission Orders - Diabetic

Date/Time

  • Admit to reg nsg floor per Dr. MD / Dr. POD
  • Dx: cellulitis R foot secondary to infected ulcer
  • Condition: stable
  • Vitals: q shift
  • Activity: CBR c bedpan, strict NWB right foot
  • Nsg: Keep dsg C,D,I, podiatry service to change. Bolster dsg as necessary. Accu check q Q 6h/Q 4h if NPO
  • Diet: High/ Medium or Low CCC Diet
  • I/O:
    • IVF to heplock
    • If dehydrated, orthostatic start NSS @100cc/h unless renal compromise, Then 80cc/h is safe.
  • Labs:
    • CBC-D
    • CMP
    • CRP
    • ESR
    • HgA1C
    • cultures
    • blood Cx
    • PVR's
    • TCOM's - all longstanding wounds, chronic infections, all DM patients over 50 y/o and all patients with DM >10 years.
      • written as - Consult respritory Therapy for Transcutaneous oxygen measurements
      • Specify where you want measurments taken. Keep in mind the plantar foot is not a good location due to thickness of skin.
    • PT/PTT/INR
    • UA
    • CXR and EKG - if to go to OR
  • Meds:
    • all home meds - confirm with admitting MD
    • IV Abx = confirm with attending / ID if already involved
    • Lovenox 40mg SQ daily
    • Ambien 5mg po qhs prn insomnia
    • Multivitamins, arginate, zinc if nutritional status is low.
  • X-rays: 3 views
    • MRI, bone scan when indicated.
  • Consult:
    • Infectious Disease consult
    • Medical clearance, Cardiology clearance if to OR
    • Vascular consult if needed
    • Dietary consult if needed.
    • Social services for SNF placement if anticipated or Medicaid pending number if no insurance.

Admission Orders - Trauma

Date/Time

  • Admit to reg nsg floor per Dr. MD/ Dr. POD
  • Dx: ankle fracture right
  • Condition: stable
  • Vitals: q shift
  • Activity: CBR c bedpan, strict NWB right foot
  • Nsg:
    • Keep dsg C,D,I. Bolster dsg as necessary (call resident if strikethrough)
    • Accu check q Q 6h if diabetic (q 4h if NPO)
    • Elevate left foot on foam elevator with popliteal support
    • Ice to posterior knee 2o min of every hour, or maintain polar care unit
    • Incentive spirometry to bedside with instruction
    • SCD's in place and functioning at all times
  • Diet: 2,000 calorie, adjust dep. on patient. Dinner tray to bedside now if late.
  • I/O:
    • Continue IVF @ 100cc/hr until PO tolerant then heplock
    • Monitor I/O's
    • Monitor drain output, stripping, etc if drain in place.
  • Labs:
    • CBC-D
    • CMP in am, monitor H&H if big case
    • Check PT/PTT/INR if medicine admit b/c everyone is on heparin!
    • EKG
    • UA
    • CXR
    • tox screens, ETOH dep. On Patient
    • Hep profile
    • HIV when indicated
    • HCG when indicated
  • Meds:
    • all home meds = if needed
    • IV Abx = open fracture, etc
    • Lovenox 40mg SQ daily, Fragmin if long-term anticoagulation
    • Morphine 2-10mg prn severe pain
    • Vicodin or Percocet 5mg po q 4-6h prn mod pain
    • Prednisone taper (60-50-40-30-20-10)vs Motrin for swelling
    • Flexeril 10mg tid if tendon injury
    • Toradol 30 mg IV q6 unless contraindicated, only x 5 days
    • Phenergan 12.5mg IV Q6-8h prn
    • Ambien 5mg po qhs prn insomnia
    • Reg. insulin sliding scale if diabetic
  • NPO orders if to OR in am
  • Medical, cardiology clearance if to OR

Admission Orders - Post-OP

Date/Time

  • Extended recovery per Dr. podiatry attending Or readmit the pt to RNF per Dr. (pt's primary doctor, if the doctor is not a SVCH staff we usually ask Drs. Wardega, Tahir, and Tcaciuc)/Dr. podiatry attending
  • Dx: s/p name of the procedure R/L foot/leg
  • Condition: stable
  • Vitals: Per shift (consider q4 hours if febrile)
  • Activity: CBR with bedpan or bedside commode, strict NWB
  • NSG: Keep DSG C/D/I, call resident if strikethrough.
    • Incentive spirometry to bedside with instruction.
    • Please make sure that SCD is properly placed and working
    • *Polar care unit, (recirculate Q3 hours if Cryo/Cuff)
    • Elevate R/L foot with a foam elevator with popliteal support
  • Diet: Regular/Low,Medium or High CCC diet depending on the pt advance as tolerated. Dinner tray to bedside now if late.
  • I/O: Continue IVF (NSS) @100cc/hr (depending on the current rate) to heplock when pt is p.o. tolerant
    • D/C Foley catheter (if the pt has one)
    • Record I/Os
    • Empty the J/P drain when halfway filled and record the amount (if drain placed), strip drain q 2 hours.
  • Labs: CBC with Diff, BMP in a.m.
    • H&H now (if pt lost a large volume of blood)
  • Meds : Already prescribed home meds +
    • Ancef 1g q8 hours x 3 doses
    • Morphine 2-10mg IV q4-6 hours PRN breakthrough pain
    • Vicodin 5mg T-TT p.o. q4-6 hours PRN moderate to severe pain (or Percocet)
    • Toradol (be careful with PUD) 30mg IV q6 hours x 5 days
    • Phenergan 12.5mg IV q4-6 hours PRN N/V (again this can mask constitutional symptoms)
    • Ambien 5mg T p.o. qhs PRN insomnia
    • Flexeril 10mg T p.o. TID (if tendon work has been done)
    • Lovenox 40mg SC daily
    • Multivitamins, Zinc, any nutritional deficit should be covered
    • Cepacol Lozenges to bedside PRN sore throat
  • Xrays: 3 views R/L ankle/foot with specific post-op diagnosis
  • Consults: Physical therapy consult in a.m. for evaluation and training NWB R/L. dx: s/p procedure

 

* Be sure to culture all drain tips in a dry, sterile specimen cup when pulled*

Pre-OP Orders

Date/Time

  • NPO after midnight
  • Pt may take am meds with a sip of water
  • Hold all am po hyploglycemics
  • Begin D5 & 1/2NS @ 80-100 cc/hr at midnight.
  • Accu check q4h while NPO.
  • PT / PTT / INR if on heparin, coumadin
  • EKG - done?
  • Medical clearance? Cardiology Clearance?