Name of Facility Sacramento/Roseville Room # Name:
PHYSICIAN’S ORDER SHEET Page 1 of MR #
GERIATRIC ADMISSION ORDERS
Physician, Check box to activate order. If no box, line through order not desired.
Dispensing by non-proprietary name is authorized unless otherwise ordered.
No Known Allergies Allergies/Type of reaction (specify): :
Admission Diagnosis:
Code status discussed with patient/family: No Yes Full Code or See Desired Intensity of
Care
Non Modifiable Delirium Risk Factors: History of Dementia or other Chronic Neurological condition,
Age>60, History of Substance abuse
Modifiable Delirium Risk Factors: Sleep Deprivation, Immobility, Dehydration, Sight or hearing deficit,
Medications, Urinary retention, impacted bowels, untreated pain
2. Vital Signs: q shift-hold BP/Temp while asleep 21:00-07:00-check HR/RR q four hours 21:00-07:00
Activity: Progressive mobilization protocol-start with bed rest dangle up to chair Ambulate
OOB to chair with each meal
Limit any unnecessary awakenings at night. Avoid transfers at night
Encourage self-care in all activities of daily living
PT eval for acute functional decline, need for assistance device or
recurrent falls within the last three months
3. Notify MD for: T>38.5, HR>___, HR_____,SBP>_____, DBP>____, SBP_____
4. Diet:______
Offer snack between meals and at bedtime
No caffeinated beverages after 2:00 PM daily
5. Is/Os- Assist with oral fluid intake every two hours while awake.
6. IVF _____ @ _____ ml/hour-Hep lock 21:00-07:00 daily to facilitate sleeping. Hep Lock when taking >1 liter
fluid daily or after 48 hours after admission which ever come first.
IVF ________ @ ml/hour. Hep lock when taking >1 liter fluid daily
Date Time Title Print Name
PHYSICIAN’S SIGNATURE:
Date Time RN Signature: Print Name
7. Nursing: Assess for hearing deficit and provide assistant device
Assess for visual impairment and provide eye glasses as family is able to provide
Encourage family member to spend time at bedside and to spend night if possible.
Elicit information from them regarding the patient in order to individualize care
Place orientation sign at bedside
Do not transfer or relocate patient between sunset and 07:00 daily
Initiate interdisciplinary care of plan for:
Cognitive Impairment
Non-Pharmacological Sleep
Fall Prevention.
6 Medications: Tylenol 650 mg every six hours routine hold midnight dose if asleep
Dilaudid _____ mg po q 4hours routine (Dilaudid wears off after 3-4 hours)
Dilaudid 0.5-1 mg po q 2 hours prn moderate-severe pain-call MD for frequent dosing
Dilaudid 0.25-.5 mg IV q 2 hours prn moderate-severe pain-call MD for frequent dosing
Colace 250 mg po daily-hold for excess loose BMs
Senokot one tab twice daily-hold for excess loose BMs
Sorbitol 60 ml daily prn constipation,
fleets enema daily prn constipation refractory to above and sorbitol-,If constipation
continues call MD
Dulcolax suppository prn constipation-if constipation continues-call MD
Haldol 0.5 mg -1 mg IV/PO q 6 hours prn agitated delirium. Notify rounding physician in
morning after giving first dose. Call MD on call if no improvement within 2 hours of dose.
Trazodone 25mg po at bedtime prn insomnia refractory to nonpharmacologic sleep
protocol
Haldol 0.5 mg po three times daily routine-for delirium prophylaxis-consider in patients
who underwent Hip Surgery
Ancillary services: Clinical nutrition Geriatric nurse specialist Psychiatric liaison Social
services Palliative Care
Time Title Print Name
PHYSICIAN’S SIGNATURE:
Date Time RN Signature: Print Name
Date
2
Room # Name:
PHYSICIAN’S ORDER SHEET Page 2 of 2 MR #
Physician, Check box to activate order. If no box, line through order not desired.
Dispensing by non-proprietary name is authorized unless otherwise ordered.
Information written in this space will not fax properly.
Date Time PHYSICIAN’S SIGNATURE: Title Print Name
Date Time RN Signature: Print Name
Last rev. 03/06/03 last reviewed by P&T Distribution: Original inpatient
Created by:
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