Room #

							                 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<,____ RR>_____,SBP>_____, DBP>____, SBP<____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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