What are the initial orders for a patient requiring hospital admission?

Hospital Admission Orders: A Structured Approach

Initial Assessment and Monitoring

All admitted patients require standardized vital sign monitoring with specific parameters: pulse oximetry, respiratory rate, blood pressure, and heart rate should be assessed every 4 hours for the first 48 hours, then adjusted based on clinical status. 1

Vital Signs Protocol

• Temperature monitoring every 4 hours for first 48 hours, with increased frequency if temperature exceeds 37.5°C 1
• Continuous pulse oximetry for patients with cardiorespiratory compromise 1
• Daily weight and accurate fluid balance charting for all patients 1
• Daily renal function and electrolyte monitoring during hospitalization 1

Oxygen Therapy Orders

Target oxygen saturation of 94-98% for most hospitalized patients, with adjustment to 88-92% specifically for COPD patients. 2 This represents the optimal range associated with lowest mortality across multiple conditions 3, 4.

Oxygen Administration Guidelines

• Initiate supplemental oxygen only when SpO2 falls below target range 2
• Consider humidification when oxygen flows exceed 4 L/min 2
• For acute heart failure patients with SpO2 <90%, oxygen therapy is indicated 1
• Avoid high-flow oxygen (>6 L/min) in infectious respiratory conditions to minimize aerosol generation 1

Special Populations

• COPD exacerbations: strict target of 88-92% regardless of carbon dioxide levels, as higher saturations (93-96% or 97-100%) increase mortality risk with odds ratios of 1.98 and 2.97 respectively 3
• Acute myocardial infarction: target SpO2 94-96% as this range shows lowest mortality in a U-shaped curve relationship 4

Venous Thromboembolism Prophylaxis

Initiate intermittent pneumatic compression (IPC) devices within 24 hours of admission for all immobile patients, continuing until independent mobility, discharge, or 30 days. 1

VTE Prevention Protocol

• Low-molecular-weight heparin (enoxaparin) for high-risk patients with normal renal function 1
• Unfractionated heparin for patients with renal failure 1
• Daily skin integrity assessment for patients wearing IPC devices 1
• Early mobilization and adequate hydration for all patients 1
• Do not use anti-embolism stockings alone as they are ineffective 1

Early Mobilization Orders

Rehabilitation assessment should be initiated within 48 hours of admission, with active therapy beginning as soon as medically stable. 1

Mobilization Protocol

• Frequent, brief out-of-bed activity (sitting, standing, walking) beginning within 24 hours if no contraindications exist 1
• Initial screening by rehabilitation professionals within 48 hours 1
• Clinical judgment required as more intense early sessions show no additional benefit 1

Condition-Specific Admission Orders

Acute Heart Failure

• Intravenous furosemide 20-40 mg initial dose for all patients 1
• For volume overload: furosemide IV bolus at least equivalent to oral maintenance dose (40 mg IV for new-onset HF, higher for chronic HF exacerbations) 1
• Intravenous vasodilators when systolic BP >110 mmHg for symptomatic relief 1
• Arterial line placement for cardiogenic shock (SBP <90 mmHg with hypoperfusion signs) 1

Acute Stroke

• Temperature monitoring every 4 hours for 48 hours 1
• For temperature >37.5°C: investigate infection (pneumonia, UTI) and initiate antipyretics/antimicrobials 1
• Single self-limiting seizures within 24 hours do not require long-term anticonvulsants 1
• Recurrent seizures: treat with lorazepam IV if not self-limiting 1

Asthma Exacerbations (Pediatric)

• Inhaled salbutamol via MDI-spacer: 2-10 puffs every 20-30 minutes for first hour 1
• Nebulized salbutamol: 2.5-5.0 mg every 20 minutes for three doses 1
• Ipratropium bromide: 4-8 puffs every 20 minutes via MDI-spacer, then every 4-6 hours 1
• Oral corticosteroids: prednisolone 1-2 mg/kg (maximum 40 mg) daily for 3-5 days 1
• Oxygen supplementation targeting saturation 92-95% 1

Moderate Diabetic Ketoacidosis

• Continuous insulin infusion for blood glucose >500 mg/dL or pH <7.2 without altered sensorium 1
• Cardiac monitoring for electrolyte abnormalities 1
• Frequent blood glucose and electrolyte monitoring 1

Level of Care Determination

ICU/CCU Criteria (Immediate Transfer Required)

• Respiratory rate >25, SpO2 <90%, or use of accessory muscles 1
• **Systolic BP <90 mmHg or signs of hypoperfusion** (oliguria, cold peripheries, altered mental status, lactate >2 mmol/L, metabolic acidosis) 1
• Need for intubation or already intubated 1

Stepdown Unit Criteria

• Continuous cardiorespiratory monitoring without mechanical ventilation 5
• Hemodynamically stable post-MI patients after 12-24 hours of CCU stability 5
• Non-invasive ventilation or high-flow oxygen requirements 5
• Moderate diabetic ketoacidosis on continuous insulin infusion 1, 5

General Medical Ward Criteria

• Hemodynamic stability with systolic BP ≥90 mmHg without vasopressor support 6
• Moderate pulmonary disease requiring supplemental oxygen without high-flow needs 6
• Responding to fluid resuscitation without inotropic requirements 6

Common Pitfalls to Avoid

• Never delay oxygen administration awaiting written orders in emergency situations 7
• Avoid excessive oxygen supplementation (SpO2 >96%) in AMI patients as it increases mortality 4
• Do not use different oxygen targets based on carbon dioxide levels in COPD - maintain 88-92% for all 3
• Avoid aerosol-generating procedures (high-flow oxygen >6 L/min, CPAP, NIV) in infectious respiratory conditions without appropriate isolation 1
• Do not discharge patients with asthma exacerbations without oral corticosteroids, written action plan, and follow-up within 1 week 8