Clinical Orientation Manual - University of Kansas Medical Center

surgical preps, showers, etc.
Dressing changes and wound care
Respiratory care: Although respiratory care is generally provided by Respiratory Therapy rather than
nursing, Respiratory Therapy orders that do not include medications are often included here, for
instance, PD&C (percussion and postural drainage), TC&DB (turn cough and deep breathe),
incentive spirometry, nasotracheal suctioning, etc.
Notify house officer if: This establishes parameters in vital signs beyond which nursing will notify the
patient's resident for further orders, for instance, notify HO for temp>38, systolic BP20,
etc.
8. Diet: NPO, regular, mechanical soft, clear liquid, 1600 cal ADA, 2 gm sodium restriction, tube feedings,
protein restricted, etc.
9. Intake and output: This includes the frequency with which nursing will monitor and record I&O as well
as any tubes, drains, or lines the patient might have, for instance:
Record hourly I&O
NG tube to low intermittent suction
Foley catheter to dependent drainage
Hemovac, surgical drains, chest tubes
Endotracheal tubes, arterial lines, central venous lines
10. Specific drugs: This includes all medications to be given on a specific schedule, for instance,
antibiotics, diuretics, cardiovascular drugs, etc. Also include allergies to medications. IV
orders include simply the type of IV solution and the rate at which it is to be infused, for
instance, D5 1/2NS TRA 50 cc/hr. When the patient has both central and peripheral
lines, these are specified separately, for example, D5 1/2NS TRA TKO via peripheral
line and D5 1/2NS TRA 100 cc/hr via central line. Inpatient medication orders are
written with the name of the drug, dosage, route of administration, and frequency of
administration specified, for instance, Digoxin 0.125 mg PO Qday.
11. Symptomatic drugs: This includes all drugs to be given on a PRN basis, for instance, pain meds,
laxatives, sedatives, etc.
12. Extras: This includes any diagnostic procedures to be performed, for instance, EKG, chest x-ray, CT
scan, sonogram, etc.
13. Labs: CBC w/ diff, urinalysis, etc. These can be one-time orders for admission lab work or can be for
standing orders for continuous monitoring, for example, daily INR.
Discharge Orders:
At KUMC, O2 is used for discharge orders. The KCVA uses a different system. You use the same order
form for discharges as you do for your other orders. Discharge orders should include the following basic
information. (Note: most of the discharge paperwork will now be completed on the computer, but the
information provided here still holds).
1. Discharge: Give location patient will be going after leaving hospital (i.e. home, nursing
home). Specify what date and time.
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