Name
Item
Name of attending physician
text
Phone
Item
Phone number of attending physician
integer
Admitting Diagnosis
Item
Upper Gl Bleed Contributing Diagnoses
text
Activity
Item
Bed rest with bedside commode
boolean
Activity
Item
Bathroom privileges with assistance
boolean
Nursing
Item
ICU: per routine
boolean
Nursing
Item
Telemetry or medical: every 1 hr until stable X4, then every 2 hrs until stable X4, then every 4 hrs
boolean
Nursing
Item
Notify MD for: BP < 90/60 or > 170/110, P < 60 or > 120, Urine output < 30 cc/hr over 4 hrs, all H/H results
boolean
Nursing
Item
If NG to suction, replace NG fluid cc for cc with NG with 20 mEq KCl every 12 hrs
boolean
Medications
Item
Protonix 40 mg PO/IV every 12 hrs
boolean
Medications
Item
Other
boolean
Medications
Item
If Other, please specify
text
IV
Item
Bolus normal saline___cc over__
boolean
IV
Item
If Bolus normal saline, please specify amount
integer
IV
Item
If Bolus normal saline, please specify duration
text
IV
Item
Dextrose 5% normal saline with 20 mEq KCl/l @___mL/hr total
boolean
IV
Item
If Dextrose 5% normal saline, please specify amount
integer
Lab
Item
Hemogram, comp met profile, PT/PTT/INR on admission
boolean
Lab
Item
HH every 4 hrs X3
boolean
Lab
Item
Type and screen for __units PRBC
boolean
Lab
Item
If type and screen, please specify amount of units PRBC
integer