Tips on Surviving Floor Rotations

8/6/2019 Tips on Surviving Floor Rotations

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Tips on surviving floor rotations

1) Be organized AND always write things down! You need to develop a good

system to keep track of your patients information/daily labs/ to do

list. Some suggestions:

a. Copy your dictated H/P, fold it in half and write your daily vitals, labs

, studies and to do list on the back. You can also have a separate to

do list (examples on page 31.32).

b. There are pre-printed H/P and daily sheets you can use but many find them

too time consuming. (http://www.medfools.com/downloads/medicine)

c. Copy every pts H&P, daily progress note and put it in a folder. Just

dont lose your folder. You may want to put your contact information so

that they can page you if it is found.

d. Use your daily sign-out sheet and put whatever important information on

the sign-out sheet during the day.

2) Pre-round: 6:30-9:00AM (You have to pick up your sign-out sheet by 7:00AM

)

a. Get to work early and get your notes started or finished before rounds.

It really helps to have your notes done before rounds so you can work on

other things after rounds.

b. Many people pre-write or pre-type their progress notes. This makes a lot

of sense particularly for chronic patients where the plan does not changevery much. If you do this, leave some room under the active issues so that

you can hand-write additional thoughts based on that mornings labs. You

dont have to have the perfect plan or have all the labs in the morning.

You can add addendum to your notes later if the plan changes during rounds.

c. Correct abnormal electrolytes early. At the beginning of the year you may

feel a little uncomfortable so call your resident. Below are some

recommendations.

i. Potassium: Each 10 mEq is equivalent to 0.1 increase on the lab level.1. Supplement all potassium below 3.8-4.0 unless pt has renal failure (3.0-3

.4 may be acceptable, check with resident)

2. KCl 10mEq IV (run over one hour)

a. If pt has a central line you can run IV per protocol

b. Can give 1ml of 1% lidocaine with each 10mEq bag if its painful: be

careful with pts with cardiac conditions

3. K-Dur 10mEq PO (tablet)


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4. K-Lyte 25mEq PO (liquid)

a. Has a lot of bicarb so if pt is alkolotic give KCl

5. K-Phos 2 tabs PO

6. K-Phos 10mmol IV (run over one hour)

7. Give 10mEq for every 0.1 below 4.0

8. Watch potassium closely in pts on lasix.9. You can also add 20mEq KCl to each 1L bag of IV fluid

10. Remember K+ will not correct unless you replace Mg

11. Make sure to correct potassium cautiously in patients with renal disease

, particularly those with end-stage renal disease.

ii. Magnesium

1. Supplement all Mg below 2.0 unless pt has renal failure (around 1.6 is

fine, check with resident)

2. For every 0.5 deficit, give 1 g of Mg

3. Magnesium Sulfate 1 g IV (run over 1 hour) or 400mEq MgOxide po BID or

TID

iii. Phosphorous

1. Consider supplement if less than 2.0

2. Particularly important for patients in respiratory distress (ATP).

3. K-Phos 2 tabs PO q daily

4. Neutra-Phos 2 packs PO q daily

a. only helps pts taking po

b. give it with meals

c. K-phos 10mmol IV

5. Na-phos 10mmol IViv. Calcium

1. check albumin to correct level

2. calcium carbonate

a. Tums: 500mg tab = 25 mEq cal

b. Os-Cal: 650mg = 13 mEq cal

3) Progress Notes: (sample on page 31)

a. SOAP notei. S: what happened overnight (start with telemetry events or acute events)

ii. O: vital signs (include finger stick glucose checks, I/O, weight if

applicable)

iii. A/P: Assessment of pt and your plan for the day

iv. Code status

v. Social (update family), disposition plan


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4) Rounds: Time for rounding is usually between 9:30-11:30 but can vary.

Rounding is a time to present your pts and also for learning and teaching.

a. Presentation: Concise and relevant information only. Always get the most

recent lab data and look at all micro, radiology studies (listen to all

reports before rounds)b. Teaching: Interns are not expected to read all the time but you should

read on topics related to your patients. Its always good to bring in

articles. You can access KP on-line library (http://cl.kp.org ) or use Up-to-date for

information.

5) After Rounds: You need to prioritize your to do list. Call consults,

put in e-consults for studies and replace electrolytes early. Always take

care of your sickest patients first.

6) Always ask for help when you need it. Your team should work together. If

you are overwhelmed tell your resident. There are usually two interns on a

team, so help each other. Sometimes the patient load is very uneven, and it

is the residents responsibility to redistribute.

7) Take care of your patients as you would your family members. Remember to

keep your patients and their family members updated. You may not always see

family around so ask the nurse to call you when they are there. Trust me, it

will save you a lot of time at discharge and will also help avoid angryfamily members and patients.

8) Dealing with patients family:

a. Large family: You dont have time to explain everything to everyone. The

best thing to do is ask family members to designate a spokesperson to

contact for updates.

b. Angry patient or family: Dont try to handle the situation yourself.

Tell the pt/family member you see that they are upset/angry and that you

need to call your resident/attending to be present.

9) Be nice to nurses, clerks, PT, OT, RT and all other medical staff because

they can make your life a lot easier. Interns are sleep-deprived and

stressed, but remember to keep your cool. If you run into problems with a

staff member call your resident/attending.


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10) Verbal Orders: It is a privilege and can be taken away if we abuse it.

All verbal orders must be signed within 24 hours. You can sign someone else

s verbal order. If you disagree with the order you can write on the order

that you are signing for Dr.X, but you should still sign it. For all

verbal orders remember to have the nurse read it back to you and double-check the name of the patient.

Tips on Admissions

1) Most of the information for H/P can be found in CIPS. But, before you

start looking things up check on your pt. Introduce yourself and tell the pt

you will be back after reviewing their information. (Look under CIPS

section in this booklet for helpful tips.)

Note: Sometimes patients will have seen their primary care physician a few

days before coming to the hospital, so check under Visits for category

and read notes.

2) Forms you need to fill out:

1) General Adult Medicine Admission Orders

i. Suggestions for general admissions (remember every pt is different so go

over pts baseline vitals before filling this part out)

1. HR less 60 or greater than 100

2. RR less than 10 or greater than 24

3. SBP less than 90 or greater than 145

a. For stroke pts: call for SBP greater than 1804. Temperature greater than 100.6-101

5. Activity

a. Bedrest for AMS, stroke, seizure, ACS pts

b. Anyone bedbound: decubitus precautions/care

c. Head of bed elevated 30o for anyone at risk of aspiration

6. Diet:

a. You should always write: bedside swallow eval before diet for anyone

you think may have trouble swallowing (ex. pts with CVA). Always include:

if fails bedside swallow eval please consult OT for swallow evaluation.

b. For anyone who may be malnourished you can add instant carnationbreakfast drinks. Usually 1 can q daily to TID

7. IV fluids: Most commonly used is NS or D51/2 NS.

a. For anyone on NPO you should consider D51/2 NS and dont forget to D/C

fluid when pt can eat. 75-100cc/hr

b. Ringers lactate is usually used in the ICU.

c. Put a limit on your IV fluids.

i. Ex: NS at 100cc/hr x 2 L. This way you dont forget to d/c fluid and put


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someone in CHF.

d.

Fluid Na Cl HCO3 Sugar

NS (0.9%) 154 154

D5W 50g /L

LR 130 109 28

8. Pain Meds: Find something you are comfortable with.

a. Example 1: (pt can take po)

i. Tylenol 650mg po q 6h prn mild pain (make sure pt LFT is not extremely

high): no greater than 4 g per day (2 g per day in patients with liver

disease.

ii. Vicodin 1 tab po q 6 hours prn mod. pain

iii. Vicodin 2 tab po q 6 hours prn severe pain

b. Example 2: (pt cant take po)

i. Tylenol 650 mg pr (per rectum) q 6hr. prn mild pain

ii. 1mg morphine q 3h IV prn mod. pain

iii. 2mg morphine q 3h IV prn severe pain

iv. Hold morphine (any narcotics) for RR


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mg po q 6-8 hours, 5-25 mg PR q12 (may cause SIADH)

c. zofran: 4-8mg po or IV q 8 hours

d. reglan 5-10 mg po or IV q6 hours

12. Order inpatient and outpatient charts early. Many reports (e.g. previous

colonoscopy and cardiac cath reports) are not on the computer.

13. If pt has wounds write order for wound care consult early.a. Decubitus ulcers/pressure ulcers:

i. Clean with NS. Apply petrolatum or petrolatum gauze to ulcer and dry 4x4

gauze on top.

ii. Tegaderm: cover for non-infected erosions and superficial ulcers

2) Admission room request form:

- Patients with positive troponins need to be on Stepdown

- Neuro/Stroke patients usually go to Stroke/TCU

- Syncope or R/O MI patients go to telemetry (if no positive troponin)

3) Cardiac form: complete if pt is r/o MI or being admitted to tele, SDU,

ICU

4) CHF form: complete if pt coming in with heart failure

5) COPD form: for COPD exacerbation

6) GI Bleeding: for upper and lower GI bleeding.

7) CIWA/COWA: for alcohol/benzo (CIWA) and opiate (COWA) detoxification.

8) Community acquired pneumonia care pack: any pt coming in with community

acquired pneumonia.

9) Code Status form: Always go over code status with patients and explain in

detail what his or her options are. ID DPA if there is one and document it

in your H/P. You need an attending to sign all code status forms other thanfull code.

10) Transfusion form:

i. PRBC

1. 1 unit will increase the Hct by 1 and hemoglobin by 3

2. type and screen expires in 72 hours

3. can pre-medicate with 650mg of Tylenol and 25mg benadryl half hour before


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transfusion

4. some may need lasix: usually 10-20mg IV lasix after 1-2 units

5. consider 1 gram of calcium gluconate for every 3 bags of transfusion

ii. Fresh frozen plasma

1. give each unit over 30 minutes or wide open

iii. Platelets1. each unit increase platelet by 5,000-10,000.

3) Extra Tips for admission:

1) Get a social services consult for any elderly patient, which will

expedite your disposition.

2) PT evaluation for nearly all elderly patients, or deconditioned patients.

Mobilize them early on your admission form OOB to chair BID, ambulate

daily, etc.

3) Nutrition evaluation for anyone elderly or who looks malnourished.

Nutrition teaching for diabetics, obese patients. Most patients with renal

disease (CKD III or worse) will need a 40-70 gram protein restricted diet.

Neutropenic patients need neutropenic diet.

4) Document in your H&P patients baseline mobility status (cane/walker;

how far they walk)

5) Document last Hgb A1c, last lipid panel, last echo result or functional

study (myocardial perfusion), EF if they have CHF.

6) For oxygen, check the boxes to record room air O2 sats and WEAN patients

daily.7) For DNR/DNI patients, document whether pressors or BIPAP are allowed.

Tips on Discharge

You will find out very quickly that discharge planning is a very important

part of taking care of your patient. You want to make sure your patients

have good follow-up care. Good discharge will also prevent patients from

coming back to the hospital and to you as kickbacks.

1) Things to do after pt is admitted:

a. Touch base with PCC (Patient Care Coordinator) if pt is from a SNF. Write

order for SW consult if there are social issues that will need to be

addressed (e.g. long-term placement planning).

b. Always write in your progress note what the discharge plan is. It will

allow PCC/SW to start things early.

c. Remember that the SNF office is closed on weekends so try to place your


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patients during the week.

2) Things to do 1-2 days before discharge:

a. D/C foley: if pt has had a foley for > 4-5 days consider bladder training

.b. Check pts diet and make sure pts diet is up-dated.

c. Always call family the day before discharge. If you anticipate discharge

before 11 AM make sure the night before that the pt has a ride.

d. Talk with PCC/SW early. It takes a day to deliver oxygen and nebulizer

equipments.

e. Ask PT to evaluate pt early (24 hours prior to SNF placement) if you are

planning for discharge. You can leave a message on the PT line and state

anticipated discharge today or tomorrow to expedite their coming to see

your patient. It will often take an additional 24 hours to actually place

the patient.

f. Fill out the three green SNF forms and dictate your patient under 21

for a transfer dictation.

3) On discharge day:

a. Go over medications with your patient and family. Dont forget to

complete Medication Reconciliation.

b. Check on CIPS to make sure patient has the appropriate follow-up

appointment set up. (type pt MR number and type in CAT: app to check)

c. Give your patient your card, especially if you want to add them to your

panel.d. Remember to give lab slips for follow-up labs.

e. If you want, you can call PCP yourself to leave a message. Just let your

resident know.

4) Discharge options:

a. Home: make sure a ride home is arranged. Pt can also go home with home

care for lab draws, IV antibiotics, and PT/OT f/u. Even if PT doesnt skill

them for home PT (say, if the patient is uncooperative with PT in the

hospital), you can have a home health nurse go to the home later to evaluatefor the PT needs.

b. SNF/nursing homes: Arrange with PCC/SW. If pt is going to SNF, have all

discharge summary (stat line [2][1]) and all orders written as soon as a

placement may be available. Pt may get a bed anytime and you want to be

ready for transfer.

c. Hospice: Usually hospice is arranged through palliative care. You have to

consult them by calling palliative care M.D. on call and send e-consult.


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There will be a packet for you to fill out. PCC and SW also need to be aware

of the situation.

Tips on Radiological Studies

CT scans:

- give mucomyst alone or with bicarb drip to decrease risk of nephropathy.

- 3ml/kg 1 hour before procedure and 1ml/kg for 6 hours after

1) CT abd: obstruction or most other abdominal processes can be well

visualized with PO contrast only

-if concern for an abscess PO and IV contrast is necessary

-IV contrast for vascular structures and lymphadenopathy

-retroperitoneal bleed is well visualized without any contrast

-NPO for 4 hours prior to procedure if contrast is ordered.

2) CT chest: high resolution CT chest for evaluation of the lung parenchymal

3) CT head: contrast is needed for r/o brain mets or masses

MRI:

- contraindications: pacemaker, caranial aneurysm clips before 1992, recent

stent (4-6 wks), some IVC filters, indwelling insulin pump

1) T1: fluid is dark, good for anatomy, most similar to CT: good for gray-

white differentiation, hypodensity can be ischemia or edema

2) T2: fluid is bright, good for pathology. Bone is dark because not much

water and fat

3) Flare: ischemia and edema both look white so cant distinguish them

4) Diffusion weighted image: best for strokes edema does not light up,

ischemia turns white within 15-20min and stays white for 7-10 days so can

distinguish between acute and subacute strokes

5) Gadolinium: metastasis light up

ICU Tips

(Jessica Murphy)

The first thing to keep in mind is that while you are in the ICU, the

overall concept is that it is a team approach to patient care. Get to know

everyone, because everyone has a crucial role in taking care of these


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patients. It is crucial that you communicate clearly and effectively to all

people involved in patient care to ensure that no loose ends are missed.

Besides the attending and your resident, the team includes: Pharmacists,

Nurses, Respiratory Therapists, Social Workers, Patient Care Coordinators,

nutritionists. You will learn the most in the ICU if you take the

opportunity to learn from these experienced individuals. Also know that partof their job is to protect the patient from us new, but eager Physicians!

As the intern, you are responsible for knowing your patients well, and

following up on important issues. You are the first person who sees the

patient in the morning, and therefore, important issues will be brought to

your attention before anyone else.

Make sure you communicate with your senior resident any issues that came up

overnight, or anything you are unsure of. It is better to iron out issues

before attending rounds if possible.

Ventilators/Intubation

Indications for Intubation:

- tachypnea (in general RR >35)

- apnea

- hypercarbia (Pco2 >50)

- hypoxia (Po2


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breath except the pressure limit

In your note write down the following information: Mode/Volume or pressure

Control seting/Pressure Support (if applicable)/PEEP/FiO2 and Check ABGs Q

AM to ensure you are properly ventilating the patient.

Things to Consider for Your Patients

1) Ambulate patients or at least write orders for OOB to chair/cardiac chair

ASAP

2) Advance diet whenever possible

3) Air mattress for elderly pts/bedbound pts

4) Order heal protectors to prevent heel drop/ulcers

5) Order incentive spirometry to prevent atelectasis for all pts in bed>1-2

days.

6) When putting in an NG tube consider using exactacaine spray or 2%

lidocaine gel.

7) Tell pt your plan for the day. You can also write it on the board in pt

room.

Tips on Preventing Nurses From Calling You

1) Write orders clearly

2) Hold IV fluid when pt is getting transfusions esp. for CHF patients

3) Resume previous diet after a procedure/study4) Dont forget to NPO pts for next-day procedures or surgeries

5) Always use your stamp so nurses know who to call

6) Write orders for any studies in the chart and not just e-consult so

nurses are aware of the plan

7) NG tube: check if pt can have meds crushed (ask pharm D for help)

8) Corpak placement: general rule is below diaphragm and cross the midline

Deaths

In the room:

1) introduce yourself and explain why you are there

2) check pt ID bracelet

3) check overall appearance of body

4) check verbal and tactile stimuli

5) listen for heart sound and feel for carotid pulse


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6) look and listen for respiration

7) check size, position of pupils, check light reflex

8) write down the time you completed your assessment

9) ask family if they would like an autopsy

Death Summary: cause of death should be listed in chart or on the sign-out

sheet

1) Exam: pupils fixed and dilated, no chest rising observed, no resp or

heart sounds by auscultation, no pulses felt, pt not responding to verbal or

tactile stimulation, etc.

2) Pt officially pronounced expired at H:M

3) Pts family at bedside or family was notified (name of the person

contacted)

4) Pt is/is not coroners case (if it is a coroners case youll have to

call the coroners office and write down the case number). Criteria for

coroners case can be found in the death packet.

5) Autopsy pending or pts family declined autopsy.

6) Primary care physician Dr. X was notified. (dont forget to call the PCP

)

Death Packet:

1) ask for the death packet

2) you have to let an attending know about the death and document the

attendings name

3) if pt needs an autopsy remember to fill out the appropriate form and call

the pathologist.

Procedures

Dont forget to log in your procedures and have them signed the same day.You need to fill out a consent form and complex procedure form for each pt.

with exception of ABG. Let the nursing staff know you are going to do a

procedure as soon as possible.

Procedure requirements

1) Arterial Puncture 5


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2) Central Venous Line 5

3) Knee Arthrocentesis 3

4) Lumbar uncture 5

5) Nasogastric Intubation 3

6) Paracentesis 3

7) Rectal Exam 58) Thoracentesis 5

Tips on common procedures:

ABG

i. ABG kite, a cup of ice, fill out the ABG form

ii. Procedure:

i. go in at 45 degree angle

ii. ask someone to hold pt hand for you or tape pt wrist and hand down over

a rolled up towel

iii. You can go to ABG lab (5th floor) and get the result sooner.

LP

i. Always check coags before doing an LP: platelet should be at least >50K

and PT/PTT should be close to normal.

ii. Get a non-contrast CT of head before doing an LP to rule out mass effect: Age>65, immunocompomised sate, focal neurologic symptoms, increased ICP/

papilledema.

iii. Warn your pts about post LP HA- can last up to one week after LP.

Hydrate pt well and have pt flat for at least 2 hours post LP.

iv. If you are going to get opening pressure, you need to LP with the pt

laying on their side. Otherwise you can have them sit up and lean over a

table.

v. Get things ready before calling your resident/attending

vi. LP tray (2), sterile gloves, face shield, sterile gowns, 1 bottle of

lidocain, betadine swab or 2-3 chloraprep, 5 name labels with initials/time/date

vii. special labs form and microlab form

viii. help pt get into position (side or sitting up: use a table with a

pillow over it to rest pt head)

ix. Tube 1 cell count. diff / Tube 2: gram stain, Cx / Tube 3: Chemistry (

total protein, glucose, crypto Ag, RPR, anything else special/ Tube 4: cell

count, diff, hold for further studies: PCR for EBV, VZV, HSV, CMV, VDRL, IgG


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albumin index If suspicion for MS simultaneous sample of serum should be

sent together.

x. if you want to get a pressure reading the pt has to be on his/her side

Paracentesis

1) Get things ready before calling resident/attending

i. Yueh catheter (2) and blood transfusion tubing (in ICU storage room or

order them before-hand)

ii. sterile gloves, 2-3 vacutane bottles, 1% lidocaine bottle, 18 gauge

needles (2), one 40 cc syringe and 2 x 20cc syringes, culture bottles (

aerobic and anaerobic), 1 jungle top, 2 red tops, and 1 green top, 1 bandaid

, 2-3 chloraprep

iii. procedure forms, consent forms

iv. special labs form, micro form, path forms, 5 labels and sign with

initials, date and time.

v. labs to order: gram stain, bacterial culture aerobic/anerobic, fungus,

LDH, total protein, albumin, cell count and diff.

vi. Dont forget to add LDH and glucose to earlier serum study

vii. if its pts first tap do not remove more than 1-1.5 L. If removing

more than 1.5 L consider giving albumin (comes in 25g bottles)

Thorocentesis

1) Thorocentesis kite2) order stat chest X-ray after procedure to r/o pneumothorax

3) Labs: LDH, Glucose, cell count with differential, gram stain+ culture, pH

(send on ice), TP, AFB, adenosine deaminase, cytology, amylase,

triglycerides, rheumatoid factors.

Tips - Cardiology studies:

- light breakfast is okay for most cardiac studies

- hold isordil/nitro for p-thal studies, but no need to hold b-blockers

- hold beta blockers, Ca channel blockers and isordil/nitro for exercisetreadmill studies

Tips - Renal:

- spin the urine and look at it under the microscope whenever you have an

acute renal failure pt:


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1. get a sample of 10-20 cc of urine.

2. spin the urine for 5 min then place a drop of the concentrated urine on a

slide with cover slip

3. lab staff are usually very helpful. You can also call the nephrologists

on call to look at it with you. Call them early.

Tips - Hematology:

- call lab to have them perform a blood smear and save it for you to look at

with the hematologist. Its especially important to do before you give any

transfusion product.

Tips: - DM team:

Learn to manage DM pts. Do not depend on DM team. They are there to help

with difficult cases and discharge medications/teaching. Also, let them know

if you need recommendation for discharge meds. Get HA1C on admission if

there isnt one in past 3-4 months. Also write in your H/P pts insulin

regimen prior to admission.

Tips - GI:

Be prepared to report last EGD or colonoscopy information, whether the last

bowel movement is still bloody, NG lavage results, COLOR of stool as well as

guiac status, baseline HctIf pt is anemic have results of iron panel including ferritin available.

Make sure you know the H/H trend, coag. Have most recent vital signs ready

Tips on avoiding calls from a Pharm:

1. Check Vanco trough 30 minutes before 4th dose. Target is 5-15mcg/mL

2. For pts with renal disease always renal dose all medications. If pt is

receiving Vanco you can check Vanco random levels with AM labs.

3. Each medication ordered must have a documented diagnosis, condition orindication for use especially for prn orders.

4. Write clearly, sign/date, and use stamp.

5. Always use a leading zero (write 0.1 and not .1)

6. Always check to make sure you are writing orders in the right chart!

7. Abbreviations you are not allowed to use and what you should write:

a. qd = qdaily

b. QOD= every other day


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c. MgSo4= Magnesium Sulfate

d. U or u= Units

e. MS=Morphine Sulfate

8. Hold spiriva if you put pt on atrovent

9. Xopenox can be used in pts with tachycardia its 0.63mg or 1.25mg q 8h

nebs10. Dont forget to fill out IV antibiotic forms EVERY time you order IV

antibiotics

Check Lists

End of the day check list:

2) Make sure all AM labs are ordered!

3) Make sure your sign-out sheet is updated

4) Always check on the board in the resident lounge to make sure you are not

presenting at the intern report.

5) Check voicemail

6) Check lotus note

7) Document work hours

8) Check CIPS for any outpatient and inpatient follow up labs and dictations

Weekly check list:

1) Mailbox with your name on it is located at the back of the hospital near

the loading dock.

Rotation check list:

1) Log procedures

2)_Sign off on Attestation sheet (only time you dont need to is during

inpatient rotations)

On-line Resources:

http://www4.umdnj.edu/rwjcweb/docs/handbook/imreview.html

http://medicine.ucsf.edu/housestaff/handbook (This is a great handbook to have inyour pocket. The handbook include section on ICU, NF and Floor)

http://info.med.yale.edu/intmed/cardio/imaging/contents.html

Palm Resources:

1) Epocrates: http://www.epocrates.com


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2) Antibiotic guide: http://www.hopkins-abxguide.org

3) ABG Calc: http://www.stacworks.com

4) MedCal: http://medcalc.med-ia.net

5) PalmEKG: http://www.eMedic.com

6) GFR Est.: http://www.nephron.com

Recommended pocketbooks:

Pocket Medicine (The Massachusetts General Hospital Handbook of Internal

Medicine) by Marc S. Sabatine

Maxwell Quick Medical Reference

--

:WWW : mitbbs.cn : mitbbs.com[FROM: 98.210.]

winebaby

[] [] [] [] [] [] [] [] [] []

[ 2 ]

: winebaby (Let\\\'s get smart), : MedicalCareer

: Re: zzintern guide

: BBS (Tue Mar 29 15:27:39 2011, )

I think EXTENSOR posted this long time ago.

goodgene (Addison):

: Tips on surviving floor rotations

: 1) Be organized AND always write things down! You need to develop a good

: system to keep track of your patients information/daily labs/ to do

: list. Some suggestions:


18/22

: a. Copy your dictated H/P, fold it in half and write your daily vitals,

labs

: , studies and to do list on the back. You can also have a separate

to

: do list (examples on page 31.32).

: b. There are pre-printed H/P and daily sheets you can use but many findthem

: too time consuming. (http://www.medfools.com/downloads/medicine)

: c. Copy every pts H&P, daily progress note and put it in a folder. Just

: ...................

--

:WWW : mitbbs.cn : mitbbs.com[FROM: 69.74.]

goodgene

[] [] [] [] [] [] [] [] [] []

[ 3 ]

: goodgene (Addison), : MedicalCareer

: Re: zzintern guide

: BBS (Tue Mar 29 15:35:40 2011, )

Check out - What do you want me to do with that?

Try to do a TO DO LIST in a separate sheet and review this list through the

night frequently, otherwise youll miss something important to doPAIN

If liver failure = avoid Tylenol and give Ibuprofen If renal failure =

avoid Ibuprofen and give Tylenol

Percocet 5/325mg 1 Tab PO q4h PRN pain 1st dose now

If pain continues or patient not tolerating PO:

* Morphine 2mg IV STATx1 or 2 mg IV q4h PRN pain, call in 1 hour to check if

pt still having pain


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* alternate: Dilaudid 0.5-1mg IV STATx1

Pruritis = Benadryl 25mg POx1 or hydroxyzine (vistaril or atarax) 25-100mg

PO Q6-8hrs PRN (may need 1st dose now)

Nausea = Phenergan 12.5-25mg IV q6-8hr PRN 1st dose now or Ondansetron (

zofran) 4mg IV Q6-8hrs PRN 1st dose now (zofran more commonly used in cancer

patients)RESTRAINTS

When a nurse asks for a restraints order, ask the reason why: usually it

is b/c the pt is being uncooperative; always check: VS, urine output (if

foley in place, otherwise evaluate pt for bladder distention), r/o fever and

hypoxia as cause of AMS in pts

If tachycardia >120 HR, get an EKG

If pt still agitated may try Haldol (dose ranges from 0.5mg-5mg) IM or IV

STAT; Call back to nurse in 1 hour to see if patient is less agitated

REFLUX

Antacids = Maalox 30cc PO x1 now or GI cocktail green goddess (Mylanta (

Maalox) 30cc + Viscous lidocaine 2% 10cc +Donnatal 10cc) PO x1- you cant

write GI cocktail, and you must write out all the meds

BP

Hydralazine 25mg POx1, call MD in 1 hour with new BP, Clonidine 0.1mg PO x1,

call MD in 1 hour with new BP, may also be able to increase patients

current BP meds (always check pulse before increasing beta-blocker or

calcium-channel blocker though); also, if BP seems out of place, go to the

floor and check a manual BP to make sure the original BP was correct.

CHEST PAIN

Questions to ask the nurse: Is the pt stable? What are the VS?

Question to ask yourself: Does the CP appear to be cardiac in nature?Let the nurse know: I am on my way there, please obtain an EKG, draw 1st set

of cardiac enzymes (CPK, CKMB, troponin), and place pt in 2L O2 STAT

*If CP appears to be cardiac and SBP>90 = Nitroglycerin 0.4SL q/5min x3

doses, ASA 325 mg PO x1 now, Metoprolol 12.5 or 25mg PO x1 now, possibly

start heparin drip too (completely appropriate to call your NF resident for

assistance!)

GI BLEEDING

Is pt orthostatic? Need to go evaluate patient!

Type&Cross (if you are sure youll use blood) / Type&screen (if you are

not sure youll use the blood)Let NF resident, pt may need to be transfer to MICU if hemodynamically

unstable

SOB

Is pt tachypneic? Desaturating (


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1) O2 Sat >90% 2) ABG 3) CXR (portable) 4) possibly an EKG 5) possible CBG

Different modes of O2

1. O2 by nasal cannula up to 5 L/min

2. O2 by face mask up to 50%

3. O2 by venture mask 50%-80%

4. O2 by non-rebreeding face mask (100%)- need to be contacting both yourresident and the ICU fellow on call by this time (unless pt is DNR/DNI)

SEIZURE

Ativan 2mg IV x1 and may repeat q1min if patient still seizing; if no IV

access, may use diazepam 5mg-10mg PR

Phenytoin = load dose Fosphenytoin IV then Phenytoin PO maintenance dose (

100 mg PO TID) Ask for levels next morning (always need to adjust level for

patients albumin)

ELEVATED BLOOD SUGAR

Frequently you will receive calls from elevated blood sugars. When you

receive a diabetic patient ask the main team for the Correction Factor (CF)

CF is the grams/dl of blood sugar metabolized for each unit of insulin in

any given patient the way to obtain it is

CF= 1700 / Total Daily Dose of Insulin or CF= 1700 / (Wt in Kg x 0.45)

Dose of Insulin = Current CBG 150 / CF

FEVER >38.3

If known cause = Tylenol + cold compresses

If unknown cause = Pan-culture pt (not necessarilly in all pts though-

therefore need to ask when the pt was last cultured) + Tylenol (give after

pt is cultured)Pan-culture:

Blood culture x2 sets

UA & Urine culture

Sputum gram stain & culture (if cough or URI symptoms)

Stool gram stain & culture (if Diarrhea) + think about C. diff toxin

(esp if pt has been on Abx)and fecal WBCs

CROSSCOVERING INTERN NOTE

Notes for: Chest pain, tachycardia, SOB, Bleeding, falls

i.e.: called by nurse staff because pt was c/o ________, pt seen and

evaluated at bedside, reported..Assessment:

*Chest Pain: DDx includes After obtaining history, physical exam,

lab data, and imaging studies, patient most likely having.

Plan:

* ____, _______, _____, Fellow was called and decided to ..(if this is

applicable).

* Reevaluation in 2 hours


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DNR NOTE / ORDERS (VA)

When the pt is admitted, the resident writes a DNR note which will expire in

24 h. Make sure to communicate to the team that their attending needs to

write a DNR order and note in the chart, otherwise the nurses will be

calling you every night because those notes usually expires at midnight.

If the pt has a note signed by the attending or if there is a Non-attending note written within 24 hours, but done on a different service-

you could write a text order saying Pts DNR order signed by Dr XXXX on

xx/xx/xx at xx:xx am and make sure to communicate the situation to the

team the next morning.

If you have to renew a DNR because it has expired during the

night, the first question is: Does the pt have decision making capacity? If

not, who is the next of kin? You have to talk to the pt or his family about

the DNR, resuscitation, electric shocks, endotracheal intubation, and

mechanical ventilation issues. Once you have this information covered you

can write a Non-attending DNR order that will expire in 24 hours (be sure to

communicate to the team). If the pt or his family changes their mind (try

to avoid this situation) write an explicit note explaining the situation and

why the pt decided to change his code status.

PRONOUNCING DEATH ON CALL

1. First you must examine the pt for:

a. Response to verbal or tactile stimuli (none)

b. Spontaneous respiration (none)

c. Heart sounds and pulses (absent)

d. Pupillary response (pupils fixed and dilated)

2. Document the time the pt was pronounced death

3. Notify the family immediately and inquire whether they request anautopsy and if they have thought in organ donation: (at VA concersation with

family needs to be recorded by AOD ext2044)

a. Familiarized yourself with the pt medical history and mode of death.

b. Identify yourself to the family in a humble and caring manner and

inform that their next of kin has expired. Inform them when the pt was

pronounced death and try to comfort them that their relative died peacefully.

c. If it is not clear from the pt's records, inquire whether the family

requests an autopsy. Autopsys DO NOT delay funeral services and are NO

COST to the family!

d. Ask the next of kin if the family wishes to come to the hospital toview the body before it is transported to the hospital morgue. Notify the

charge nurse of their decision immediately.

4. Document the findings on pt's chart in a brief progress note format: i

.e.: ''called by charge nurse to pronounce Mr. XXXX dead. Pt examined,

unresponsive to verbal or tactile stimuli, no spontaneous respirations noted

, absent heart sounds, no palpable pulses, pupils fixed and dilated. Pt

pronounced dead at XX:XX am/pm. Family was notified and requested/denied


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autopsy. Patients organs will/will not be donated. Funeral home will be

...''

5. There will be many forms to fill out:

a. Brief history

b. Hospital course

c. Medical problemsd. Death Certificates = Reason of death (code 99 or CPR is not acceptable)

6. Do I need to call the Coroner?

a. Coroners case = if the death is unexpected (any other cause than a

chronic medical condition) and if the patient expires within 24 hours of

admission

7. As the NF intern, you are not responsible for doing the death

dictation; this is the responsibility of the primary team

Documents

Tips on Surviving Floor Rotations