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Ward Management Essentials

Things to Know About your Patients

  • Old EKGs: Most adult patients will have an EKG, and it’s a good idea to know what it looks like - from a medication standpoint, the QTc is the most important thing to look at because it may affect your choices. Always go to Care Everywhere to review outside records if unable to find data in chart review.
  • Prior echocardiogram: What was their most recent ejection fraction? Any severe valvular disease?
  • Creatinine: Normal, or do they have CKD?
  • Hemoglobin: baseline, most recent

Electrolyte Replacement

Potassium

Rule of thumb: 10 mEq generally increases level by 0.1 (0.2 in renal disease/CKD)

  • If the gut works, use it (IV burns and you have to give it slow)
  • PO can be pill or packet – let RN and patient decide (pill is large, sometimes hard to swallow)
  • Max PO is 40 mEq q3-4 hrs or IV 10 mEq q1h (or 20 mEq through CVC)
  • Replace if <3.4 or so in healthy pt, <4.0 in cardiac pt
  • If <2.9, would consider tele and repeating lab after replacement
  • Check Mag: if low, will not absorb K properly and need to replete

Magnesium

  • Oral tablets (400-800 mg/24 hrs or IV 1-4g depending on severity)
  • Replace if <1.6 or so in healthy pt, <2 in cardiac pt

Phosphorus

  • Oral (K phos neutral tablet or Phos-nak solution) or IV (potassium or sodium phosphate)
  • Replace orally unless cannot take PO. IV phos is dangerous (can cause arrhythmias and renal failure) and is run really slowly, like 4-12 hours
  • Replace if <2 and look on uptodate or ask pharmacy for specific dosing (typically 1-1.3 mmol/kg divided in 3-4 doses in 24 hrs)
  • Be cautious in severe renal dysfunction (check and see if pt is on a phosphate binder, calcium acetate or Phoslo).

Electrolyte Derangements

Hypoglycemia

There is a hypoglycemia protocol that you can order:

  • If ≤70 and pt A&O, have RN give orange juice/crackers and recheck in 20 min
  • If ≤70 and not alert and oriented or cannot take PO/swallow, give 1 amp of D50. If no IV access for whatever reason, then can give 1 mg of glucagon SQ or IM. Recheck BG every 20 min or so

Hyperglycemia

Typically hold oral anti-diabetic medications once admitted. Order basal-bolus regimen (recommended based on RABBIT 2 trial) or sliding scale insulin alone (SSI).

  • If they don't have diabetes DO NOT give them insulin unless necessary. People have stress-induced hyperglycemia in hospital so it is normal to see slightly high glucose in even the healthiest of patients.
  • If BS greater than the limit of the sliding scale, can give a one-time Humalog dose (only if >1hr after last insulin was given) and then either adjust long-acting insulin or sliding scale or sign out to daytime to do so.
  • Review sliding scale requirements every day in glucose tab (under summary tab) and use this to guide long-acting dosage and/or add on standing short-acting. Talk to senior about this as it is not intuitive!

Hyperkalemia

  • Make sure it is real (ie, not a hemolyzed sample)
  • 3 typical mechanisms causing hyperK: increased K intake (meds, IVF, TPN, pRBCc), transcellular K shifts (like in rhabdo), or impaired K excretion (AKI, CKD, RAAS inhibition, aldosterone antagonism)
  • There is not a well-defined treatment threshold but typically give acute treatment if ≥6+EKG changes or ≥6.5 regardless of EKG changes. Most people typically start treating around 6.
  • K 5.5 – 5.9: review med list (ACE-i/ARBs?, K- sparing diuretics), r/o urinary obstruction (via bladder scan), and check glucose as hyperglycemia alone can cause hyperkalemia. Recheck in 6-8 hrs to see if up-trending.
  • If EKG changes present (peaked T waves, widening QRS), place pt on cardiac monitor and give 1 g IV calcium gluconate over 15-60 min (in addition to treatment below). Then recheck EKG and re-dose calcium if changes still present (keep doing this as necessary).
  • Get rid of K through urine if you can (i.e patient is not anuric).
  • If patient is anuric, then use Kayexalate (30 g) but ensure they have normal bowel function and not a "sick bowel" (GI bleed, obstruction, recent surgery), as there is risk of colonic necrosis.

Acute therapies:

  • An order set is available on Epic by searching Hyperkalemia in the Orders tab. You will have various treatment options including insulin + dextrose, albuterol, sodium zirconium - Lokelma, and others.
  • Loop diuretics and saline (can use one or the other or both as they increase Na delivery to ENac channels causing K excretion). Another rational for saline is you don't want to make a euvolemic patient hypovolemic. Don't give saline if hypervolemic.
  • Insulin + Dextrose but omit dextrose if patient already hyperglycemia. Be aware of hypoglycemia, especially in CKD pts. Recheck glucose q30 min-1 hr x 2-4 times
  • Less common: Albuterol 10-20 g!! (typical dose is 2.5 g), Kayexelate, if anuric as stated above
  • As stated above, don't forget to r/o urinary obstruction and hyperglycemia

Transfusion Guidelines

  • Cryoprecipitate, FFP should only be ordered in certain circumstances on discussion with team.
  • Note: These have changed due to the blood transfusion shortage, check with your team regarding current policies.

pRBC

  • Typically transfuse if Hgb <7, sometimes <8 in cardiac patients, and in pts with active bleeding
  • 1 unit (~300 ml) should raise Hgb by about 1g

Platelets

  • Typically transfuse for <10k if no active bleeding, <50k if active bleeding or invasive procedure, and <100k for neurosurgical procedures or concern for active ICH
  • 1 unit should raise platelets ~20k – 30k but can be variable

Acute Issues

1. Bradycardia

  • Get a full set of vitals first. Go see the patient. Are they sleeping? Does the HR improve when they wake up?
  • If they are symptomatic (dizzy, chest pain, syncope) or hemodynamically unstable, follow ACLS guidelines. Put patient in Trendelenburg. Call your senior and a Rapid Response.
  • If stable, order atropine to the bedside and consider placing the patient on telemetry.
  • Place pacer pads on the patient (can always take them off) and get stat ECG.
  • If ECG shows either Type II second degree or 3rd degree AV block, consider transcutaneous pacing and possibly a transvenous pacer. Call Cardiology ASAP.
  • If the patient is stable and not symptomatic, take a quick look at the chart to try and determine why this might be happening.

DDX:

  • Meds: β-blockers, Calcium-channel blockers, digoxin, amiodarone, clonidine.
  • Cardiac: sick sinus syndrome, inferior MI, vasovagal (usually transient), 2nd or 3rd degree AV block, junctional rhythm.
  • Autonomic N.S: neurocardiogenic syncope, carotid-sinus hypersensitivity, cough/micturition/emesis/defecation induced.
  • Other: idiopathic degeneration (aging), infiltrative disease in the conducting system (sarcoid, amyloid), collagen vascular disease, surgical trauma, endocarditis, hypothyroidism, hypothermia, increased intracranial pressure (Cushing's reflex), hyperkalemia, hypokalemia, OSA, normal variant (marathon runner).

If you think this is medication induced, consider holding a dose of the med if stable.

  • Consider calcium or glucagon administration if you believe it to be secondary to the calcium channel or beta blocker the patient is taking.

2. Hypotension

  • Ddx is quite broad but most common causes in hospital are hypovolemia (dehydration or bleeding) or infection/sepsis
  • Always see what the pt's baseline BP is (cirrhotic pt may normally run 90/50).
  • Ask the RN to check a manual BP before acting. If truly low, go examine pt and notify senior.
  • Is patient well or ill appearing? Symptomatic (lightheaded/dizzy, AMS) or asymptomatic? Cap refill? Cool or warm extremities? Dark or bloody stools?
  • Typical labs to obtain include: CMP, lactate, CBC, VBG. Labs signs of decreased end-organ perfusion/tissue hypoxia include elevated lactate, AKI, elevated LFTs
  • If real, intervene as below and recheck BP frequently to assess fluid responsiveness and BP trend

3. Hypoxemia (aka low SaO2/PaO2...different from cellular hypoxia)

  • Go see the patient, notify senior, and don't forget the causes of hypoxemia -> V/Q mismatch, shunt, hypoventilation, diffusion defect, low inspired FiO2
  • Make sure adequate waveform on pulse ox, try replacing pulse ox if not

  • Often, if you are getting called for acute hypoxemia/desats in the hospital, it is going to be:

    • Flash pulmonary edema
    • Atelectasis/mucous plugging
    • Aspiration pneumonitis
    • Pulmonary embolism although people typically develop PE outside hospital unless not on DVT ppx, post-op patient, or onc patient
    • Can also consider other etiologies: COPD/asthma exacerbation, valve failure, anaphylaxis / airway obstruction, pleural effusion

  • Most likely need CXR, VBG (better if concerned for hypercapnia)/ABG (better if concerned for hypoxemia), troponin (for the shortness of breath to r/o ACS), and EKG

  • Have someone call RT, reposition pt if they cannot themselves, suction oropharynx, place on some form of O2 (nasal cannula, simple face mask, non- rebreather, venturi mask, HFNC, CPAP, BiPAP)
  • CPAP for pure hypoxemia. BiPAP for hypercarbia +/- hypoxemia
  • NIPPV is particularly helpful in COPD, obesity-hypoventilation, CHF/pulm edema, and post-extubation.
  • It should be used in quickly reversible respiratory processes.
  • Do not use if patient is altered, airway instability (like vomiting or copious secretions), or hypotensive as NIPPV decreases preload and will make worse.
  • Good rule of thumb: okay to use NIPPV if RR 25-30, pH 7.25-7.35, PaCO2 45-60 Needs to be intubated if c/f airway patency, GCS <8, RR ≥35, severe dyspnea, life-threatening hypoxemia, pH <7.25 and PaCO2 >60, PaO2/FiO2 ratio <200, failure of NIPPV, persistent increased WOB
  • Patients cannot stay on the floor if this is NEW CPAP/BiPAP and you are using for extended period of time. Call the ICU.
  • On the floor, 6L NC is typically the limit of O2 delivery allowed long-term

Management based on probable etiology:

  • Atelectasis/Mucous Plug
  • If few resp secretions then can give incentive spirometer / encourage coughing / ambulate
  • If abundant resp secretions then suctioning, chest PT (if able), encourage coughing, and possible intubation if unable to protect airway
  • Pulmonary Edema/Fluid Overload
  • Suspect in pts with hx of HF, renal failure, or receiving high rates of IVF
  • CXR will show interstitial edema and you may hear crackles/see LE edema/JVD
  • Stop IVF, trial IV Lasix (20-120 mg depending on renal function and naivety to Lasix)
  • Nitrates can provide symptomatic relief (reduces afterload)
  • Can trial BiPAP but this should be for finite time period
  • Aspiration Pneumonitis/Pneumonia
  • No one will ever fault you for starting empiric abx coverage (i.e. ceftriaxone unless c/f empyema or abscess. If concerned or don't know, then start zosyn +/- vancomycin if they are unstable or you know their MRSA nares screen is positive).

4. Opioid Overdose

  • Suspect in any pts receiving opiates (heme/onc pts, sickle cell on PCI pump in particular) or hx of addiction - look for somnolence, pinpoint pupils, and decreased RR.
  • Naloxone (Narcan) will save a life so give it if you are even thinking about it.
  • Diagnosis is made by IMMEDIATE improvement in mental status / RR.
  • Can start with 0.4 mg IV (or IN)
  • You don't want to reverse the pain effects of opioids / precipitate withdrawal, so heme/onc pts may only need 0.1 mg as a starting dose
  • Be aware you may need to redose in 30- 60 min depending on opioid.

5. Seizures

  • Go see pt, ask about vital signs on your way and how long the patient has been seizing, get fingerstick glucose, place on O2/monitor, determine IV access (at least two), and have suction nearby in case they vomit.
  • Make sure patient is in left lateral decubitus position
  • Labs to consider include BMP, Mg, Phos, LFTs, CBC, AED levels (if appropriate), Utox, VBG/ABG, CK
  • Consider lactate - but usually elevated for a few hours after seizure

Things to Think about:

  • If pt has hx of epilepsy or first-time seizure as need to determine etiology (this will likely be done after the matter)
  • Determine if seizure activity is suppressible ie: if R arm twitching see if you can hold it down without reciprocal movement, if they withdraw to painful stimuli

  • If the patient is stable and you have time to take a video for Neuro, it is helpful!

  • If seizing has stopped when you arrive, draw stat labs, review chart, talk to witnesses, consider CT, and AEDs as needed.

  • Allow 3 min for seizure to stop spontaneously. If lasting longer, trial 2-3 mg IV lorazepam to break seizure; repeat q2-4 min until seizure stops (max at 0.1 mg/kg total, so 8 mg for 80 kg person)
  • If you are needing more than 1 dose, have someone call neurology for assistance
  • Be cautious about respiratory depression or hypotension with benzos
  • If no IV access, ask what IM/IN options available on that floor (i.e IM midazolam 5-10 mg)
  • If continues to seize and neurology isn't there yet, consider IV fosphenytoin load 20 mg/kg (can cause hypotension, works VERY fast)
  • If patient required several doses of benzo to break seizure, need to load with non- benzo AED (talk to neuro but consider keppra, fosphenytoin, valproate).

Less Acute but Common Complaints

1. Anxiety

  • Assess why the patient is anxious.
  • Good first line med is Vistaril – typical starting dose is 25 mg for anxiety but can give lower dose if c/f sedation (don't give to elderly).
  • For select pts, can consider lorazepam (Ativan) – typically would start at low doses such as 0.25 – 0.5 mg PO. Benzos can worsen delirium in pts that are already agitated and should be avoided in the elderly.
  • For pt with delirium and anxiety, can trial low dose PO/IV Haldol if QTc permits (<500).

2. Acute Pain

  • First assess vitals and mental status. If BP already low and/or altered, avoid opiates if able. You can utilize nursing input to assess mental status.
  • Is it somatic pain, visceral pain, or neuropathic pain?
  • Consider renal function and LFTs when choosing med.
  • Tylenol is good starting med (limit 4 g per day in most patients and 2 g per day in pts with cirrhosis).
  • Can give NSAIDs to select group of pts (contraindicated in renal disease, heart disease, cirrhosis, thrombocytopenia, etc).
  • Heat and topicals such as capsaicin cream or lidocaine patches are great for localized pain.
  • Neuropathic pain: can consider agents like gabapentin, pregabalin, and/or amitriptyline
  • Opioids are typically the next step IF somatic pain (watch for resp depression – see section on opioid overdose in Hypoxemia section)
  • Typical rule of thumb is use oral form if able to take PO.
  • Oxycodone: 2.5-5mg q4-6h for those who are relatively opioid naïve. Comes in PO or liquid.
  • Morphine: IV/PO/liquid. Avoid in renal dysfunction. Starting doses typically 10-15 mg PO or 2-4 mg IV for naïve patients
  • Hydromorphone (Dilaudid): IV/PO. 10x more potent than morphine. Typical starting dose is 2-4 mg tablets (different dosage for solution) or 0.2-0.5 mg IV for naïve patients

3. Headache

  • Assess patient's clinical status and severity of headache
  • If severe, eval patient and perform neuro exam / consider CT Head to r/o brain bleed.
  • What do they take at home for headaches?
  • Safest medication in hospital is Tylenol (can give up to 2 g in liver pts)
  • 2g IV magnesium is also great for headaches (can give 400mg PO too)
  • Can give NSAIDs to pts w/o contraindications
  • Consider headache cocktail (ex: 975 mg of acetaminophen, IV 5 mg Compazine or PO 10mg, and/or PO 25 mg Benadryl)
  • AVOID NARCOTICS

4. Insomnia

  • The hospital is not a restful place for even the greatest of sleepers
  • Be sure to ask RN to make sure TV and lights are off in the room and noises/distractions minimized
  • Ask what patient takes at home for sleep / check home meds
  • If pt does not take anything, would trial ramelteon 8 mg or melatonin.
  • Second line option includes trazodone

5. Nausea

  • First line: ondansetron (Zofran) – usual dose is 4-8 mg IV/PO/ODT
  • Second line: consider prochlorperazine (Compazine), lorazepam, or Benadryl
  • Compazine: oral 10 mg tablets q6h prn (or IV 5-10 mg)
  • Other options include low dose Zyprexa (olanzapine)/Haldol, metoclopramide, or promethazine
  • Ondansetron, Haldol, and metoclopramide can prolong QTc. You do not necessarily have to check it on everyone but get EKG on those requiring high / frequent doses or are on other meds that prolong QTc

6. Pruritus

  • Good go-to med is Atarax 10 mg TID PRN as it is typically not as sedating as Benadryl
  • Sarna or Lac-Hydrin lotion are good topical options
  • Can also consider PO Benadryl 12.5 – 25 mg but typically avoid in pts with AMS and older pts
  • Reserve use of IV Benadryl for pts who cannot tolerate PO or those who have an allergic rxn as it can cause a euphoric effect similar to opiates.

7. Constipation

  • Especially since almost everyone is on narcotics for pain control.
  • Colace 100 mg PO BID and Senna® 2 tabs PO qHS are essential. Glycolax is also a good option.
  • Be sure to add a HOLD order for loose stools as well.
  • The problem arises when Colace, Senna, or Glycolax are not doing the trick; this is where PRN bowel care will help you and the nursing staff out. You can dose with milk of magnesia 30 cc PO PRN constipation. If that does not work, I move on to Dulcolax 10 mg PO/ PR (per rectum) daily PRN no bowel movement. The last resort, to my mind, is lactulose 30 mL PO q4h until bowel movement, or a "pink lady" enema once; these will usually get things moving.

Disclaimer

Always verify with your superiors before taking action based on this guide. The information is intended to help, but not to dictate your course of work. Always use critical judgment and your clinical knowledge skills. This guide will be constantly revised and updated according to evidence-based medicine.

Last update: April 12, 2026