PLACE LABEL HERE
PYELONEPHRITIS OBSERVATION
ORDERS
The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
1. Status: q Place in Observation for: ______
2. Level of Care: Acute Care Location/Specialty Unit Preference 5 South
3. q Telemetry: If patient Medical/Surgical, must complete form # 36084
4. q Isolation: q Contact q Droplet q Airborne For: ______
5. Consults: ______q Notified by physician
______q Notified by physician
6. Diagnostics:
q UA
q Urine Culture and Sensitivity
q CBC
q BMP
q Serum hCG for any menstruating female ≥ 12 years of age
q Other: ______
Radiology ______
7. Vital signs per unit routine or q ____ hrs
8. Diet: q NPO q Clear Liquids q Full Liquid q Regular q Cardiac q Diabetic ______calorie
q Advance diet as tolerated to ______
9. Activity: q Bed Rest q Bedside commode q Bathroom privileges
q Up ad lib q Up with assistance
SCHEDULED MEDICATIONS:
10. IVF: q NS q LR q D5NS q D5 ½ NS with 20 KCl at ______ml/hr
11. Antibiotics (choose IV or oral option)
IV antibiotic:
q Cipro (ciprofloxacin) 400 mg IV q 12 hrs (Call physician when tolerated po diet for oral antibiotic orders)
or
q Rocephin (ceftriaxone) 1 gm IV q 24 hrs (Call physician when tolerated po diet for oral antibiotic orders)
or
Oral antibiotic:
q Cipro (ciprofloxacin) 500 mg po bid
or
q Bactrim DS (trimethoprim/sulfamethoxazole) 1 tablet po bid
12. VTE Prophylaxis: Initiate Venous Thromboembolism (VTE) Prophylaxis Orders (form # 33058)
q Low risk: No pharmacologic or mechanical prophylaxis, ambulate 3 times daily
q Heparin 5,000 units SQ q 8 hrs (q 12 hrs if wt < 50 kg or age > 75)
or q Lovenox (enoxaparin) 40 mg SQ daily at 1700 (30 mg if CrCl < 30 ml/min)
and/or q Mechanical devices: SCDs
The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicate (multipage).
PRN MEDICATIONS See policy 520-06 for range orders and pain intensity guidelines.
13. q Electrolyte Replacement Protocol (form # 21340)
14. Mild Pain, Temp >100.5°F, HA: q Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
15. Moderate Pain:
q Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered.
or q If patient can not take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po q 4 hrs prn intead of Norco. DC if Percocet ordered.
or q Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Norco ordered.
and/or q Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (15 mg if CrCl 31-50, > 65 y/o old or < 50 kg) or 10 mg po q 6 hrs prn (max combined duration of IV and po ketorolac is 5 days). DC if CrCl < 30.
16. Severe Pain (Begin when Epidural or PCA has been discontinued)
q Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered.
or q Dilaudid (HYDROmorphone) 0.25-0.5 mg IV q 3 hrs prn. If CrCl < 30, dose at 0.25 mg. Hold for excessive sedation. DC if Morphine ordered.
17. Nausea/Vomiting: q Zofran (ondansetron) 4 mg IV or po q 6 hrs prn
q If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)
18. Sleep: q Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn
19. Indigestion: q Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
20. Stool Softener: q Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
21. Constipation: q Milk of Magnesia (MOM) 30 ml po daily prn
If no BM after 48 hrs q Dulcolax (biscodyl) 10 mg per rectum daily prn
and/or q Senokot-S (docusate/senna) 2 tablets po at bedtime nightly
22. Cough: q Robitussin (guaifenesin) 15 ml po q 4 hrs prn
23. Sore Throat: q Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn
ADDITIONAL ORDERS:
______
______
______
Date Time Physician Signature PID Number
Copy to pharmacy
FORM 3-37200 REV. 12/2014 Page 2 of 2