PLACE LABEL HERE
ALLERGIC REACTION
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 indicate (multipage).
1. Status: q Place in Observation for: ______
2. Level of Care: q 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 Chem 7 q CBC
q Other: ______
7. q CXR, q Portable q PA/Lat Reason: ______
8. Respiratory:
q O2 per Protocol (form # 34431)
q Micronephrine (racemic EPInephrine) nebulizer treatment 0.5 ml in NS q 2 hrs prn for stridor
9. Notify physician for stridor, SaO2 < 90%, SBP < 100 mmHg, RR > 24 BPM
10. Vital signs per unit routine or q ______hrs
11. Diet: q Regular q Clear Liquids q Cardiac q Diabetic ____ calorie q Renal q Other: ______
12. Activity: q Bedrest q Bedside commode q Bathroom privileges
q Up ad lib q Up with assistance
SCHEDULED MEDICATIONS:
13. IVF: q NS q LR q D5NS q D5 ½ NS with 20 KCl at ______ml/hr
14. q Solumedrol (methylprednisolone) 40 mg IV push q 6 hrs
15. q Benadryl (diphenhydramine) 25 mg IVP q 6 hrs
or q Benadryl (diphenhydramine) 25 mg po q 6 hrs
16. q Pepcid (famotidine) 20 mg IV q 12 hrs
or q Pepcid (famotidine) 20 mg po q 12 hrs
17. 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.
18. q Electrolyte Replacement Protocol (form # 21340)
19. Mild Pain, Temp >100.5°F, HA: q Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
20. 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.
21. 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.
22. 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)
23. Sleep: q Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn
24. Indigestion: q Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
25. Stool Softener: q Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
26. 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
27. Cough: q Robitussin (guaifenesin) 15 ml po q 4 hrs prn
28. Sore Throat: q Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn
ADDITIONAL ORDERS:
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Date Time Physician Signature PID Number
Copy to pharmacy
FORM 3-37188 REV. 12/2014 Page 2 of 2