PLACE LABEL HERE

DEHYDRATION

OBSERVATION ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

  1. Status: Place in Observation for:______
  2. Level of Care: Acute Care Location/Specialty Unit Preference 5 South
  3. Telemetry: If patient Medical/Surgical, must complete form # 36084
  4. Isolation:  Contact  Droplet  Airborne For: ______

5.Consults:______Notified by physician

______Notified by physician

6.Diagnostics:

STAT: hCG for any menstruatingfemale ≥ 12 years of age

AM: CMP  Chem 7

Other: ______

7.Intake and output: q 8 hrs q _____ hrs

8.Vital signs per unit routine or q ____ hrs. Orthostaticvital signs on arrival and prior to discharge.

9.Notify physician for fever, increased abdominal pain, SBP < 90 or > 190 mmHg, DBP <60 or >100 mmHg

10.Diet: NPO initially, advance to clear liquids as tolerated

11. Activity:BedrestBedside commodeBathroom privileges

Up ad libUp with assistance

SCHEDULED MEDICATIONS

12.IVF: Normal Saline 500 ml IV bolus over 30 min x 1, may repeat x 1 if ______

Replacement fluids: NS LR D5 NS D5 ½ NS IV at ______ml/hr

13. VTE prophylaxis, Initiate Venous Thromboembolism (VTE) Prophylaxis Orders (form # 33058)

 Low risk: No pharmacologic or mechanical prophylaxis, ambulate 3 times daily

Heparin 5,000 units SQ q 8 hrs (q 12 hrs if wt < 50 kg or age > 75)

or Lovenox (enoxaparin) 40 mg SQ daily at 1700 (30 mg if CrCl < 30 ml/min)

and/or Mechanical devices: SCDs

PRN MEDICATIONS See policy 520-06 for range orders and pain intensity guidelines.

14.Abdominal pain:

 Bentyl (dicyclomine) 20 mg po q 12 hrs prn

or  Bentyl (dicyclomine) 20 mg IM q 12 hrs prn

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

PRN MEDICATIONS Continued See policy 520-06 for range orders and pain intensity guidelines.

  1. Electrolyte Replacement Protocol (form # 21340)
  1. Mild Pain, Temp>100.5F, HA:Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
  1. Moderate Pain:

Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered.

or 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 Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Norco ordered.

and/or 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.

  1. Severe Pain (Begin when Epidural or PCA has been discontinued)

Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered.

or  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.

  1. Nausea/Vomiting: Zofran (ondansetron) 4 mg IV or po q 6 hrs prn

If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)

  1. Sleep: Ambien (zolpidem)5 mg (female or males ≥ 65 y/o) or 5-10mg (male < 65 y/o) po at HS prn
  1. Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
  1. Stool Softener: Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
  1. Constipation: Milk of Magnesia (MOM) 30 ml po daily prn

If no BM after 48 hrs  Dulcolax (biscodyl) 10 mg per rectum daily prn

and/or Senokot-S (docusate/senna) 2 tablets po at bedtime nightly

24.Cough:Robitussin (guaifenesin) 15 ml po q 4 hrs prn

25.Sore Throat:Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn

ADDITIONAL ORDERS:

______

______

______

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-37194 REV. 12/2014 Page 1 of 2