Physician s Order Form. Physician s Order Form. Telemetry/Progressive Care Orders. Continued on next page. >>>>>>> Continued on next page.
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1 DATE: TIME: DATE TIME INTRAVENOS FLID and MEDICATION Status: Admit to Telemetry Admit to Progressive Care nit Transfer to Progressive Care nit Note: Discontinue Previous Orders Transfer to Telemetry nit Note: Discontinue Previous Orders Code Status: Full DNR Advance Directive New Consult(s)/rgency: Admitting MD: #1 (Name of consulting physician) Spoke with: (Name of person) Date: _ Time: rgency: Routine Call STAT consult for: #2 (Name of consulting physician) Spoke with: (Name of person) Date: Time: rgency: Routine Call STAT consult for: Social Services Consult Reason: _ IVF and MEDICATION ONLY IVF and MEDICATION ONLY IVF and MEDICATION ONLY IVF and MEDICATION ONLY IV: Peripheral IV insertion. Saline lock with routine flushes per protocol Maintain IV access at all times on Progressive Care & Telemetry. IV Fluid_ to run at _ ml/hour PRN Medication Orders: (may be used if Rx not crossed out, and NO applicable allergies) Magnesium Hydroxide (Milk of Magnesia) 30ml PO every 8 hr PRN constipation Bisacodyl (Dulcolax) 1 supp PR. PRN constipation times one daily Acetaminophen (Tylenol) 650 mg PO every 4 hr PRN for temperature greater than F (38.6 C) or mild pain (1-3) Total Acetaminophen not to exceed 4 gms in 24 hours Halcion 0.125mg PO every HS PRN insomnia Prochlorperazine (Compazine) 5 mg slow IV over 2 minutes every 6 hr PRN nausea. May give oral or IM. Ondansetron (Zofran) 4mg IV every 6 hr PRN, nausea Morphine Sulfate 2-4 mg IV every 4 hr PRN pain: Moderate pain (pain 5-7) = 2 mg Severe pain (pain 8-10) = 4 mg Lorazepam 0.5 mg PO every 8 hr, PRN, anxiety Blood Glucose Management: Initiate ADLT Subcutaneous Insulin Protocol. Ensure signed by physician. Vaccinations Influenza Vaccine 0.5mL IM x 1 dose Pneumovax 0.5mL IM x 1 dose Page 1 of 5 DO NOT SE: I O 4
2 Nursing - Vital Signs & Monitoring: Record Vital signs every four (4) hours Strict intake and output Daily weight Continuous cardiac monitoring Oximetry check every shift Patient may leave floor without nursing supervision Patient may shower without telemetry Other: _ Notify physician if: HR less than 50 or greater than 120 /O less than 30ml/hr for two hours Temp greater than F (38.6 C) Resp. rate less than 10 bpm or greater than 30 bpm Activity: Bedrest strict Bedrest with BRP Ambulate with assistance p Ad Lib Bedrest with bedside PT Eval./treatment consult commode p to chair daily High fall risk OT Eval./treatment consult Cardiac Rehab Consult Respiratory Therapy: Adminsiter oxygen at 2 liter NC to maintain sats greater than 92% OR %. Call if SpO2 less than %. Continuous Pulse Oximetry Oximeter Spot Check Reference Respiratory Therapy Physician Orders for nebulizer treatments. Ensure order sheet is signed. Smoking Cessation Smoking cessation counseling IVF and MEDICATION ONLY IVF and MEDICATION ONLY IVF and MEDICATION ONLY IVF and MEDICATION ONLY DATE TIME INTRAVENOS FLID and MEDICATION DVT Prophylaxis: Pharmacological (Preferred): Choose 1 only Contraindications include active bleeding, coagulopathy, intracranial hemorrhage Heparin 5,000 units SQ every 8 hours Heparin 5,000 units OR Anticoagulation Therapy See Enoxaparin Therapy Orders. Ensure signed by physician. See Weight Based Heparin Infusion Protocol Order. Ensure signed by physician. Pressure lcer Management Wound Care Precautions MD Signature: DO NOT SE: I O 4 Page 2 of 5
3 Diet: NPO Regular _ calorie ADA Clear Liquid Cardiac Other: NGT to Low Intermittent Suction Small bore feeding tube with KB for placement Speech therapy consult Nutrition Consult Renal Entural Feeding of _ DVT Prophylaxis: Non-pharmacological se when anticoagulation contraindicated Sequential compression device to lower extremities Apply TEDS thigh Apply TEDS knee Diagnostics: Chest X-ray PA/Lateral Routine EKG Routine Other: _ Labs: Chem 7 on admission CBC on admission Chem 20 on admission PT/PTT on admission Chem 7 Routine Daily PTT (APTT) Routine Daily PT/INR Routine Daily Cardiac Enzymes & Troponin q8hr x 3 rinalysis with reflex Other: _ IVF and MEDICATION ONLY IVF and MEDICATION ONLY IVF and MEDICATION ONLY IVF and MEDICATION ONLY DATE TIME INTRAVENOS FLID and MEDICATION DO NOT SE: I O 4 Page 3 of 5
4 For the following orders: Initiate Emergency Response Order Set Adult (Below) *Notify physician when implemented Call Rapid Response Team* General Response to Deteriorating Condition (Breathing/Circulation) () Oxygen 2 L/min, Nasal Cannula, Titrate to keep O2 Sat greater than 90% Oximeter Continuous Peripheral IV Insertion If no IV access already established () Acute Respiratory Distress Distress (Sudden onset RR greater than 24, dyspnea, rales, O2 sat less than 90%, complaint of shortness of breath) Chest Single View Adult Portable STAT, Portable, Acute Respiratory Distress Change to VM 50% or NRB 100% (O2 sat less than 90%, Sudden onset RR greater than 24, cardiac perfusion, altered mental status). HHN Nebulizer treatment as needed ABG STAT if no improvement post HHN and changes of O2 set up. Chest pain distress (Sudden onset chest pain, dyspnea, chest pressure ) () NGT x 3 PRN for chest pain EKG stat Morphine sulfate 2 to 4mg IV every 4hr PRN for chest pain Cardiac Enzymes w/troponin stat, then every 8hr x 3. Call physician post result () Signs and Symptoms of Hypotension/Bleeding Symptomatic Hypotension Note: DO NOT order NS (bolus) if pt primary diagnosis of Heart Failure (Systolic BP less than 90, change in LOC, nausea, dizziness, diaphoresis, decrease oxygen level, tachypnea, decreased urine output) Sodium Chloride 0.9% Bolus (NS Bolus) 250mL IV injection, one time ONLY, STAT, over 15 minutes. H&H STAT order if bleeding is suspected PT/PTT STAT order if bleeding is suspected DO DO NOT NOT SE: SE: I I O O 4 4 Q.D. Q.D. MgSO MgSO 4 4 Q.O.D. Trailing zero zero Lack Lack of of leading zero zero Page 4 of 5
5 () () Suspected Opiate Related Significant Respiratory Depression (Receiving opiod medications with decreased RR less than 8, somnolence, or becoming unresponsive) Discontinue Narcotic/opiate or sedative medication PCA or IV drip immediately Naloxone (Narcan) 0.2mg IV every 2 minutes, may give SubQ or IM if no IV fluid. May repeat 2 minute intervals, Maximum dose 5mg Notify physician. Signs & Symptoms of Suspected Stroke (weakness/paresis of extremity facial droop, aphasia, altered level of consciousness) Neuro check every 4 hours. Treatment for Hypokalemia and Hypomagnesemia (If potassium level below 3.0 and magnesium () level below 1.5) The following may be initiated by trained Rapid Response Team Members: () RSP SVN Albuterol 0.083% (3 ml D), PRN 1 dose STAT. May repeat x 1 as needed for evidence of respiratory distress. CKMB, Troponin I Assay - STAT Arterial Blood Gas STAT Portable Chest X-Ray STAT Symptomatic bradycardia less than 40 bpm Atropine 0.5 mg IV every three to five minutes for a max dose of 3 mg (unless patient is with Acute Coronary Syndrome) MD Signature: DO DO NOT NOT SE: SE: I I O O 4 4 Q.D. Q.D. MgSO MgSO 4 4 Q.O.D. Trailing zero zero Lack Lack of of leading zero zero Page 5 of 5
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