Alcohol Withdrawal
This document was uploaded by user and they confirmed that they have the permission to share it. If you are author or own the copyright of this book, please report to us by using this DMCA report form. Report DMCA
Overview
Download & View Alcohol Withdrawal as PDF for free.
More details
- Words: 1,300
- Pages: 2
Print Only Selected Items
PHYSICIAN'S ORDER SHEET Alcohol Withdrawal Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated.
Print All
patient imprint
Allergies: ____________________ Admission Status
Respiratory Consider assessing severity using the revised Clinical c Oxygen via nasal cannula to maintain sat at or greater d e f g Institute Withdrawal Assessment for Alcohol scale (CIWA than 90%. Ar) Evidence c Pulse oximetry Evidence d e f g c Admit to Inpatient to Dr. _______ service d e f g Diet c Admit to observation to Dr. ________service. d e f g c Clear liquid diet d e f g Admission Location c Regular diet d e f g c Admit to Unlocked Unit d e f g c Therapeutic diet _______ d e f g c Admit to Locked Unit d e f g IV Fluids Code Status c Dextrose 5% with 0.45% NaCl @ _____mL/hr for 24 d e f g c Resuscitation status Full Code d e f g hours. c Resuscitation status Do Not Resuscitate / Do Not d e f g c Dextrose 5% with 0.9% NaCl @ _____mL/hr for 24 d e f g Intubate (allow natural death) hours. c Resuscitation status Chemical Code d e f g c Sodium Chloride 0.9% @ _____mL/hr for 24 hours. d e f g Vital Signs c Sodium Chloride 0.9% 1000 mL with 2 G magnesium d e f g sulfate plus 1 mg folic acid plus 1 amp MVI, 100mg c Vitals per unit protocol d e f g Thiamine @ _____mL/hr for 24 hours. c Vital signs with neuro checks every _______ hours. d e f g Dextrose 5% with 0.45% NaCl 1000 mL with 2 G c d e f g Activity magnesium sulfate plus 1 mg folic acid plus 1 amp MVI, Level 1 (every 15 minute rounding) 100mg Thiamine @ _____mL/hr for 24 hours. c Homicidal d e f g c Additives d e f g Suicidal c d e f g Medications c Elopement d e f g Antiemetics c Safety d e f g c metoclopramide /REGLAN 10 milligram intravenously d e f g Level 2 (Close observation) every 6 hours as needed for nausea/vomiting c Homicidal d e f g metoclopramide /REGLAN 10 milligram orally every 6 c d e f g Suicidal c d e f g hours as needed for nausea/vomiting c Elopement d e f g Benzodiazepines Evidence c Safety d e f g Fixedschedule Dosing Level 3 (arm's length) c diazepam /VALIUM 5 milligram orally every 6 d e f g c Homicidal d e f g hours c Suicidal d e f g c diazepam /VALIUM 10 milligram orally every 6 d e f g c Elopement d e f g hours c Safety d e f g c LORazepam /ATIVAN 1 milligram orally every 6 d e f g c ad lib d e f g hours c Bed rest d e f g c LORazepam /ATIVAN 2 milligram orally every 6 d e f g c Ambulate with assistance d e f g hours Nursing Orders c oxazepam /SERAX 15 milligram orally 3 times a d e f g Assessments day Symptomtriggered Dosing (Need to review with c Assess pain d e f g other colleagues. Need some additional detail to c Cardiac monitor Evidence d e f g clearly walk through steps. Especially since many Contingency of these pts are treated on med/surg floor) c Notify provider temp > 101; HR < 60 or > 120; RR > d e f g 30; BP , 90 or > 180; bs > 450; uo < 120 ML/ 4 HR. c chlordiazepoxide /LIBRIUM 50 milligram orally d e f g every hour for 2 doses as needed for symptoms of Interventions alcohol withdrawal c Peripheral venous cannula insertion/management d e f g
Order Initiated By: _________________________ Date/Time: _______________ Physician Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: April 2, 2009 Page &p of &P
PHYSICIAN'S ORDER SHEET
patient imprint
Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated. c chlordiazepoxide /LIBRIUM 100 milligram orally d e f g c disulfiram/ANTABUSE 250 mg tal po qd d e f g every hour for 2 doses as needed for symptoms of c acamprosate/CAMPRAL 333 mg tab 2 tablets tid d e f g alcohol withdrawal Laboratory c diazepam /VALIUM 10 milligram orally every hour d e f g Chemistry for 3 doses as needed for symptoms of alcohol c Calcium level, serum, total d e f g withdrawal c Glucose, serum, random d e f g c diazepam /VALIUM 20 milligram orally every hour d e f g c Vitamin B12 level d e f g for 3 doses as needed for symptoms of alcohol c Folate level d e f g withdrawal c Magnesium (Mg) d e f g c LORazepam /ATIVAN 1 milligram orally every hour d e f g c Ammonia, plasma d e f g for 3 doses as needed for symptoms of alcohol c Lipase, serum d e f g withdrawal Hematology c LORazepam /ATIVAN 2 milligram orally every hour d e f g c Complete blood cell count with automated white blood d e f g for 3 doses as needed for symptoms of alcohol cell differential withdrawal Prothrombin time (PT) and international normalized c d e f g c LORazepam /ATIVAN 1 milligram intravenously d e f g ratio (INR) every hour for 3 doses as needed for symptoms of Panels alcohol withdrawal c Basic metabolic panel d e f g c LORazepam /ATIVAN 2 milligram intravenously d e f g c Comprehensive metabolic panel d e f g every hour for 3 doses as needed for symptoms of c Hepatic function panel d e f g alcohol withdrawal Consults BetaBlockers Evidence c atenolol /TENORMIN 50 milligram orally once a day d e f g c Consult to hospitalist d e f g c atenolol /TENORMIN 100 milligram orally once a day d e f g c Consult to neurology d e f g Magnesium Supplements (Suggestion to remove c Consult to Intensive Outpatient Program Therapist (IOP) d e f g pending review. Likely do not need because of use of g c Consult for individual therapy d e f banana bag) Evidence c Consult to GI d e f g c magnesium sulfate 1 gram intramuscularly every 6 d e f g hours for 4 doses Other: ____________________ c magnesium sulfate 1 gram intravenously once for 60 d e f g minutes c magnesium sulfate 2 gram intravenously once for 10 d e f g minute Neuroleptic Agents Evidence c haloperidol /HALDOL 1 milligram intravenously every d e f g 2 hours as needed for delirium c haloperidol /HALDOL 1 milligram intravenously every d e f g 4 hours as needed for delirium Barbiturates c PHENOBARBITAL 30 mg orally 4 times a day d e f g c phenobarbital 30mg orally or IM every 2hours PRN for d e f g agitation Vitamins Vitamin B Preparations Evidence c folic acid /VITAMIN B9 1 milligram orally once a d e f g day c thiamine /VITAMIN B1 100 milligram orally once a d e f g day c multivitamin 1 orally every day d e f g Recovery Drug c naltrexone/REVIA 10 mg po bid d e f g Order Initiated By: _________________________ Date/Time: _______________ Physician Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: April 2, 2009 Page &p of &P
Print Only Selected Items
Print All
PHYSICIAN'S ORDER SHEET Alcohol Withdrawal Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated.
Print All
patient imprint
Allergies: ____________________ Admission Status
Respiratory Consider assessing severity using the revised Clinical c Oxygen via nasal cannula to maintain sat at or greater d e f g Institute Withdrawal Assessment for Alcohol scale (CIWA than 90%. Ar) Evidence c Pulse oximetry Evidence d e f g c Admit to Inpatient to Dr. _______ service d e f g Diet c Admit to observation to Dr. ________service. d e f g c Clear liquid diet d e f g Admission Location c Regular diet d e f g c Admit to Unlocked Unit d e f g c Therapeutic diet _______ d e f g c Admit to Locked Unit d e f g IV Fluids Code Status c Dextrose 5% with 0.45% NaCl @ _____mL/hr for 24 d e f g c Resuscitation status Full Code d e f g hours. c Resuscitation status Do Not Resuscitate / Do Not d e f g c Dextrose 5% with 0.9% NaCl @ _____mL/hr for 24 d e f g Intubate (allow natural death) hours. c Resuscitation status Chemical Code d e f g c Sodium Chloride 0.9% @ _____mL/hr for 24 hours. d e f g Vital Signs c Sodium Chloride 0.9% 1000 mL with 2 G magnesium d e f g sulfate plus 1 mg folic acid plus 1 amp MVI, 100mg c Vitals per unit protocol d e f g Thiamine @ _____mL/hr for 24 hours. c Vital signs with neuro checks every _______ hours. d e f g Dextrose 5% with 0.45% NaCl 1000 mL with 2 G c d e f g Activity magnesium sulfate plus 1 mg folic acid plus 1 amp MVI, Level 1 (every 15 minute rounding) 100mg Thiamine @ _____mL/hr for 24 hours. c Homicidal d e f g c Additives d e f g Suicidal c d e f g Medications c Elopement d e f g Antiemetics c Safety d e f g c metoclopramide /REGLAN 10 milligram intravenously d e f g Level 2 (Close observation) every 6 hours as needed for nausea/vomiting c Homicidal d e f g metoclopramide /REGLAN 10 milligram orally every 6 c d e f g Suicidal c d e f g hours as needed for nausea/vomiting c Elopement d e f g Benzodiazepines Evidence c Safety d e f g Fixedschedule Dosing Level 3 (arm's length) c diazepam /VALIUM 5 milligram orally every 6 d e f g c Homicidal d e f g hours c Suicidal d e f g c diazepam /VALIUM 10 milligram orally every 6 d e f g c Elopement d e f g hours c Safety d e f g c LORazepam /ATIVAN 1 milligram orally every 6 d e f g c ad lib d e f g hours c Bed rest d e f g c LORazepam /ATIVAN 2 milligram orally every 6 d e f g c Ambulate with assistance d e f g hours Nursing Orders c oxazepam /SERAX 15 milligram orally 3 times a d e f g Assessments day Symptomtriggered Dosing (Need to review with c Assess pain d e f g other colleagues. Need some additional detail to c Cardiac monitor Evidence d e f g clearly walk through steps. Especially since many Contingency of these pts are treated on med/surg floor) c Notify provider temp > 101; HR < 60 or > 120; RR > d e f g 30; BP , 90 or > 180; bs > 450; uo < 120 ML/ 4 HR. c chlordiazepoxide /LIBRIUM 50 milligram orally d e f g every hour for 2 doses as needed for symptoms of Interventions alcohol withdrawal c Peripheral venous cannula insertion/management d e f g
Order Initiated By: _________________________ Date/Time: _______________ Physician Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: April 2, 2009 Page &p of &P
PHYSICIAN'S ORDER SHEET
patient imprint
Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated. c chlordiazepoxide /LIBRIUM 100 milligram orally d e f g c disulfiram/ANTABUSE 250 mg tal po qd d e f g every hour for 2 doses as needed for symptoms of c acamprosate/CAMPRAL 333 mg tab 2 tablets tid d e f g alcohol withdrawal Laboratory c diazepam /VALIUM 10 milligram orally every hour d e f g Chemistry for 3 doses as needed for symptoms of alcohol c Calcium level, serum, total d e f g withdrawal c Glucose, serum, random d e f g c diazepam /VALIUM 20 milligram orally every hour d e f g c Vitamin B12 level d e f g for 3 doses as needed for symptoms of alcohol c Folate level d e f g withdrawal c Magnesium (Mg) d e f g c LORazepam /ATIVAN 1 milligram orally every hour d e f g c Ammonia, plasma d e f g for 3 doses as needed for symptoms of alcohol c Lipase, serum d e f g withdrawal Hematology c LORazepam /ATIVAN 2 milligram orally every hour d e f g c Complete blood cell count with automated white blood d e f g for 3 doses as needed for symptoms of alcohol cell differential withdrawal Prothrombin time (PT) and international normalized c d e f g c LORazepam /ATIVAN 1 milligram intravenously d e f g ratio (INR) every hour for 3 doses as needed for symptoms of Panels alcohol withdrawal c Basic metabolic panel d e f g c LORazepam /ATIVAN 2 milligram intravenously d e f g c Comprehensive metabolic panel d e f g every hour for 3 doses as needed for symptoms of c Hepatic function panel d e f g alcohol withdrawal Consults BetaBlockers Evidence c atenolol /TENORMIN 50 milligram orally once a day d e f g c Consult to hospitalist d e f g c atenolol /TENORMIN 100 milligram orally once a day d e f g c Consult to neurology d e f g Magnesium Supplements (Suggestion to remove c Consult to Intensive Outpatient Program Therapist (IOP) d e f g pending review. Likely do not need because of use of g c Consult for individual therapy d e f banana bag) Evidence c Consult to GI d e f g c magnesium sulfate 1 gram intramuscularly every 6 d e f g hours for 4 doses Other: ____________________ c magnesium sulfate 1 gram intravenously once for 60 d e f g minutes c magnesium sulfate 2 gram intravenously once for 10 d e f g minute Neuroleptic Agents Evidence c haloperidol /HALDOL 1 milligram intravenously every d e f g 2 hours as needed for delirium c haloperidol /HALDOL 1 milligram intravenously every d e f g 4 hours as needed for delirium Barbiturates c PHENOBARBITAL 30 mg orally 4 times a day d e f g c phenobarbital 30mg orally or IM every 2hours PRN for d e f g agitation Vitamins Vitamin B Preparations Evidence c folic acid /VITAMIN B9 1 milligram orally once a d e f g day c thiamine /VITAMIN B1 100 milligram orally once a d e f g day c multivitamin 1 orally every day d e f g Recovery Drug c naltrexone/REVIA 10 mg po bid d e f g Order Initiated By: _________________________ Date/Time: _______________ Physician Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: April 2, 2009 Page &p of &P
Print Only Selected Items
Print All
Related Documents
Alcohol Withdrawal
May 2020 4
Alcohol Withdrawal Management
December 2019 12
Alcohol Withdrawal Assessment Sheets
June 2020 5
Alcohol
December 2019 22
Alcohol
May 2020 13