Hypo Nat Re Mia
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PHYSICIAN'S ORDER SHEET Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated.
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patient imprint
Hyponatremia Admission Status
Respiratory
g Admit to inpatient to Dr. ______service. c d e f c Admit to observation to Dr. _________ service. d e f g Admit Location c Admit to location __________________ d e f g
c Oxygen via nasal cannula as needed. Titrate O2 to pulse d e f g ox of 90% c Oxygen via nonrebreather face mask d e f g c Oxygen via simple face mask d e f g c Oxygen via Venturi mask d e f g Allergies c Pulse oximetry d e f g c NKA d e f g Diet c _____________________________ d e f g NPO c d e f g Code Status Clear liquids c d e f g c Resuscitation status Full Code d e f g Therapeutic diet ______________. c d e f g Resuscitation status Do Not Resuscitate (allow natural g c d e f c Diet, regular d e f g death) c Fluid restrict ____ml d e f g c Resuscitation status partial code ( __ Intubation d e f g __Defibrillation __ ACLS Meds __Chest Compressions ) IV Fluids c Dextrose 5% with 0.9% NaCl @ _____mL/hr for 24 d e f g Vital Signs hours. c Vitals per unit protocol d e f g c Dextrose 5% with 0.45% NaCl @ _____mL/hr for 24 d e f g c Vital signs every_______hours and then every d e f g hours. _____________ c Sodium Chloride 0.9% @ ______mL/hr for 24 hours. d e f g c Measure and document intake and output Total for d e f g c Additives ______________________ d e f g every 8 hours c Saline lock. d e f g Activity g Ambulate with Assistance every 8 hours c d e f c Up ad lib d e f g c Bed rest. d e f g c Bed rest with bedside commode d e f g
Medications
Nursing Orders Assessments Consider calculating Body Mass Index for assessment of disease severity Calculator for BMI Source c Glucose, blood, fingerstick. _______ One Time. Other d e f g Frequency _______________ c Assess neurologic status d e f g c Weigh upon admission d e f g c Daily weights d e f g Contingency c Notify provider for Temp >101 F, HR >120, HR<60, RR d e f g < 8 or >30, SBP <90 or >180, Urine Output < 120ml for 4 hrs, Pulse Ox <90% Interventions c Foley catheter d e f g c If unable to void after 6 hours or bladder scan post d e f g void residual greater than 200 then initiate urinary catheter. c Please notify primary care of admission and status. d e f g
Serum sodium level 120 – 134 mEq/L. The patient with a hyponatremia with mild symptoms has a low sodium that usually develops slowly. The sodium is usually over 120 mEq/L. This condition does not require active management but rather diagnostic workup. The patient with SIADH is often hypervolemic. This should be treated by managing the underlying cause, by stopping culpable medication (thiazide but also chemotherapeutics, neuroleptics, anti depressants, SSRIs) and by restricting water intake to 500700 mL/day. Heart failure combined with high doses of diuretics can cause a mild hyponatremia with serum sodium between 125130 mEq. The condition may be corrected by adding an ACEi to the drug regimen. Mild hyponatremia associated with severe HF, cirrhosis and nephrotic syndrome is reversed by treating the underlying cause. With corticoid deficiencies, the patient is hypovolemic and hypotonic and rarely has neurologic symptoms. This is treated with isotonic saline and corticoids. Salt loss (vomiting and diarrhea) is also treated with isotonic saline and additional potassium as needed. Serum sodium should not be increased by more than 10 12 mEq/24 hours.
Initiated By: _________________________ Date/Time: _______________ Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: 7/29/2009
PHYSICIAN'S ORDER SHEET Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated. Serum sodium level less than 120 mEq/L or if hypertonic saline is ordered. (3%, 5%, or > ) Hyponatremia should be corrected slowly at a rate of about 0.5 mEq/hr. Do not change the serum sodium by more than 1012 mEq/24 hr. Hypertonic saline (3%) should be reserved for patients with focal neurologic deficit, seizure or coma caused by hyponatremia. The usual recommended dose in this setting (usually VERY low sodiums < /= 100 mEq) is 3% saline 100 mL/10 minutes then 100 mL/50 minutes then STOP. This will generally raise the serum sodium level by 36 mEq/L. Repeat serum sodium level. Switch to 0.9% saline and correct the hyponatremia at about 0.5 mEq/hr to a serum sodium level between 120134 mEq/L. c Demeclocycline/DECLOMYCIN 150/300 mg PO twice a d e f g day Hypertonic Saline Sodium replacement calculator Source c 3% sodium chloride100 mL over 10 min, then 100 mL d e f g over 50 min c 3% sodium chloride ___mL over ___ min. d e f g Analgesics Mild Pain (13) Evidence c acetaminophen /TYLENOL ____650 mg ____650 mg d e f g orally or rectally _____every 4 hours ____every 6 hours as needed for pain c ibuprofen /MOTRIN 400 milligram orally every 4 d e f g hours as needed for pain (Contraindicated in pregnant women and children < 6 mos. of age) Moderate Pain (46) c hydrocodone/APAP/LORTAB d e f g ____5/500_____7.5/500 ______10/500 tablet orally every ____4 hr._____6 hr. as needed for pain c oxycodoneAPAP/PERCOCET d e f g ____5/325______7.5/325_____10/325 tablet orally every _____4hr._____6hr. as needed for pain c oxycodone _____mg tablet orally every d e f g _____4hr._____6hr. as needed for pain Severe Pain (710) Evidence Consider the use of an opioid analgesic; morphine at a dose of 0.1 mg/kg body weight has limited effectiveness Evidence c HYDROmorphone /DILAUDID 1 milligram SC/IV d e f g every __ 4 hrs. __ 6 hours as needed for pain c morphine ____ milligram intravenously every d e f g ____hours as needed for pain c morphine ____mg intravenously every 5 minutes to d e f g a maximum of 10 mg/hr.
patient imprint
Antidotes and Rescue Agents c naloxone /NARCAN ___ (0.42) milligram d e f g intravenously every ____min. (23) as needed for opiate reversal to improve mentation and RR > 10 and notify physician STAT Antipyretics c acetaminophen /TYLENOL 650 milligram orally or d e f g rectally every 4 hours as needed for fever >100.4 c acetaminophen /TYLENOL 650 milligram orally or d e f g rectally every 6 hours as needed for fever greater than 100.4 Laxatives c magnesium hydroxide /MILK OF MAGNESIA 30 d e f g milliliter orally once a day as needed for constipation c docusate sodium /COLACE 100 milligram orally 2 d e f g times a day c bisacodyl /DULCOLAX 5 milligram orally once a day as d e f g needed for constipation c bisacodyl /DULCOLAX 10 milligram suppository d e f g rectally once a day as needed for constipation Sedatives Evidence c LORazepam /ATIVAN 1 milligram intravenously every d e f g 6 hours as needed for sedation c LORazepam /ATIVAN 1 milligram orally 2 times a day d e f g as needed for sedation c zolpidem /AMBIEN 5 milligram orally once a day, at d e f g bedtime as needed for insomnia c zolpidem /AMBIEN 10 milligram orally once a day, at d e f g bedtime as needed for insomnia DVT Prophylaxis Mechanical methods of prophylaxis should be used primarily in patients who are at high risk of bleeding or as an adjunct to anticoagulantbased prophylaxis. Consider renal impairment when deciding on doses of LMWH, the direct thrombin inhibitors, and other antithrombotic drugs that are cleared by the kidneys, particularly in elderly patients and those who are at high risk for bleeding. In acutely ill medical patients who have been admitted to the hospital with CHF or severe respiratory disease, or who are confined to bed and have one or more adtioanla risk factors, inclujding active CA, previous VTE, sepsis, acute neurologic disease, or inflammatory bowel disease, prophylaxis with LDUH or LMWH is recommended. In meidcal patients with risk factors for VTE in whom there is a contraindication to anticoagulant prophylaxis, GCS or IPC is recommended. c Early and persistant mobilization d e f g c Graded compression stockings (1530 mm Hg of d e f g pressure at the ankle) c Sequential Compression Device d e f g
Initiated By: _________________________ Date/Time: _______________ Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: 7/29/2009
PHYSICIAN'S ORDER SHEET Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated.
patient imprint
c CBC every other day starting on day 4 of heparin d e f g therapy thru day 14 or until Unfractionated heparin/LMWH is discontinued.
LowDose Unfractionated Heparin c heparin 5,000 unit subcutaneously every 8 hours d e f g LowMolecularWeight Heparins c enoxaparin /LOVENOX 40 milligram subcutaneously d e f g once a day c enoxaparin /LOVENOX 30 milligram subcutaneously d e f g once a day (dose for patients with CrCl < 30 mL/min) Laboratory c Measured serum osmolarity d e f g c Potassium level, serum repeat in _____ hrs d e f g c Serum uric acid d e f g c TSH d e f g c Cortisol d e f g c Albumin d e f g c Serum electrophoresis d e f g c Renin and aldosterone levels d e f g c Triglycerides d e f g c T3; T4 d e f g c Serum sodium d e f g c Complete blood cell count with automated white blood d e f g cell differential c Basic metabolic panel d e f g c Comprehensive metabolic panel d e f g c Urine osmolality d e f g c Urinalysis d e f g c Urine spot lytes (__Na, __K, __creatinine) d e f g c Corticotropin stimulation test d e f g Diagnostic Tests Avoid the routine use of Holter monitoring c Echo d e f g c 12lead ECG d e f g Consider obtaining a chest radiograph; the obtainment of a chest radiograph should not delay reperfusion treatment when indicated c Radiograph, chest, 1 view d e f g c Radiograph, chest, 2 views d e f g c CT scan of the brain d e f g Consults c Consult hospitalist d e f g c Consult nephrology d e f g Other c _____________________________ d e f g c _____________________________ d e f g
Initiated By: _________________________ Date/Time: _______________ Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: 7/29/2009
Print Only Selected Items
Print All
PHYSICIAN'S ORDER SHEET 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
Hyponatremia Admission Status
Respiratory
g Admit to inpatient to Dr. ______service. c d e f c Admit to observation to Dr. _________ service. d e f g Admit Location c Admit to location __________________ d e f g
c Oxygen via nasal cannula as needed. Titrate O2 to pulse d e f g ox of 90% c Oxygen via nonrebreather face mask d e f g c Oxygen via simple face mask d e f g c Oxygen via Venturi mask d e f g Allergies c Pulse oximetry d e f g c NKA d e f g Diet c _____________________________ d e f g NPO c d e f g Code Status Clear liquids c d e f g c Resuscitation status Full Code d e f g Therapeutic diet ______________. c d e f g Resuscitation status Do Not Resuscitate (allow natural g c d e f c Diet, regular d e f g death) c Fluid restrict ____ml d e f g c Resuscitation status partial code ( __ Intubation d e f g __Defibrillation __ ACLS Meds __Chest Compressions ) IV Fluids c Dextrose 5% with 0.9% NaCl @ _____mL/hr for 24 d e f g Vital Signs hours. c Vitals per unit protocol d e f g c Dextrose 5% with 0.45% NaCl @ _____mL/hr for 24 d e f g c Vital signs every_______hours and then every d e f g hours. _____________ c Sodium Chloride 0.9% @ ______mL/hr for 24 hours. d e f g c Measure and document intake and output Total for d e f g c Additives ______________________ d e f g every 8 hours c Saline lock. d e f g Activity g Ambulate with Assistance every 8 hours c d e f c Up ad lib d e f g c Bed rest. d e f g c Bed rest with bedside commode d e f g
Medications
Nursing Orders Assessments Consider calculating Body Mass Index for assessment of disease severity Calculator for BMI Source c Glucose, blood, fingerstick. _______ One Time. Other d e f g Frequency _______________ c Assess neurologic status d e f g c Weigh upon admission d e f g c Daily weights d e f g Contingency c Notify provider for Temp >101 F, HR >120, HR<60, RR d e f g < 8 or >30, SBP <90 or >180, Urine Output < 120ml for 4 hrs, Pulse Ox <90% Interventions c Foley catheter d e f g c If unable to void after 6 hours or bladder scan post d e f g void residual greater than 200 then initiate urinary catheter. c Please notify primary care of admission and status. d e f g
Serum sodium level 120 – 134 mEq/L. The patient with a hyponatremia with mild symptoms has a low sodium that usually develops slowly. The sodium is usually over 120 mEq/L. This condition does not require active management but rather diagnostic workup. The patient with SIADH is often hypervolemic. This should be treated by managing the underlying cause, by stopping culpable medication (thiazide but also chemotherapeutics, neuroleptics, anti depressants, SSRIs) and by restricting water intake to 500700 mL/day. Heart failure combined with high doses of diuretics can cause a mild hyponatremia with serum sodium between 125130 mEq. The condition may be corrected by adding an ACEi to the drug regimen. Mild hyponatremia associated with severe HF, cirrhosis and nephrotic syndrome is reversed by treating the underlying cause. With corticoid deficiencies, the patient is hypovolemic and hypotonic and rarely has neurologic symptoms. This is treated with isotonic saline and corticoids. Salt loss (vomiting and diarrhea) is also treated with isotonic saline and additional potassium as needed. Serum sodium should not be increased by more than 10 12 mEq/24 hours.
Initiated By: _________________________ Date/Time: _______________ Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: 7/29/2009
PHYSICIAN'S ORDER SHEET Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated. Serum sodium level less than 120 mEq/L or if hypertonic saline is ordered. (3%, 5%, or > ) Hyponatremia should be corrected slowly at a rate of about 0.5 mEq/hr. Do not change the serum sodium by more than 1012 mEq/24 hr. Hypertonic saline (3%) should be reserved for patients with focal neurologic deficit, seizure or coma caused by hyponatremia. The usual recommended dose in this setting (usually VERY low sodiums < /= 100 mEq) is 3% saline 100 mL/10 minutes then 100 mL/50 minutes then STOP. This will generally raise the serum sodium level by 36 mEq/L. Repeat serum sodium level. Switch to 0.9% saline and correct the hyponatremia at about 0.5 mEq/hr to a serum sodium level between 120134 mEq/L. c Demeclocycline/DECLOMYCIN 150/300 mg PO twice a d e f g day Hypertonic Saline Sodium replacement calculator Source c 3% sodium chloride100 mL over 10 min, then 100 mL d e f g over 50 min c 3% sodium chloride ___mL over ___ min. d e f g Analgesics Mild Pain (13) Evidence c acetaminophen /TYLENOL ____650 mg ____650 mg d e f g orally or rectally _____every 4 hours ____every 6 hours as needed for pain c ibuprofen /MOTRIN 400 milligram orally every 4 d e f g hours as needed for pain (Contraindicated in pregnant women and children < 6 mos. of age) Moderate Pain (46) c hydrocodone/APAP/LORTAB d e f g ____5/500_____7.5/500 ______10/500 tablet orally every ____4 hr._____6 hr. as needed for pain c oxycodoneAPAP/PERCOCET d e f g ____5/325______7.5/325_____10/325 tablet orally every _____4hr._____6hr. as needed for pain c oxycodone _____mg tablet orally every d e f g _____4hr._____6hr. as needed for pain Severe Pain (710) Evidence Consider the use of an opioid analgesic; morphine at a dose of 0.1 mg/kg body weight has limited effectiveness Evidence c HYDROmorphone /DILAUDID 1 milligram SC/IV d e f g every __ 4 hrs. __ 6 hours as needed for pain c morphine ____ milligram intravenously every d e f g ____hours as needed for pain c morphine ____mg intravenously every 5 minutes to d e f g a maximum of 10 mg/hr.
patient imprint
Antidotes and Rescue Agents c naloxone /NARCAN ___ (0.42) milligram d e f g intravenously every ____min. (23) as needed for opiate reversal to improve mentation and RR > 10 and notify physician STAT Antipyretics c acetaminophen /TYLENOL 650 milligram orally or d e f g rectally every 4 hours as needed for fever >100.4 c acetaminophen /TYLENOL 650 milligram orally or d e f g rectally every 6 hours as needed for fever greater than 100.4 Laxatives c magnesium hydroxide /MILK OF MAGNESIA 30 d e f g milliliter orally once a day as needed for constipation c docusate sodium /COLACE 100 milligram orally 2 d e f g times a day c bisacodyl /DULCOLAX 5 milligram orally once a day as d e f g needed for constipation c bisacodyl /DULCOLAX 10 milligram suppository d e f g rectally once a day as needed for constipation Sedatives Evidence c LORazepam /ATIVAN 1 milligram intravenously every d e f g 6 hours as needed for sedation c LORazepam /ATIVAN 1 milligram orally 2 times a day d e f g as needed for sedation c zolpidem /AMBIEN 5 milligram orally once a day, at d e f g bedtime as needed for insomnia c zolpidem /AMBIEN 10 milligram orally once a day, at d e f g bedtime as needed for insomnia DVT Prophylaxis Mechanical methods of prophylaxis should be used primarily in patients who are at high risk of bleeding or as an adjunct to anticoagulantbased prophylaxis. Consider renal impairment when deciding on doses of LMWH, the direct thrombin inhibitors, and other antithrombotic drugs that are cleared by the kidneys, particularly in elderly patients and those who are at high risk for bleeding. In acutely ill medical patients who have been admitted to the hospital with CHF or severe respiratory disease, or who are confined to bed and have one or more adtioanla risk factors, inclujding active CA, previous VTE, sepsis, acute neurologic disease, or inflammatory bowel disease, prophylaxis with LDUH or LMWH is recommended. In meidcal patients with risk factors for VTE in whom there is a contraindication to anticoagulant prophylaxis, GCS or IPC is recommended. c Early and persistant mobilization d e f g c Graded compression stockings (1530 mm Hg of d e f g pressure at the ankle) c Sequential Compression Device d e f g
Initiated By: _________________________ Date/Time: _______________ Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: 7/29/2009
PHYSICIAN'S ORDER SHEET Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated.
patient imprint
c CBC every other day starting on day 4 of heparin d e f g therapy thru day 14 or until Unfractionated heparin/LMWH is discontinued.
LowDose Unfractionated Heparin c heparin 5,000 unit subcutaneously every 8 hours d e f g LowMolecularWeight Heparins c enoxaparin /LOVENOX 40 milligram subcutaneously d e f g once a day c enoxaparin /LOVENOX 30 milligram subcutaneously d e f g once a day (dose for patients with CrCl < 30 mL/min) Laboratory c Measured serum osmolarity d e f g c Potassium level, serum repeat in _____ hrs d e f g c Serum uric acid d e f g c TSH d e f g c Cortisol d e f g c Albumin d e f g c Serum electrophoresis d e f g c Renin and aldosterone levels d e f g c Triglycerides d e f g c T3; T4 d e f g c Serum sodium d e f g c Complete blood cell count with automated white blood d e f g cell differential c Basic metabolic panel d e f g c Comprehensive metabolic panel d e f g c Urine osmolality d e f g c Urinalysis d e f g c Urine spot lytes (__Na, __K, __creatinine) d e f g c Corticotropin stimulation test d e f g Diagnostic Tests Avoid the routine use of Holter monitoring c Echo d e f g c 12lead ECG d e f g Consider obtaining a chest radiograph; the obtainment of a chest radiograph should not delay reperfusion treatment when indicated c Radiograph, chest, 1 view d e f g c Radiograph, chest, 2 views d e f g c CT scan of the brain d e f g Consults c Consult hospitalist d e f g c Consult nephrology d e f g Other c _____________________________ d e f g c _____________________________ d e f g
Initiated By: _________________________ Date/Time: _______________ Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: 7/29/2009
Print Only Selected Items
Print All
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