Mr Form 1c - Neurology Epilepsy Monitoring Hospital Orders Page 3
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1
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3PHYSICIAN ORDERS
DIAGNOSIS:
DRUG SENSITIVITY:
Patient Identification
NEUROLOGY EPILEPSY MONITORING HOSPITAL ORDERS
Outpatient Medication: - check “Hold” if medication is not to be given
HOLD CONT.
HOLD
CONT.
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10. ___________________________________
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2. _________________________________
11. ___________________________________
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3. _________________________________
12. ___________________________________
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4. _________________________________
13. ___________________________________
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5. _________________________________
14. ___________________________________
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6. _________________________________
15. ___________________________________
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7. _________________________________
16. ___________________________________
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8. _________________________________
17. ___________________________________
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9. _________________________________
18. ___________________________________
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New medication for this admission:
Medications during seizure:
Lorazepam 1 mg IV (dilute with equal volume of 0.9% sodium chloride or D5W) to be given over 30 seconds for seizure
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lasting greater than 3 minutes. May repeat x 1 if no response to initial dose within 5 minutes of time of initial injection
Ativan 1 mg IV for seizure greater than 3 minutes. May repeat x 2 if seizure does not resolve in 5 minutes. If seizure is
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greater that 5 minutes, load with anticonvulsant.
Zofran 4mg PO/IV every 6-8 hours prn nausea.
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Benadryl 25mg PO every 6-8 hours prn itching.
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Ibuprofen 800mg PO every 8 hours prn itching.
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Nicotine patch 14 mcg every 24 hours prn (if needed)
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Further orders on medication list specific for patient.
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Comfort Medications
Milk of Magnesia 30 mL PO q12h PRN constipation, OR Dulcolax 5 mg PO once daily PRN constipation (for patients
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with renal insufficiency)
Mylanta/Maalox 30 mL PO q6h PRN indigestion OR Calcium carbonate 15 mL PO q4h PRN indigestion (for patients with
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renal insufficiency)
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Acetaminophen 650 mg PO q6h PRN mild or headache pain (Unless patient is taking other acetaminophen-containing meds)
Chloraseptic / Cepastat 1 loze nge q2h PRN dry mouth or sore / irritated throat
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See appended orders:
PCA
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_________/_________/_________
_____________________
Date
Time
_________________________________
____________________
____________________________________________
Physician Name (Print)
Pager
Physician Signature
Rev. 9/12 rpl 9/21/12 Page 3 of 3
MR FORM 1C
8/96
Distribution: White - Chart Copy
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