Fillable Mr Form 1c - Sickle Cell Pain Crisis Hospital Orders (Page 2 of 4) in pdf

PHYSICIAN ORDERS

DIAGNOSIS:

DRUG SENSITIVITY:

Patient Identification

SICKLE CELL PAIN CRISIS HOSPITAL ORDERS

Drug Allergies (List Reaction) ________________________________________________________________________________

Outpatient Medication: - check “Hold” if medication is not to be given

HOLD

CONT.

HOLD

CONT.

1. _________________________________

10. ___________________________________

2. _________________________________

11. ___________________________________

3. _________________________________

12. ___________________________________

4. _________________________________

13. ___________________________________

5. _________________________________

14. ___________________________________

6. _________________________________

15. ___________________________________

7. _________________________________

16. ___________________________________

8. _________________________________

17. ___________________________________

9. _________________________________

18. ___________________________________

New medication for this admission:

IVF: D5 1/2 NS at 125 ml/hour.

Hold hydroxyurea.

G Folic Acid 1 mg PO daily.

G Prochlorperazine 25 mg suppository every 12 hours PRN nausea/vomiting or

G Prochlorperazine 10 mg PO every 6 hours PRN nausea.

G Diphenhydramine 25 mg PO every 4 hours PRN itching.

____________________________________________________________________________________________

PAIN MEDICATIONS: *Initially, consider using patient’s regular long-acting pain medication at usual dose and

interval to serve as basal medication. Use PCA dose for breakthrough (short-acting) pain relief.

NO MEPERIDINE.

Initial bolus:

Morphine sulfate 5 mg IV, repeat every 20 minutes up to 3 doses to achieve pain relief

OR if true morphine allergy give ________________________________________________________

Ketorolac 30 mg IV/IM every 8 hours for pain. Only use IM if patient does not have IV access. Maximum of

90 mg/day. Maximum duration is 5 days. (Check creatinine on day 1 and day 3 if starting Ketorolac.

DO NOT administer if creatinine greater than 1 mg/dL).

Continue scheduled and prn home oral pain medication regimen.

Scheduled: ____________________________________________________________________________________

PRN: _________________________________________________________________________________________

___________________________________________________________________________________________________

Comfort Medications

Milk of Magnesia 30 mL PO q12h PRN constipation, OR Dulcolax 5 mg PO once daily PRN constipation (for patients with renal

insufficiency)

G Mylanta/Maalox 30 mL PO q6h PRN indigestion OR Calcium carbonate 15 mL PO q4h PRN indigestion (for patients with renal

insufficiency)

G Acetaminophen 650 mg PO q6h PRN mild or headache pain (Unless patient is taking other acetaminophen-containing meds)

G Chloraseptic / Cepastat 1 lozenge q2h PRN dry mouth or sore / irritated throat

See appended orders:

DVT Prophylaxis

PCA

_________/_________/_________

_____________________

Date

Time

_________________________________

____________________

____________________________________________

Physician Name (Print)

Pager

Physician Signature

MR FORM 1C

Rev. 4/13

JH 4/4/13 Page 2 of 4

8/96

Distribution: White - Chart Copy

Mr Form 1c - Sickle Cell Pain Crisis Hospital Orders Page 2

Related Articles

Related forms

Related Categories