Physician'S Orders: Magnesium Sulfate Administration In Labor And Delivery Form
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1INSTRUCTIONS:
1.
Before placing in chart, imprint patient’s
plate as indicated below
2.
After doctor writes a medication order
scan duplicate copy to Pharmacy
Page 1 of____
Imprint Patient’s name Plate or Print Information Above
NOTED BY/
PHYSICIAN’S ORDERS:
ORDERED
TIME DATE
AND
Magnesium Sulfate Administration in Labor and Delivery
DATE
TIME
SIGNATURE
•
Infuse __________________solution at ___________ml/hr
IV: PRIMARY
(Type of solution)
via infusion pump
•
Total IV intake not to exceed______ml/ hr
IV:
SECONDARY
Magnesium Sulfate (40 Gm/1000 ml in sterile water) IVPB
per infusion pump:
Administer 4 gram
over 20 minutes
(100 ml)
(Set pump at 300 ml/hr)
Administer 5 gram
over 20 minutes
(125 ml)
(Set pump at 375 ml/hr)
Administer 6 gram
over 20 minutes
(150 ml)
(Set pump at 450 ml/hr)
OR
Administer 4 gram
over 30 minutes
(100 ml)
(Set pump at 200 ml/hr)
Administer 5 gram
over 30 minutes
(125 ml)
(Set pump at 250 ml/hr)
Administer 6 gram
over 30 minutes
(
(150 ml)
Set pump at 300 ml/hr)
•
Then administer maintenance dose:
1
gram/hr
(Set pump at 25 ml/hr)
1.5 grams/hr
(Set pump at 38 ml/hr)
2
grams/hr
(Set pump at 50 ml/hr)
2.5 grams/hr
(Set pump at 63 ml/hr)
3
grams/hr
(Set pump at 75 ml/hr)
•
Notify physician if any of the following occur:
* deep tendon reflexes absent
* urinary output< 30 ml/hr
* respirations<12
* serum magnesium level is < 5 mg/dl or >8 mg/dl
Other:
Incentive spirometry hourly during magnesium infusion
Strict I&0
Vital signs hourly with deep tendon reflexes
Serum magnesium level every ____ hours
Other:
Physician/CNM Signature:
Date:
Time:
Sent To Pharmacy
Date: _________ Time:________ Initials: ________
Last Update: 04/24/06
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