Download Oncology Admission [30400070] General

Oncology Admission [30400070]
If appropriate for this patients condition please consider the following order sets:
Hydration Order for Reducing Risk of Radiocontrast Induced Nephrotoxicity (if patients GFR is decreased and the patient
requires IV contrast study #683
Febrile Neutropenia, Initial Management ADDENDUM Physician Order #895
Patient Controlled Analgesia (PCA) Physician Order #564
VTE Risk Assessment (must follow VTE orders in Oncology Order Set if Risk Assessment not completed) #718
Height_____________________
Weight_____________________
Allergies____________________
General
Level of Care (Single Response) [120549]
()
Admit to Inpatient [ADT1]
_____________________________________REQUIRED
Diagnosis:
Estimated length of stay:
Certification: I reasonably expect the patient will require
inpatient services that span a period of time over twomidnights. (See Rationale Section in the order for options)
Additional documentation will be found in progress notes
and admission history and physical.
Must be completed by Physician for Inpatient Admissions:
Rationale for Inpatient Admission:
Plans for post hospital care: See Discharge Summary/
Progress Note
Level of Care:
()
Refer to Observation [ADT12]
_____________________________________REQUIRED
Diagnosis:
Monitor for:
Notify provider when:
Level of Care:
SAH, SCH, SFH, SJMC & Highline Code Status (Single Response) [120501]
()
Full code [COD2]
_____________________________________REQUIRED
This code status was determined by:
()
Full treatment WITH intubation but WITHOUT ACLS
[COD3]
_____________________________________REQUIRED
This code status was determined by:
- Initiate Code Blue for management of airway in the
presence of a primary respiratory event
- Therapeutic plan is otherwise unaltered
- Transfer to critical care if indicated
Provider’s Initial:
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PATIENT INFORMATION
()
Full treatment WITHOUT intubation and WITHOUT
ACLS [COD4]
_____________________________________REQUIRED
This code status was determined by:
- Do NOT initiate Code Blue
- Therapeutic plan is otherwise unaltered
- Transfer to critical care if indicated.
()
Comfort Care [COD1]
_____________________________________REQUIRED
This code status was determined by:
1) Provider must complete comfort care orders #668
2) RN or designee to place a purple wristband on Patient
3) Do NOT initiate Code Blue
4) Do NOT transfer to higher level of care
SAH, SCH, SFH, SJMC & Highline Code Status (Single Response) [122823]
()
Full code [COD2]
_____________________________________REQUIRED
This code status was determined by:
()
Full treatment WITH intubation but WITHOUT ACLS
[COD3]
_____________________________________REQUIRED
This code status was determined by:
- Initiate Code Blue for management of airway in the
presence of a primary respiratory event
- Therapeutic plan is otherwise unaltered
- Transfer to critical care if indicated
()
Full treatment WITHOUT intubation and WITHOUT
ACLS [COD4]
_____________________________________REQUIRED
This code status was determined by:
- Do NOT initiate Code Blue
- Therapeutic plan is otherwise unaltered
- Transfer to critical care if indicated.
()
Comfort Care [COD1]
_____________________________________REQUIRED
This code status was determined by:
1) Provider must complete comfort care orders #668
2) RN or designee to place a purple wristband on Patient
3) Do NOT initiate Code Blue
4) Do NOT transfer to higher level of care
Harrison Code Status (Single Response) [171325]
()
Full code [COD2]
_____________________________________REQUIRED
This code status was determined by:
()
Full treatment WITH intubation but WITHOUT ACLS
[COD3]
_____________________________________REQUIRED
This code status was determined by:
- Initiate Code Blue for management of airway in the
presence of a primary respiratory event
- Therapeutic plan is otherwise unaltered
- Transfer to critical care if indicated
Provider’s Initial:
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PATIENT INFORMATION
()
Full treatment WITHOUT intubation but WITH ACLS
[COD9]
_____________________________________REQUIRED
This code status was determined by:
-Initiate Code Blue for management of cardiac arrhythmias
in the presence of a primary cardiac event
- Therapeutic plan is otherwise unaltered
- Transfer to critical care if indicated
()
Full treatment WITHOUT intubation and WITHOUT
ACLS [COD4]
_____________________________________REQUIRED
This code status was determined by:
- Do NOT initiate Code Blue
- Therapeutic plan is otherwise unaltered
- Transfer to critical care if indicated.
()
Comfort Care [COD1]
_____________________________________REQUIRED
This code status was determined by:
1) Provider must complete comfort care orders #668
2) RN or designee to place a purple wristband on Patient
3) Do NOT initiate Code Blue
4) Do NOT transfer to higher level of care
Harrison Code Status (Single Response) [171326]
()
Full code [COD2]
_____________________________________REQUIRED
This code status was determined by:
()
Full treatment WITH intubation but WITHOUT ACLS
[COD3]
_____________________________________REQUIRED
This code status was determined by:
- Initiate Code Blue for management of airway in the
presence of a primary respiratory event
- Therapeutic plan is otherwise unaltered
- Transfer to critical care if indicated
()
Full treatment WITHOUT intubation but WITH ACLS
[COD9]
_____________________________________REQUIRED
This code status was determined by:
-Initiate Code Blue for management of cardiac arrhythmias
in the presence of a primary cardiac event
- Therapeutic plan is otherwise unaltered
- Transfer to critical care if indicated
()
Full treatment WITHOUT intubation and WITHOUT
ACLS [COD4]
_____________________________________REQUIRED
This code status was determined by:
- Do NOT initiate Code Blue
- Therapeutic plan is otherwise unaltered
- Transfer to critical care if indicated.
()
Comfort Care [COD1]
_____________________________________REQUIRED
This code status was determined by:
1) Provider must complete comfort care orders #668
2) RN or designee to place a purple wristband on Patient
3) Do NOT initiate Code Blue
4) Do NOT transfer to higher level of care
Provider’s Initial:
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PATIENT INFORMATION
Vital Signs [120647]
[]
Vital signs [NUR490]
Routine, Every 4 hours
[]
Pulse Oximetry [NUR585]
Routine, Every 4 hours
Keep O2 saturation greater than or equal to:
[]
Cardiac monitoring [NUR436]
Routine, Until discontinued, Starting S
Notify Provider [120648]
[]
Provider communication order [NUR195]
Routine, Until discontinued, Starting S
Provider Name:
Notify provider of admission.
[]
Notify Provider [NUR183]
Routine, Until discontinued, Starting S
Pulse greater than:
Respiratory rate less than:
Respiratory rate greater than:
Temperature greater than (celsius):
Urine output less than (mL/hr):
Systolic BP greater than:
Systolic BP less than:
Diastolic BP greater than:
Diastolic BP less than:
Other:
Notify physician if Oxygen Saturation is consistently less
than 92% or patient requires increasing oxygen support.
Activity [123077]
[]
Activity as tolerated [NUR129]
Routine, Until discontinued, Starting S
[]
Patient may shower [NUR550]
Routine, Until discontinued, Starting S
Diet/Nutrition [120649]
[]
Diet NPO [DIET41]
Diet effective now, Starting S
NPO Except:
Diet Comments:
[]
Diet Liquid [DIET42]
_____________________________________REQUIRED
Diet effective now, Starting S
Diet:
Diet:
Additional Modifiers:
Viscosity/Liquids:
Diet Comments:
Provider’s Initial:
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PATIENT INFORMATION
[]
Diet Cardiac [DIET44]
_____________________________________REQUIRED
Diet effective now, Starting S
Select/Nonselect:
Additional Modifiers:
Viscosity/Liquids:
Texture:
Fluid Restriction / day:
Supplement:
Diet Comments:
[]
Diet General [DIET24]
_____________________________________REQUIRED
Diet effective now, Starting S
Select/Nonselect:
Additional Modifiers:
Viscosity/Liquids:
Texture:
Fluid Restriction / day:
Supplement:
Diet Comments:
[]
Diet Diabetic [DIET16]
_____________________________________REQUIRED
Diet effective now, Starting S
Diet, Diabetic:
Select/Nonselect:
Additional Modifiers:
Viscosity/Liquids:
Texture:
Fluid Restriction / day:
Supplement:
Diet Comments:
Nursing Assessments [121100]
[]
Daily weights [NUR450]
Routine, Daily
[]
Strict intake and output [NUR618]
Routine, Until discontinued, Starting S, If urine output less
than 300 mL every 8 hours then notify provider.
Nursing Interventions [120730]
[X] CVAD management protocol [NUR2016]
Routine, Until discontinued, Starting S, Nurse may initiate
CVAD management protocol per policy
[X] Nurse may use local anesthetic for CVAD access per
nursing procedure [NUR185]
Routine, Until discontinued, Starting S
[]
Routine, Now then every 4 hours
With the following limitations:
Every 4 hours and PRN oral care.
Sodium Chloride 0.9% (Normal Saline) oral rinse
[NUR6]
Provider’s Initial:
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PATIENT INFORMATION
[]
Initiate Mucositis oncology unit specific nursing
protocol [NUR185]
Routine, Until discontinued, Starting S
[]
Straight cath [NUR385]
Routine, As needed, Straight cath every 4-6 hours PRN
inability to void or feelings of discomfort/distention.
[]
Insert urinary retention catheter [NUR380]
_____________________________________REQUIRED
Routine, As needed
Type of Catheter:
Insert as needed for inability to void or feelings of discomfort
or distention.
Initiate Medical Staff Approved Urinary Catheter Protocol
[X] Nurse may initiate OTC Pt Care Products [NUR2066]
_____________________________________REQUIRED
Routine, As needed
Respiratory Interventions [120731]
[]
Oxygen therapy [RT83]
Routine, Continuous
O2 Delivery Method: Nasal cannula
Titrate to saturation of: 90%
Indications for O2: Hypoxemia
Indicate LPM/FiO2:
Provider Consults [120662]
[]
Inpatient consult to Radiation Oncology [CON20]
_____________________________________REQUIRED
Reason for Consult?
RN/Secretary to contact the consulting provider?
[]
Inpatient consult to Infectious Diseases [CON5]
_____________________________________REQUIRED
Reason for Consult?
RN/Secretary to contact the consulting provider?
[]
Inpatient consult to Palliative Care [CON27]
_____________________________________REQUIRED
Reason for Consult?
RN/Secretary to contact the consulting provider?
[]
Inpatient consult to Hospice [CON41]
_____________________________________REQUIRED
Reason for Consult?
RN/Secretary to contact the consulting provider?
[]
Obtain medical records [NUR571]
_____________________________________REQUIRED
Routine, Once, Starting S For 1 Occurrences
Obtain records from:
Provider’s Initial:
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PATIENT INFORMATION
Ancillary Consults [123075]
[]
PT eval and treat [PT4]
Routine, Once
Reason for PT?
[]
OT eval and treat [OT1]
Routine, Once
Reason for OT?
[]
Speech and language pathology eval and treat [SLP2]
Routine, Once For 1 Occurrences
Type? Bedside swallow
dysphagia evaluation
[X] IP consult to Care Management [CON583]
_____________________________________REQUIRED
Reason for Consult?
[]
Inpatient consult to Wound Care [CON506]
_____________________________________REQUIRED
Reason for Consult?
[]
Inpatient consult to IV therapy [CON582]
_____________________________________REQUIRED
Reason for Consult?
[]
Inpatient consult to Spiritual Care [CON22]
Reason for Consult?
[]
Pharmacy general consult [CON100]
Routine, Once
[]
Inpatient consult to Registered Dietitian [CON34]
_____________________________________REQUIRED
Reason for Consult?
Patient Transport [120667]
[X] Telemetry patient may be transported without RN or
ECG monitoring [NUR185]
Routine, Until discontinued, Starting S, The following
conditions must be met:
- No new neuro symptoms
- Stable cardiac rhythm for last 12 hours
- SaO2 greater than or equal to 92% on 4 liters or less of
oxygen
- Systolic blood pressure greater than 90 mmHg
Labs
Do not repeat admission labs if already done in the ED.
Chemistry [120682]
[]
Basic metabolic panel [LAB15]
Once
[]
Lactate dehydrogenase (LDH) [LAB96]
Once For 1 Occurrences
[]
Comprehensive metabolic panel [LAB17]
Once For 1 Occurrences
[]
Basic metabolic plus panel [LAB3420]
Once For 1 Occurrences
For patients not on TPN
Provider’s Initial:
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PATIENT INFORMATION
Hematology [120579]
[]
CBC and differential [LAB293]
Once For 1 Occurrences
Coagulation [120653]
[]
Protime-INR [LAB320]
Once
[]
Activated partial thromboplastin time [LAB325]
Once
If not on heparin
[]
Heparin level UFH (Anti-Xa) [LAB317]
Timed Study
[]
Low molecular wgt heparin (Anti-Xa) [LAB316]
Once
Microbiology [120690]
[X] MRSA PCR screen [LAB1747]
_____________________________________REQUIRED
STAT, Starting S For 1 Occurrences
Order contact isolation, if indicated, per MRSA screening
protocol.
[]
Respiratory culture and gram stain [LAB3003]
_____________________________________REQUIRED
Once
[]
Blood Culture - Adult [120614]
[X] Blood culture - Specimen #1 [LAB462]
Once For 1 Occurrences
[X] Blood culture - Specimen #2 [LAB462]
Once For 1 Occurrences
Urine [120581]
[]
Urinalysis with culture, if indicated [LAB3205]
Once, Urinalysis with Culture if indicated reflex to Urine
Microscopic when: cloudy appearance that does not clear
when warming, color other than yellow, pale yellow, or
colorless, protein present in any amount, blood present in
any amount, positive nitrite, positive WBC screen (leukocyte
esterase); also Urine Culture when: positive nitrate, positive
yeast, leukocyte esterase >Trace, more than 10 WBC's, or
bacteria >10
Provider’s Initial:
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PATIENT INFORMATION
Imaging
#683 Hydration Order for Reducing Risk of Radiocontrast Induced Nephrotoxicity (if patients GFR is decreased and the
patient requires IV contrast study
Imaging - CT Abdomen & Pelvis [120737]
[]
CT Abdomen with IV Contrast [IMG237]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Oral Contrast Requirement: Per Radiologist Protocol
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
[]
CT Abdomen without IV Contrast [IMG785]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Oral Contrast Requirement: Per Radiologist Protocol
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
[]
CT Abdomen with and without IV Contrast [IMG238]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Oral Contrast Requirement: Per Radiologist Protocol
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
[]
CT Abdomen Pelvis with IV Contrast [IMG794]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Oral Contrast Requirement: Per Radiologist Protocol
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
[]
CT Abdomen Pelvis without IV Contrast [IMG784]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Oral Contrast Requirement: Per Radiologist Protocol
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
Provider’s Initial:
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PATIENT INFORMATION
[]
CT Abdomen Pelvis with and without IV Contrast
[IMG783]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Oral Contrast Requirement: Per Radiologist Protocol
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
[]
CT Pelvis with IV Contrast [IMG218]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Oral Contrast Requirement: Per Radiologist Protocol
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
[]
CT Pelvis without IV Contrast [IMG217]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Oral Contrast Requirement: Per Radiologist Protocol
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
[]
CT Pelvis with and without IV Contrast [IMG219]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Oral Contrast Requirement: Per Radiologist Protocol
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
Imaging - CT & MRI Head & Neck [120858]
[]
CT Head with IV Contrast [IMG182]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
[]
CT Head without IV Contrast [IMG181]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
Provider’s Initial:
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PATIENT INFORMATION
[]
CT Head with and without IV Contrast [IMG183]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
[]
CT Soft Tissue Neck with IV Contrast [IMG192]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
[]
CT Soft Tissue Neck without IV Contrast [IMG191]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
[]
CT Soft Tissue Neck with and without IV Contrast
[IMG193]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
[]
MRI Brain with IV Contrast [IMG270]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
[]
MRI Brain without IV Contrast [IMG269]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
[]
MRI Brain with and without IV Contrast [IMG271]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
Provider’s Initial:
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PATIENT INFORMATION
Imaging - XR Chest [120720]
[]
CT Chest with IV Contrast [IMG202]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
[]
CT Chest without IV Contrast [IMG200]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
[]
CT Chest with and without IV Contrast [IMG203]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Is the patient pregnant?
What is the patient's sedation/anesthesia requirement?
Transport Mode:
[]
XR Chest 1 View [IMG34]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Is the patient pregnant?
Transport Mode:
Transport Mode:
[]
XR Chest 1 View - Portable [IMG34]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Is the patient pregnant?
Transport Mode: Portable
Transport Mode:
[]
XR Chest 2 Views [IMG36]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Is the patient pregnant?
Transport Mode:
Transport Mode:
Provider’s Initial:
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PATIENT INFORMATION
Harrison - Imaging - Cardiac - ECG 12 Lead & ECHO [177335]
[]
ECG 12 Lead [ECG1]
Routine, As needed
Reason for Exam (Signs & Symptoms):
Reason for Exam (Signs & Symptoms):
ECG PRN for recurrent chest pain and notify MD.
[]
Echocardiogram 2D without Color Doppler [ECH30]
Routine, 1 time imaging
Reason for Exam:
Where should test be performed?
Transport Mode:
To be read by on-call Cardiologist of provider specified.
[]
Provider Communication Order - Call ordering provider
or provider specified with results. [NUR195]
Routine, Until discontinued, Starting S, Call ordering
provider or provider specified with results.
SAH, SCH, SFH, SJMC, & Highline - Imaging - Cardiac - ECG 12 Lead & ECHO [120721]
[]
ECG 12 Lead Unit Performed - On Admission [ECG4]
_____________________________________REQUIRED
Routine, Once For 1 Occurrences
Reason for Exam (Signs & Symptoms):
Reason for Exam (Signs & Symptoms):
Order details.
[]
ECG 12 Lead [ECG1]
_____________________________________REQUIRED
Routine, As needed
Reason for Exam (Signs & Symptoms):
Reason for Exam (Signs & Symptoms):
ECG PRN for RECURRENT chest pain and notify MD.
[]
Echocardiogram 2D without Color Doppler [ECH30]
_____________________________________REQUIRED
Routine, 1 time imaging For 1 Occurrences
Reason for Exam:
Where should test be performed?
Transport Mode:
To be read by on-call Cardiologist of provider specified.
[]
Provider Communication Order - Call ordering provider
or provider specified with results. [NUR195]
Routine, Until discontinued, Starting S, Call ordering
provider or provider specified with results.
IV Fluids
IV Fluids [408121813]
[]
Saline Lock and Flush Panel [408128749]
[]
Saline lock IV [IVT11]
Routine, Continuous
[]
sodium chloride 0.9 % syringe [7319]
10 mL, IntraVENous, Every 8 hours
Provider’s Initial:
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PATIENT INFORMATION
[]
dextrose 5 % and sodium chloride 0.45 % infusion
[9814]
100 mL/hr, IntraVENous, Continuous
[]
dextrose 5 % and sodium chloride 0.45 % with KCl 20
mEq/L infusion [9801]
100 mL/hr, IntraVENous, Continuous
[]
sodium chloride 0.9% (NS) infusion [27838]
100 mL/hr, IntraVENous, Continuous
[]
sodium chloride 0.9 % with KCl 20 mEq/L infusion
[11081]
_____________________________________REQUIRED
IntraVENous, Continuous
Medications
Medications: Pain [195051]
[]
Analgesics: FIRST CHOICE (Single Response)
[195052]
()
HYDROMORPHONE IV ORDERABLE [420079]
IntraVENous, For 7 Days
Give this medication 1st. Nurse to call provider to clarify if
multiple orders with the same therapeutic indication are
numbered to give 1st. If duplicative therapeutic orders are
NOT numbered, nurse to call the prescriber for
clarification.
()
MORPHINE SULFATE IV ORDERABLE [420065]
2 mg, IntraVENous, Every 4 hours PRN, severe pain
Give this medication 1st. Nurse to call provider to clarify if
multiple orders with the same therapeutic indication are
numbered to give 1st. If duplicative therapeutic orders are
NOT numbered, nurse to call the prescriber for
clarification.
()
ketorolac (TORADOL) injection [22473]
15 mg, IntraVENous, For 5 Days
Give this medication 1st. Nurse to call provider to clarify if
multiple orders with the same therapeutic indication are
numbered to give 1st. If duplicative therapeutic orders are
NOT numbered, nurse to call the prescriber for
clarification.
()
oxyCODONE-acetaminophen (PERCOCET) 5-325
mg per tablet [5940]
1 tablet, Oral, Every 4 hours PRN, moderate pain
Give this medication 1st. Nurse to call provider to clarify if
multiple orders with the same therapeutic indication are
numbered to give 1st. If duplicative therapeutic orders are
NOT numbered, nurse to call the prescriber for
clarification.
Provider’s Initial:
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PATIENT INFORMATION
()
oxyCODONE (ROXICODONE) immediate release
tablet [10814]
5 mg, Oral
Give this medication 1st. Nurse to call provider to clarify if
multiple orders with the same therapeutic indication are
numbered to give 1st. If duplicative therapeutic orders are
NOT numbered, nurse to call the prescriber for
clarification.
()
HYDROmorphone (DILAUDID) tablet [3760]
2 mg, Oral, Every 4 hours PRN, severe pain, For 7 Days
Give this medication 1st. Nurse to call provider to clarify if
multiple orders with the same therapeutic indication are
numbered to give 1st. If duplicative therapeutic orders are
NOT numbered, nurse to call the prescriber for
clarification.
()
HYDROcodone-acetaminophen (NORCO) 7.5-325
mg per tablet [34544]
1 tablet, Oral, Every 6 hours PRN, moderate pain, severe
pain
Give this medication 1st. Nurse to call provider to clarify if
multiple orders with the same therapeutic indication are
numbered to give 1st. If duplicative therapeutic orders are
NOT numbered, nurse to call the prescriber for
clarification.
()
HYDROcodone-acetaminophen (NORCO) 5-325 mg
per tablet [34505]
1 tablet, Oral, Every 6 hours PRN, moderate pain, severe
pain
Give this medication 1st. Nurse to call provider to clarify if
multiple orders with the same therapeutic indication are
numbered to give 1st. If duplicative therapeutic orders are
NOT numbered, nurse to call the prescriber for
clarification.
()
ibuprofen (ADVIL,MOTRIN) tablet [3843]
400 mg, Oral, Every 6 hours PRN, mild pain
Start 6 hours after last ketorolac [TORADOL] dose, if
given.
Give this medication 1st. Nurse to call provider to clarify if
multiple orders with the same therapeutic indication are
numbered to give 1st. If duplicative therapeutic orders are
NOT numbered, nurse to call the prescriber for
clarification.
()
acetaminophen (TYLENOL) tablet [101]
Oral
Give this medication 1st. Nurse to call provider to clarify if
multiple orders with the same therapeutic indication are
numbered to give 1st. If duplicative therapeutic orders are
NOT numbered, nurse to call the prescriber for
clarification.
Provider’s Initial:
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PATIENT INFORMATION
[]
Analgesics: SECOND CHOICE (Single Response)
[195053]
()
HYDROMORPHONE IV ORDERABLE [420079]
IntraVENous, For 7 Days
Give this medication 2nd if first medication is ineffective.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 2nd. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
()
MORPHINE SULFATE IV ORDERABLE [420065]
2 mg, IntraVENous, Every 4 hours PRN, severe pain
Give this medication 2nd if first medication is ineffective.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 2nd. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
()
ketorolac (TORADOL) injection [22473]
15 mg, IntraVENous, For 5 Days
Give this medication 2nd if first medication is ineffective.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 2nd. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
()
oxyCODONE-acetaminophen (PERCOCET) 5-325
mg per tablet [5940]
1 tablet, Oral, Every 4 hours PRN, moderate pain
Give this medication 2nd if first medication is ineffective.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 2nd. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
()
oxyCODONE (ROXICODONE) immediate release
tablet [10814]
5 mg, Oral
Give this medication 2nd if first medication is ineffective.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 2nd. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
()
HYDROmorphone (DILAUDID) tablet [3760]
2 mg, Oral, Every 4 hours PRN, severe pain, For 7 Days
Give this medication 2nd if first medication is ineffective.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 2nd. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
()
HYDROcodone-acetaminophen (NORCO) 7.5-325
mg per tablet [34544]
1 tablet, Oral, Every 6 hours PRN, moderate pain, severe
pain
Give this medication 2nd if first medication is ineffective.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 2nd. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
Provider’s Initial:
Page 16 of 23
Oncology Admission
[30400070]
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PATIENT INFORMATION
()
HYDROcodone-acetaminophen (NORCO) 5-325 mg
per tablet [34505]
1 tablet, Oral, Every 6 hours PRN, moderate pain, severe
pain
Give this medication 2nd if first medication is ineffective.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 2nd. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
()
ibuprofen (ADVIL,MOTRIN) tablet [3843]
400 mg, Oral, Every 6 hours PRN, mild pain
Start 6 hours after last ketorolac [TORADOL] dose, if
given.
Give this medication 2nd if first medication is ineffective.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 2nd. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
()
acetaminophen (TYLENOL) tablet [101]
Oral
Give this medication 2nd if first medication is ineffective.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 2nd. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
[]
Analgesics: THIRD CHOICE (Single Response)
[195054]
()
HYDROMORPHONE IV ORDERABLE [420079]
IntraVENous, For 7 Days
Give this medication 3rd if second medication is
ineffective. Nurse to call provider to clarify if multiple
orders with the same therapeutic indication are numbered
to give 3rd. If duplicative therapeutic orders are NOT
numbered, nurse to call the prescriber for clarification.
()
MORPHINE SULFATE IV ORDERABLE [420065]
2 mg, IntraVENous, Every 4 hours PRN, severe pain
Give this medication 3rd if second medication is
ineffective. Nurse to call provider to clarify if multiple
orders with the same therapeutic indication are numbered
to give 3rd. If duplicative therapeutic orders are NOT
numbered, nurse to call the prescriber for clarification.
()
ketorolac (TORADOL) injection [22473]
15 mg, IntraVENous, For 5 Days
Give this medication 3rd if second medication is
ineffective. Nurse to call provider to clarify if multiple
orders with the same therapeutic indication are numbered
to give 3rd. If duplicative therapeutic orders are NOT
numbered, nurse to call the prescriber for clarification.
Provider’s Initial:
Page 17 of 23
Oncology Admission
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PATIENT INFORMATION
()
oxyCODONE-acetaminophen (PERCOCET) 5-325
mg per tablet [5940]
1 tablet, Oral, Every 4 hours PRN, moderate pain
Give this medication 3rd if second medication is
ineffective. Nurse to call provider to clarify if multiple
orders with the same therapeutic indication are numbered
to give 3rd. If duplicative therapeutic orders are NOT
numbered, nurse to call the prescriber for clarification.
()
oxyCODONE (ROXICODONE) immediate release
tablet [10814]
5 mg, Oral
Give this medication 3rd if second medication is
ineffective. Nurse to call provider to clarify if multiple
orders with the same therapeutic indication are numbered
to give 3rd. If duplicative therapeutic orders are NOT
numbered, nurse to call the prescriber for clarification.
()
HYDROmorphone (DILAUDID) tablet [3760]
2 mg, Oral, Every 4 hours PRN, severe pain, For 7 Days
Give this medication 3rd if second medication is
ineffective. Nurse to call provider to clarify if multiple
orders with the same therapeutic indication are numbered
to give 3rd. If duplicative therapeutic orders are NOT
numbered, nurse to call the prescriber for clarification.
()
HYDROcodone-acetaminophen (NORCO) 7.5-325
mg per tablet [34544]
1 tablet, Oral, Every 6 hours PRN, moderate pain, severe
pain
Give this medication 3rd if second medication is
ineffective. Nurse to call provider to clarify if multiple
orders with the same therapeutic indication are numbered
to give 3rd. If duplicative therapeutic orders are NOT
numbered, nurse to call the prescriber for clarification.
()
HYDROcodone-acetaminophen (NORCO) 5-325 mg
per tablet [34505]
1 tablet, Oral, Every 6 hours PRN, moderate pain, severe
pain
Give this medication 3rd if second medication is
ineffective. Nurse to call provider to clarify if multiple
orders with the same therapeutic indication are numbered
to give 3rd. If duplicative therapeutic orders are NOT
numbered, nurse to call the prescriber for clarification.
()
ibuprofen (ADVIL,MOTRIN) tablet [3843]
400 mg, Oral, Every 6 hours PRN, mild pain
Start 6 hours after last ketorolac [TORADOL] dose, if
given.
Give this medication 3rd if second medication is
ineffective. Nurse to call provider to clarify if multiple
orders with the same therapeutic indication are numbered
to give 3rd. If duplicative therapeutic orders are NOT
numbered, nurse to call the prescriber for clarification.
()
acetaminophen (TYLENOL) tablet [101]
Oral
Give this medication 3rd if second medication is
ineffective. Nurse to call provider to clarify if multiple
orders with the same therapeutic indication are numbered
to give 3rd. If duplicative therapeutic orders are NOT
numbered, nurse to call the prescriber for clarification.
Provider’s Initial:
Page 18 of 23
Oncology Admission
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PATIENT INFORMATION
Sedatives [408121482]
[]
zolpidem (AMBIEN) tablet [11701]
5 mg, Oral, Nightly PRN, sleep
Bowel Management [408121484]
[]
docusate sodium (COLACE) capsule [2566]
100 mg, Oral, 2 times daily PRN, constipation, hold for
diarrhea
[]
senna (SENOKOT) tablet 8.6 mg [11349]
1 tablet, Oral, 2 times daily PRN, constipation, hold for
diarrhea
Antiemetic [195064]
[]
Antiemetic: FIRST CHOICE (Single Response)
[195061]
()
ondansetron (ZOFRAN) 4 mg/2 mL injection [106348]
IntraVENous
Give this medication 1st.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 1st. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
()
promethazine (PHENERGAN) IV for patients 65 years
& over (6.25-12.5 mg) [6618]
6.25-12.5 mg, IntraVENous
Give this medication 1st.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 1st. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
()
promethazine (PHENERGAN) IV for patients under 65 IntraVENous
years (12.5-25 mg) [6618]
Give this medication 1st.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 1st. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
()
metoclopramide (REGLAN) injection [5002]
5-10 mg, IntraVENous, Every 6 hours PRN, nausea,
vomiting
Give this medication 1st.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 1st. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
Provider’s Initial:
Page 19 of 23
Oncology Admission
[30400070]
(4/19/16)
PATIENT INFORMATION
[]
Antiemetic: SECOND CHOICE (Single Response)
[195062]
()
ondansetron (ZOFRAN) 4 mg/2 mL injection [106348]
IntraVENous
Give this medication 2nd if first medication is ineffective.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 2nd. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
()
promethazine (PHENERGAN) IV for patients 65 years
& over (6.25-12.5 mg) [6618]
6.25-12.5 mg, IntraVENous
Give this medication 2nd if first medication is ineffective.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 2nd. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
()
promethazine (PHENERGAN) IV for patients under 65 IntraVENous
years (12.5-25 mg) [6618]
Give this medication 2nd if first medication is ineffective.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 2nd. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
()
metoclopramide (REGLAN) injection [5002]
[]
5-10 mg, IntraVENous, Every 6 hours PRN, nausea,
vomiting
Give this medication 2nd if first medication is ineffective.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 2nd. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
Antiemetic: THIRD CHOICE (Single Response)
[195063]
()
ondansetron (ZOFRAN) 4 mg/2 mL injection [106348]
IntraVENous
Give this medication 3rd if second medication is
ineffective.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 3rd. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
()
promethazine (PHENERGAN) IV for patients 65 years
& over (6.25-12.5 mg) [6618]
6.25-12.5 mg, IntraVENous
Give this medication 3rd if second medication is
ineffective.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 3rd. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
Provider’s Initial:
Page 20 of 23
Oncology Admission
[30400070]
(4/19/16)
PATIENT INFORMATION
()
promethazine (PHENERGAN) IV for patients under 65 IntraVENous
years (12.5-25 mg) [6618]
Give this medication 3rd if second medication is
ineffective.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 3rd. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
()
metoclopramide (REGLAN) injection [5002]
5-10 mg, IntraVENous, Every 6 hours PRN, nausea,
vomiting
Give this medication 3rd if second medication is
ineffective.
Nurse to call provider to clarify if multiple orders with the
same therapeutic indication are numbered to give 3rd. If
duplicative therapeutic orders are NOT numbered, nurse
to call the prescriber for clarification.
Nicotine Replacement Therapy [408000001]
Nicotine Replacement therapy will be avoided if possible in patient with unstable acute coronary syndrome for 72 hours.
After 72 hours if chest pain, arrhythmias, and/or blood pressure have stabilized, Nicotine replacement may be
considered at ONE STEP below the calculated replacement dose. NOTE: 1/2 pack = 10 cigarettes
The nicotine products listed below may be used as monotherapy or in combination therapy. Combination therapy should
include a nicotine patch plus nicotine gum.
Smoking History
Recommended Starting Dose
Step down therapy after initial nicotine replacement for 6-7 weeks: Nicotine patch, 7mg
10 Cigarettes per Day or less, past history of cardiovascular disease or weight under 45 kg: Nicotine patch, 14 mg
Heavy smokers (More than 10 cigarettes/day: Nicotine patch, 21 mg
Smokeless tobacco users, pipe smokers or at patient request: Nicotine Gum, 2mg
Note to provider: Insulin requirements may change - monitor blood sugars. Topical Steroids and oral antihistamines may
be recommended to treat less severe skin irritations.
[]
Patient uses tobacco [206892]
[]
nicotine (NICODERM CQ) 7 mg/24 hr [27860]
1 patch, TransDermal, for 24 Hours, Daily
[]
nicotine (NICODERM CQ) 14 mg/24 hr [27862]
1 patch, TransDermal, for 24 Hours, Daily
[]
nicotine (NICODERM CQ) 21 mg/24 hr [27863]
1 patch, TransDermal, for 24 Hours, Daily
[]
nicotine polacrilex (NICORETTE) gum [10717]
2 mg, Buccal, Every 1 hour PRN, smoking cessation
[]
buPROPion (WELLBUTRIN SR) 12 hr tablet [18385]
100 mg, Oral, 2 times daily
[]
varenicline (CHANTIX) tablet [76444]
0.5 mg, Oral, 2 times daily with meals
Provider’s Initial:
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Oncology Admission
[30400070]
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PATIENT INFORMATION
[]
Patient refuses nicotine replacement medication
[COR406]
Details
[]
Patient does not use tobacco [COR405]
Details
[]
Nicotine replacement contraindicated [COR407]
_____________________________________REQUIRED
Reason for contraindication:
PRN Medications [408121521]
[]
nitroglycerin (NITROSTAT) sublingual 0.4 mg [5604]
0.4 mg, SubLINgual, Every 5 min PRN, chest pain
May repeat every 5 minutes times 3 providing SBP greater
than 90mmHg and notify physician.
VTE Risk Assessment & Orders
VTE Prophylaxis Orders [174026]
Select the VTE Risk & Bleeding Level for your patient. Additional Orders will display for selection.
[]
0-1 Risk Score & LOW or HIGH Bleeding Risk
[174038]
[X] Low Risk of VTE [COR41]
[]
Early ambulation - No mechanical or pharmacological VTE
prophylaxis required. VTE Risk Level Very Low to Low.
2-5 Risk Score & LOW Bleeding Risk [SCDs enoxaparin - heparin] [174033]
For Patients with a VTE Risk score of 5 or more, choose SCDs and Pharmacological Prophylaxis.
[]
enoxaparin (LOVENOX) injection [520296]
40 mg, SubCutaneous, Daily
[]
heparin (porcine) injection 5,000 units/mL [10181]
5,000 Units, SubCutaneous, 3 times daily
[]
Pharmacy Consult - Alternate Dosing/Alternate
Medications [400993]
_____________________________________REQUIRED
See admin instructions
[]
Place sequential compression device [NUR563]
Routine, Until discontinued, Starting S
Stocking Type:
Apply SCD's:
May use SCD's in place of medications.
[]
2-5 Risk Score & High Bleeding Risk [SCDs] [174028]
[]
Place sequential compression device [NUR563]
Routine, Until discontinued, Starting S
Stocking Type:
Apply SCD's:
Provider’s Initial:
Page 22 of 23
Oncology Admission
[30400070]
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PATIENT INFORMATION
[]
Reason for no VTE Prophylaxis [174029]
[]
Reason for no mechanical VTE prophylaxis [COR25]
Reason: Unable to wear due to size or injury
[]
Reason for no pharmacologic VTE prophylaxis
(Absolute / Relative contraindications) [COR25]
_____________________________________REQUIRED
Reason:
Fully anticoagulated NOTE: Effective anticoagulation
regimen(s) include warfarin adjusted to minimum INR 2-3,
rivaroxaban (Xarelto), dabigatran (Pradaxa),
heparin/argatroban/bivalirudin infusions, enoxaprin 1.5
mg/kg daily / 1 mg/kg every 12 hours / 1 mg/kg every 24
hours for CrCl less than 30 ml/minute.
[]
Continuing Prior to Admission VTE Pharmacologic
Prophylaxis [COR25]
_____________________________________REQUIRED
Reason for no VTE prophylaxis or only Graduated
Compression Stockings at admission?
Labs [123477]
If Heparin or enoxaparin (Lovenox) ordered. Baseline Hemogram THEN every 3 days.
[]
CBC, no diff (hemogram) [LAB294]
DATE
TIME
Every 72 hours
If Heparin or enoxaparin (Lovenox) ordered. Baseline
Hemogram THEN every 3 days.
ORDERING PROVIDER PRINT NAME
PROVIDER SIGNATURE
DATE
Page 23 of 23
Oncology Admission
[30400070]
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TIME
RN ACKNOWLEDGED
PATIENT INFORMATION