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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: Page 1 of 23 Oncology Admission [30400070] (4/19/16) 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: Page 2 of 23 Oncology Admission [30400070] (4/19/16) 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: Page 3 of 23 Oncology Admission [30400070] (4/19/16) 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: Page 4 of 23 Oncology Admission [30400070] (4/19/16) 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: Page 5 of 23 Oncology Admission [30400070] (4/19/16) 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: Page 6 of 23 Oncology Admission [30400070] (4/19/16) 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: Page 7 of 23 Oncology Admission [30400070] (4/19/16) 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: Page 8 of 23 Oncology Admission [30400070] (4/19/16) 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: Page 9 of 23 Oncology Admission [30400070] (4/19/16) 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: Page 10 of 23 Oncology Admission [30400070] (4/19/16) 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: Page 11 of 23 Oncology Admission [30400070] (4/19/16) 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: Page 12 of 23 Oncology Admission [30400070] (4/19/16) 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: Page 13 of 23 Oncology Admission [30400070] (4/19/16) 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: Page 14 of 23 Oncology Admission [30400070] (4/19/16) 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: Page 15 of 23 Oncology Admission [30400070] (4/19/16) 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] (4/19/16) 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 [30400070] (4/19/16) 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 [30400070] (4/19/16) 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: Page 21 of 23 Oncology Admission [30400070] (4/19/16) 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] (4/19/16) 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] (4/19/16) TIME RN ACKNOWLEDGED PATIENT INFORMATION