Download Hypertonic 3% Saline for Acute Symptomatic

PLACE LABEL HERE
HYPERTONIC (3%) SALINE FOR
ACUTE SYMPTOMATIC HYPONATREMIA
ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT ordered unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
1. Do you expect that the patient’s condition will require a hospital stay that will cross two midnights (includes the time
spent in outpatient- ED, surgery, OBS) and the patient has medical necessity for an inpatient admission?
 Yes, admit as inpatient, proceed to # 2 No, place in observation
2. If admitted as inpatient, Inpatient Physician Certification:
Diagnosis: ________________________________________________________________________________
Level of Care:  Critical  Intermediate
Unit Preference:
 ICU
 IMCU/PCU
 Neuro ICU
 Neuro IMCU
3.  Telemetry: If patient Medical/Surgical, must complete form # 36084
4.  Isolation:  Contact  Droplet  Airborne For: _________________
5. Consults:
Critical Care:  Nephrology for management of 3% saline (Optional)
Intermediate Care: Nephrology for management of 3% saline (Required)
6. STAT Diagnostics, IF NOT DONE IN THE LAST 4 HOURS
CMP, Magnesium, Urine sodium, Urine Osmolality
Other Diagnostics:
Sodium Level q 2 hrs x 2 then q 4 hrs or  continue q 2 hr monitoring while on 3% saline (first level in 2 hrs)
 Serum osmolality in AM
 Random serum cortisol in AM
 TSH and Free T4 in AM
7. Notify nephrologist/intensivist of each sodium result (Correction rate of serum sodium should not be > 1 mmol/L
every 2 hours or > 10 mmol/L in 24 hours)
or  Notify nephrologist/intensivist if sodium level has changed > 1 mmol/L in 2 hrs or ≥ 10 mmol/L in 24 hrs
8. Vital signs per unit routine
9. Neuro checks:
Critical Care:
Neuro checks q 1 hr while 3% saline is infusing
Intermediate Care: Neuro checks q 2 hrs x 24 hrs then q 4 hrs while 3% saline is infusing
10. Intake/Output:
Critical Care: q 1 hr while 3% saline is infusing
Intermediate Care: q 2 hrs while 3% saline is infusing
11. Urinary Catheter to urometer for critically ill/strict I&O. Maintain catheter while on hypertonic saline, then DC per
Foley catheter removal standing orders (form # 31620).
12. Foley catheter removal and voiding assessment/interventions standing orders (form # 31620)
13. Notify nephrologist/intensivist if uop > 200 ml/hr for 2 consecutive hours
14. Place 2 large bore IVs if possible. Nursing to assess IV sites q 2 hrs while 3% saline infusing
15. Fluid Restriction: No water pitchers at bedside and restrict to 1,000 ml/day or  _____ ml/day
16. Diet: NPO or  Regular
 Cardiac
17. Activity (advance as tolerated):
 Diabetic______ calories Renal
 Bedrest w/ BSC
 Bedrest w/ BRP
 Up ad lib
 May shower
Order writer’s initials _______
Copy to pharmacy
*3-39732*
 Strict Bedrest
FORM 3-39732 REV. 09/2016
Page 1 of 2
PLACE LABEL HERE
HYPERTONIC (3%) SALINE FOR
ACUTE SYMPTOMATIC HYPONATREMIA
ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT ordered unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
SCHEDULED MEDICATIONS (Evalutate sodium deficit):
18. Hypertonic Saline:
Bolus:
 3% Saline Bolus 100 ml or  _____ ml over 10 min IV STAT x 1
Infusion:
  3% Saline _____ ml over ____ hours IV STAT x 1
or  3% Saline _____ ml/hr x ____ hrs (max of 18 hrs)
PRN MEDICATIONS: See policy 520-06 for range orders and pain intensity guidelines.
19.  Electrolyte Replacement Protocol (form # 21340)
20. Mild Pain, Temp >100.5F, HA:  Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
21. Moderate Pain:
 Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered.
or  If patient cannot take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po q 4 hrs
prn instead of Norco. DC if Percocet ordered.
or  Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Norco ordered.
and/or
 Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (15 mg if CrCl 31-50, > 65 y/o old or < 50 kg)
or 10 mg po q 6 hrs prn (max combined duration of IV and po ketorolac is 5 days). DC if CrCl < 30.
22. Severe Pain (Begin when Epidural or PCA has been discontinued)
 Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered.
or  Dilaudid (HYDROmorphone) 0.25-0.5 mg IV q 3 hrs prn. If CrCl < 30, dose at 0.25 mg. Hold for excessive
sedation. DC if Morphine ordered.
23. Nausea/Vomiting:
 Zofran (ondansetron) 4 mg IV or po q 6 hrs prn
 If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)
 Melatonin 5 mg po q HS prn
24. Sleep:
or  Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn
25. Indigestion:
 Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
26. Stool Softener:
 Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
 Milk of Magnesia (MOM) 30 ml po daily prn
27. Constipation:
If no BM after 48 hrs,
and/or
 Dulcolax (biscodyl) 10 mg per rectum daily prn
 Senokot-S (docusate/senna) 2 tablets po at bedtime nightly
28. Cough:
 Robitussin (guaifenesin) 15 ml po q 4 hrs prn
29. Sore Throat:
 Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn
__________
______________
_________________________________
__________
Date
Time
Physician Signature
PID Number
Copy to pharmacy
FORM 3-39732 REV. 09/2016
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