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CHILDREN’S HOSPITAL BOSTON
NAME
____________________
DEPARTMENT OF MEDICINE
EATING DISORDERS CPG ADMITTING ORDERS
CH MRN
____________________
Page 1 of 2
DOB
____________________
If STAT – check box above
Template Revision Date: 6-24-05
Approval by Pharmacy and Therapeutics Committee: 6-24-05
☐ NKDA
Allergies / Adverse Reaction: _________________________________________
Dose Basis:
Weight: ______kg
ADMIT TO:
Height: ______cm
_______________
ATTENDING SERVICE:
_____________________________
DIAGNOSIS:
Eating Disorder complicated by
CONDITION:
☐ Stable
☐ Vital Sign instability
☐ Nutritional deficiency
☐ Other: _______________
☐Other: _______________
NURSING:
☐ Place patient on Anorexia Nervosa protocol
☐ Institute Purging Guidelines
☐ Weight/height on arrival to floor
☐ Check weight every morning after patient voids (in gown)
☐ Perform weight check while patient is facing away from scale (backwards)
☐ I&O's
VITAL SIGNS:
☑ Per Anorexia Nervosa protocol:
☑ orthostatic vital signs every morning;
☑ check heart rate, blood pressure, temperature Q4h
☑ urine specific gravity with voids
☐ Cardio-respiratory monitor when asleep
ACTIVITY:
☑ Per Anorexia Nervosa protocol
DIET:
☑ Start at _____ kcal/day, increase by 250 kcal/day to goal _____ kcal/day
_________
DATE
__________
TIME
__________________________________
Physician/Nurse Practitioner signature
_________
__________ _______________________________
DATE
TIME
RN #1 SIGNATURE
ORDERS MAY NOT BE MODIFIED ONCE SIGNED BY PRESCRIBER
___________________________
PRINTED NAME
____________________
PAGER #
______________________________ _________ __________
RN #2 SIGNATURE
DATE
TIME
131095 50/pkg 5/05
CHILDREN’S HOSPITAL BOSTON
NAME
____________________
DEPARTMENT OF MEDICINE
EATING DISORDERS CPG ADMITTING ORDERS
CH MRN
____________________
Page 2 of 2
DOB
____________________
If STAT – check box above
Template Revision Date: 6-24-05
Approval by Pharmacy and Therapeutics Committee: 6-24-05
FLUIDS:
☐ IV fluids: ____________ + _______ _____ mEq/L + _______ _____ mEq/L IV at _____ mL/hr
Base Fluid
☐ Oral fluids:
Additive
☐ 48 ounces/day
Concentration
Additive
☐ 64 ounces/day
Concentration
☐ 72 ounces/day
☐ _____ ounces/day
MEDICATIONS:
☐ Neutra-Phos® 1 packet (phosphorus 250 mg + potassium 7.1 mEq + sodium 7.1 mEq per packet) PO BID
☐ MVI with zinc 1 tablet PO daily
LABS:
☐ CBC, ESR x1 on admission
☐ serum electrolytes, BUN, serum Cr, glucose, calcium, magnesium, phosphorus, AST, ALT x1 on admission
☐ TSH x1 on admission
☐ serum electrolytes, glucose, calcium, magnesium, phosphorus daily
☐ BUN, serum Cr _____
☐ Other: ______________________________________________________
ECG:
☐ Upon arrival to floor
☐ Already in chart
CONSULTS:
☐ Nutrition consult
☐ Psychiatry consult (call x5-8606)
_________
DATE
__________
TIME
__________________________________
Physician/Nurse Practitioner signature
_________
__________ _______________________________
DATE
TIME
RN #1 SIGNATURE
ORDERS MAY NOT BE MODIFIED ONCE SIGNED BY PRESCRIBER
___________________________
PRINTED NAME
____________________
PAGER #
______________________________ _________ __________
RN #2 SIGNATURE
DATE
TIME
131095 50/pkg 5/05