Download OBSERVATION DIVERTICULITIS ORDERS

DOWNTIME
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Entered into electronic record after
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Patient Name
______________ ______________
date
time
______________
initials
Date of Birth
1 of 3
Actual
Estimated
Weight
kg
Medical Record Number
Financial Number
Actual
Estimated
Height
cm
REFER TO ALLERGY PROFILE/
POWERCHART
ALLERGIES:
Diagnosis: Diverticulitis
Attending Physician
() Check, circle and/or fill in all orders to be implemented as appropriate
1.
CODE STATUS:
Full Code DNR DNI
2.
VITAL SIGNS:
every 4 hours Other
3.
ACTIVITY:
Out of bed as tolerated
4.
Other
OXYGEN SUPPORT:
Nasal cannula at
5.
6.
DIET:
Regular diet
Clear liquid diet
Diabetic Adult diet
Low residue diet
Heart Healthy – 4 grams sodium, moderate fat
Renal diet
Nothing by mouth after midnight
Nothing by mouth until further notice
IV FLUIDS:
Saline lock
IV fluids:
IV at
mL per hour
Intake and output
7.
REFERRALS:
Physical therapy Occupational therapy Discharge Planner Other
8.
LABS:
CBC if not completed
From:
Date:
Date:
Time:
PROVIDER
TORB
Signature:
ORDERS
NOTED BY RN
Date:
Time:
Signature:
KH03004 Rev. 7/11/12
Site
Patient ID Area
Transfer to: Observation Status
NURSING
2-Hole 1/4 2 3/4 - 2-Hole 1/4 4 1/2 - 3-Hole 1/4 4 1/4
OBSERVATION DIVERTICULITIS ORDERS
Admission/Visit Date
Time:
Print Name/Stamp:
Signature:
TORB = Telephone Orders Read Back
ORDERS
Place STAT barcode sticker
within this box only on form
copy being scanned
DOWNTIME
Entered into electronic record after
downtime
Patient Name
______________ ______________
date
time
______________
initials
Date of Birth
Medical Record Number
2 of 3
9.
Site
Financial Number
Patient ID Area
MEDICATIONS:
Acetaminophen 650 mg by mouth every 6 hours as needed for pain/fever
Cephalexin 500mg PO q6h AND
Metronidazole 500 mg PO q8h
Cefoxitin 2 gm IV every 6 hours
RESERVED FOR PENICILLIN ALLERGIC PATIENTS:
Ciprofloxacin 500mg by mouth every 12 hours antibiotics for diverticulitis AND
Metronidazole 500 mg by mouth every 8 hours antibiotics for diverticulitis
Ciprofloxacin 400 mg IV every 12 hours AND
Metronidazole 500 mg IV every 8 hours antibiotics for diverticulitis
DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS
REQUIRED to ( ) check all that apply:
Heparin 5000 units subcutaneous every 8 hours
Pneumatic Compression Device (PCD): Knee High Pump
Pneumatic Compression Device (PCD): Foot Pump
Other Orders:
DVT Prophylaxis not indicated (Reason):
DVT Prophylaxis contraindicated (Reason):
Date:
Time:
Physician/NP/PA Signature:
DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS RISK ASSESSMENT
RISK FACTORS
points
AGE
greater than 60 years
41 - 60 years
2
1
IMMOBILITY
SURGERY
points
Coma
2
Patient confined to bed greater than 72 hours
2
Recent uninterrupted travel greater than 4 hours
1
Hip/Pelvic/Long Bone Fracture
Multiple Trauma
Laparoscopic/Pelvic Surgery
Major Surgery greater than 45 minute duration
points
5
5
2
2
PRE-EXISTING/CURRENT MEDICAL CONDITIONS
points
Ischemic Stroke/Paralysis
Previous DVT or Pulmonary Embolism (PE)
Hypercoagulation State*
Cancer
5
3
3
2
Central Venous Catheter greater than 1 week (excludes Renal Access)
2
Infection (severe/sepsis)
Chronic Obstructive Pulmonary Disease (COPD)/Respiratory Distress/Steroid or
Oxygen Dependent
Estrogen Use (oral contraceptives, hormone replacement therapy [HRT])
*Examples of Hypercoagulation State:
• Protein C or S deficiency
1
1
1
1
1
1
1
1
1
Chemotherapy
1
1
Family Medical History unexplained DVT
• Antithrombin III deficiency
From:
Date:
Date:
Time:
Signature:
KH03004 Rev. 7/11/12
1
• Lupus Anticoagulant
Date:
Time:
Signature:
ORDERS
NOTED BY RN
points
Current Heart Failure/Myocardial Infarction
Obesity (greater than 20% Ideal Body Weight (IBW)
Pregnancy/Postpartum less than 1 month
Severe Dehydration
Nephrotic syndrome
Varicose Veins/Vein Surgery/Phlebitis
Inflammatory Bowel Disease
PROVIDER
TORB
NURSING
2-Hole 1/4 2 3/4 - 2-Hole 1/4 4 1/2 - 3-Hole 1/4 4 1/4
OBSERVATION DIVERTICULITIS ORDERS
Admission/Visit Date
Time:
Print Name/Stamp:
Signature:
TORB = Telephone Orders Read Back
ORDERS
Place STAT barcode sticker
within this box only on form
copy being scanned
• Homocystinemia
DOWNTIME
Entered into electronic record after
downtime
______________ ______________
date
time
______________
initials
3 of 3
Ambulate
Date of Birth
Admission/Visit Date
Medical Record Number
Site
Financial Number
Patient ID Area
LOW RISK (Score of 1 or less)
No Prophylaxis
MODERATE TO HIGH RISK* (Score of 2 - 4)
HIGHEST RISK/MULTI MODAL* (Score of 5 or higher)
Heparin 5000 units subcutaneous every 8 hours -OR- PCD
Heparin 5000 units subcutaneously every 8 hours -AND- PCD
*Recommendations apply to general medical and surgical patients.
References:
Modified From : Motyke, GD, Zebal, LP and Caprini, et al. A Guide to Venous Thromboembolism Risk Factor Assessment. Journal of Thrombosis and Thrombolysis 2000.
Geerts W, Bergquist D, Pineo G et al. Prevention of Venous Thromboembolism. Chest 2008, 133: 381S-453S
10. CONSULTS:
11. Notify provider for chest pain, temperature greater than or equal to 38.5,
respiratory rate less than 10 or greater than 30, pulse less than 50 or greater than 110,
systolic blood pressure less than 100 or greater than 180, oximetry less than 92%
12. ADDITIONAL ORDERS:
Print Provider Name:
Contact #:
From:
Date:
Date:
Time:
PROVIDER
TORB
NURSING
2-Hole 1/4 2 3/4 - 2-Hole 1/4 4 1/2 - 3-Hole 1/4 4 1/4
OBSERVATION DIVERTICULITIS ORDERS
Patient Name
Signature:
ORDERS
NOTED BY RN
Date:
Time:
Signature:
KH03004 Rev. 7/11/12
Time:
Print Name/Stamp:
Signature:
TORB = Telephone Orders Read Back
ORDERS
Place STAT barcode sticker
within this box only on form
copy being scanned