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CAPC Palliative Care Discussion Forum
Designing a Program
inpatient palliative care ordersAuthor: Angela_Johnsen
Date: Feb 10, 2010 3:42 pm
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Thanks
I am very interested in reviewing other institutions order sets. I am currently trying to come up with an Order set for comfort care in the ICU as well as a policy and procedure.
Thanks
Danielle Nasello
eclecticdp@yahoo.com
Larry Boggeln, MD
Angela Johnsen APRN-NP
BEREAVEMENT ORDER (#5302) 1/21/10 (new)
NEBRASKA PULMONARY SPECIALTIES
Drs. Mansur, Chakraborty, Fiedler, Johnson, Miller, Rudersdorf, Trapp, Reichmuth, Jarrett
* Orders with a box are optional and must be checked to activate. If a line appears in the order it must be filled in to complete and activate the order. Orders without boxes are automatically done unless crossed through *
1. Give End of Life Care information from Care Notes to the family and/or caregivers.
2. Place End of Life Order 5299 on chart.
3. Offer Pastoral Support
a. Offer to make call to patient/family spiritual advisor.
4. Give and review the “What to Expect When your Loved One is Dying” sheet.
5. Offer measures to support the family’s comfort:
a. Refreshment.
b. Chairs.
c. Music.
d. Fan.
e. Fold out bed.
f. Silence alarms.
g. Turn off monitors in patient room.
h. Secure privacy.
6. Offer to make call to refer family members to the Support Service of choice.
a. Provide Grief Resources information from Care Notes to family and/or caregivers.
REMOVAL OF MECHANICAL VENTILATION/COMPASSIONATE EXTUBATION ORDER (#5301) 1/21/10 (new)
NEBRASKA PULMONARY SPECIALTIES
Drs. Mansur, Chakraborty, Fiedler, Johnson, Miller, Rudersdorf, Trapp, Reichmuth, Jarrett
*Orders with a box are optional and must be checked to activate. If a line appears in the order it must be filled in to complete and activate the order. Orders without boxes are automatically done unless crossed through*
NURSING:
1. Place End of Life order set #5299 on chart.
2. Place Bereavement order set #5302 on chart.
3. Verify adequate IV access (consult physician if access is insufficient).
4. Notify Interdisciplinary Care Team members the planned time of withdrawal.
5. Determine which family members desire to be present for withdrawal.
6. Remove restraints and restrictive devices/equipment.
7. Provide family members with items to assist their comfort:
a. Tissues, chairs, ice water, etc.
b. Position patient to facilitate hand holding with family.
8. Evaluate and ensure present symptom control:
a. Consult with family about their perception of patient comfort.
9. Remove gastric contents by suctioning gastric tube until no return of material.
10. Discontinue in-room monitors and alarms.
11. Keep head of bed elevated 30 degrees.
12. Reposition patient PRN comfort.
MEDICATIONS:
13. Discontinue all paralytic orders.
14. Discontinue all continuous IV medications unless ordered below.
15. Goals of medication therapy:
a. Respiratory rate less than 28.
b. No labored breathing.
c. No signs of pain or discomfort.
16. Morphine
□ Bolus 2-10 mg IV q 5 minutes PRN comfort
□ IV infusion 2 mg/H continuous PRN comfort.
17. □ Lorazepam (Ativan) 1-2 mg IV q 10 minutes PRN anxiety dyspnea.
RESPIRATORY THERAPY ORDERS:
18. Reduce FiO2 to 21%.
19. Cover patient chest with towel or pad.
20. Suction endotracheal tube.
21. Deflate the endotracheal tube cuff.
22. Silence the ventilator.
23. Remove the gastric tube and extubate patient to room air, unless other orders specify to leave tubes in place.
24. Suction remaining secretions.
25. Remove ventilator from room.
POST EXTUBATION ORDERS:
26. Evaluate patient for symptom control.
27. Review family perception of patient’s symptom control.
28. General care Status.
______________________________ ____________ ____________ ____________
Physician Signature ID Number Date Time
PALLIATIVE CARE ORDER (#5300) - page 1 of 5 1/21/10 (new)
NEBRASKA PULMONARY SPECIALTIES
Drs. Mansur, Chakraborty, Fiedler, Johnson, Miller, Rudersdorf, Trapp, Reichmuth, Jarrett
* Orders with a box are optional and must be checked to activate. If a line appears in the order it must be filled in to complete and activate the order. Orders without boxes are automatically done unless crossed through *
1. Resuscitation Status
□ Do Not attempt resuscitation.
□ Full resuscitation measures.
Other ________________________________________________________________________________.
2. Consultation Orders
□ Palliative Care Consult (Specify below)
a. Nebraska Pulmonary Specialties Inpatient Palliative Care MD.
Pastoral Care Consult (patient/family preference)
□ Specific spiritual advisor as requested by patient/family.
□ BryanLGH spiritual advisor.
Social Work/Care Management Consult
□ New evaluation.
□ Notification of initiation of end of life orders.
Home health/Extended Care Evaluation
□ Specific agency ________________________________.
□ No preference.
Hospice Consult
□ Specific agency ________________________________.
□ No preference.
3. Nursing Orders
□ Initiate nursing care plans for Dying/Terminal Care and Grief/Bereavement.
□ Foley catheter PRN.
□ Bladder scan PRN if possible urinary retention.
□ Saline Lock IV and follow vascular access flushing guidelines.
□ Reposition patient every two hours and PRN patient comfort.
□ Head of bed elevated 30 degrees.
□ Remove following devices ________________________________________________________.
□ Vital signs per shift and PRN request or change in status.
□ Pain, dyspnea, and anxiety assessment every 4 hours.
Other _____________________________________________________________________________.
4. Current Medication Orders
Discontinue the following medication:______________________________________________
________________________________________________________________________________
5. Respiratory Orders
□ Oxygen via canula or other comfortable delivery device. Maintain saturations: __________.
□ BiPAP protocol PRN comfort.
□ Albuterol aerosol 0.083% every 2 hours PRN dyspnea.
□ Continue current respiratory medications.
□ May gently orotracheal or nasotracheal suction PRN secretions.
Other ______________________________________________________________________________.
__________________________ __________ __________ __________
Physician Signature ID Number Date Time
Continued on page 2
PALLIATIVE CARE ORDER (#5300) - page 2 of 5 1/21/10 (new)
NEBRASKA PULMONARY SPECIALTIES
Drs. Mansur, Chakraborty, Fiedler, Johnson, Miller, Rudersdorf, Trapp, Reichmuth, Jarrett
6. Laboratory/Radiology Orders
Discontinue following laboratory, radiology and glucose monitoring orders:
_________________________________________________________________________________________
_________________________________________________________________________________________.
7. Ancillary Orders
□ Continue □ Discontinue physical therapy, occupational therapy and speech therapy.
□ Activity as patient’s condition allows.
Other: __________________________________________________________________________________.
8. Ambient Orders
□ Calming music PRN
□ Fan PRN
□ Pets PRN
□ Warm blanket or K pad PRN Discomfort.
□ Private room of adequate size to comfortably accommodate the family.
9. Nutrition Orders
□ Continue □ Discontinue tube feedings and water flush.
□ Continue □ Discontinue parenteral nutrition.
□ Evacuate/suction gastric contents if feedings discontinued.
□ Continue □ Discontinue orogastric or nasogastric tube.
level of suction ____________________________________.
□ Diet as desired by patient.
Bedside swallow evaluation and follow aspiration precautions as necessary.
Other: __________________________________________________________________________________.
10. Symptom Relief Orders
a. Dyspnea
□ See Respiratory Orders.
□ Liquid Morphine/Roxanol (20 mg/mL) 0.25 mL SL or PO q 6 hours scheduled.
□ Liquid Morphine /Roxanol (20 mg/mL) 0.25-0.5 mL SL or PO every 1 hour PRN.
□ Liquid Oxycodone (20 mg/mL) 0.2 mL SL or PO every 6 hours scheduled.
□ Liquid Oxycodone (20 mg/mL) 0.2-0.4 mL SL or PO every 1 hour PRN.
□ Morphine Sulfate 1-4 mg IV every 2 hours PRN.
□ Contact physician if dyspnea is not controlled.
Other _______________________________________________________________________________.
__________________________ __________ __________ __________
Physician Signature ID Number Date Time
Continued on page 3
PALLIATIVE CARE ORDER (#5300) - page 3 of 5 1/21/10 (new)
NEBRASKA PULMONARY SPECIALTIES
Drs. Mansur, Chakraborty, Fiedler, Johnson, Miller, Rudersdorf, Trapp, Reichmuth, Jarrett
b. Pain
Mild: □ Acetaminophen 650 mg (tablet/liquid) PO q 4 H PO PRN.
Keep total daily acetaminophen dose less than 4 grams.
□ Ibuprofen 400 mg (tablet/liquid) PO q 6 H PO PRN.
Moderate:
□ Oxycodone/acetaminophen 5 mg/325 mg 1-2 tablets PO q 4 H PRN.
□ Oxycodone/acetaminophen 10 mg/325 mg 1-2 tablets PO q 4 H PRN.
□ Hydrocodone/acetaminophen 5 mg/325 mg 1-2 tablets PO q 4 H PRN.
□ Hydrocodone/acetaminophen 10 mg/325 mg 1-2 tablets PO q 4 H PRN.
□ Hydrocodone/ibuprofen 7.5 mg/200 mg 1-2 tablets PO q 4 H PRN.
Scheduled dosing: _________________________________________________________.
Other: ____________________________________________________________________.
Severe:
a. Scheduled dosing
□ Sustained Release Morphine (MSContin) 15 mg PO q 12 H.
Other: _______________________________________________________________.
□ Sustained Release oxycodone (Oxycontin) 10 mg PO q 12 H.
Other: _______________________________________________________________.
b. Other: _________________________________________________________________.
c. □ Consult Pharmacist or Palliative Care Team to assist with dosing or conversion.
d. □ Liquid Morphine concentrate (Roxanol) (20 mg/ml) 0.25-0.75 ml PO or SL q 4 H PRN.
e. □ Liquid Oxycodone concentrate (Oxyfast) (20 mg/mL) 0.2-0.6 mL PO or SL q 4 H PRN.
f. □ Methadone _____________________________________________________________.
g. Other: __________________________________________________________________.
Adjuvants for severe pain:
□ Gabapentin 100 mg PO BID.
□ Nortriptyline 25 mg PO daily.
Other: ______________________________________________________________________.
c. Secretion Clearance
□ Atropine 1% ophthalmic drops placed SL or PO 2 drops every 2 hours PRN.
□ Atropine 1% ophthalmic drops placed SL or PO 2 drops every 4 hours scheduled.
□ Scopolamine 1.5 mg patch; 1 or 2 patches applied to skin and change every 3 days.
□ Glycopyrrolate 2 mg PO q 12 H scheduled.
** Hold above medications if mouth is too dry.
□ Glycopyrrolate 0.2 mg IV or SQ q 6 H PRN.
□ Guaifenesin 400 mg PO q 4 H PRN.
□ See respiratory orders.
Other: ____________________________________________________________________________.
d. Apprehension/Anxiety
□ Lorazepam (Ativan) 1-2 mg SL or PO every 4 hours PRN.
□ Lorazepam (Ativan) 2 mg IV every 2 hours PRN.
□ Alprazolam 0.25 mg PO every 4 hours PRN.
Other _____________________________________________________________________.
___________________________ ____________ ____________ ____________
Physician Signature ID Number Date Time
Continued on page 4
PALLIATIVE CARE ORDER (#5300) - page 4 of 5 1/21/10 (new)
NEBRASKA PULMONARY SPECIALTIES
Drs. Mansur, Chakraborty, Fiedler, Johnson, Miller, Rudersdorf, Trapp, Reichmuth, Jarrett
e. Delirium/Agitation
□ Haloperidol 1-2 mg IV every 4 hours PRN.
□ Haloperidol 1 mg PO every 1 hour PRN.
□ Lorazepam (Ativan) 0.5-2 mg PO or SL every 4 hours PRN.
□ Lorazepam (Ativan) 1-2 mg IV every 2 hours PRN.
□ Diazepam (Valium) 5 mg PO every 6 hours. Hold if too sedated.
Other _____________________________________________________________________.
f. Fever
□ Acetaminophen 650 mg PO/PR every 4 hours PRN.
□ Ibuprofen 400 mg PO every 8 hours PRN.
□ Ketorolac 5 mg IV every 6 hours PRN.
Other: ____________________________________________________________________.
g. Seizure/Myoclonus
□ Lorazepam (Ativan) 2-4 mg IV PRN. Maximum dose 8 mg.
□ Diazepam (Valium) 5 mg IV every 2 hours PRN.
* Contact physician if seizure/myoclonus not controlled.
Other __________¬¬___________________________________________________________.
h. Nausea/Vomiting
□ Haloperidol 1 mg PO every 2 hours PRN.
□ Haloperidol 2 mg IV every 2 hours PRN.
□ Prochlorperazine 5-10 mg IV every 4 hours PRN.
□ Prochlorperazine 25 mg suppository PR every 12 hours PRN.
□ Ondansetron 4 mg IV every 4 hours PRN.
□ Dexamethasone 4 mg IV every 12 hours PRN.
Other _____________________________________________________________________.
i. Wound Care
□ Cleanse affected areas with sterile saline PRN.
□ Apply dry absorptive dressing with wound cover PRN.
□ Apply non adherent gauze if bleeding or if dry dressings adhere PRN.
□ Continue to follow Wound Care Nursing orders.
□ Room deodorizer PRN.
Other _____________________________________________________________________.
j. Oral Care
□ Moistened swabs PRN.
□ Artificial saliva PRN.
□ Magic Mouthwash (Maalox/Benadryl/Viscous Lidocaine) 5-10 mL swish and swallow
every 6 hours PRN.
□ Baking soda 1 teaspoon in 8 ounces of warm water 5-15 mL swish and spit PRN.
□ Chlorhexidine oral protocol PRN.
□ Nystatin swish and swallow 5 mL 100,000 units/mL TID PRN oral candidiasis.
Other____________________________________________________________________.
k. Bladder Spasm
□ Belladonna/opium (B and O) 1 suppository PR every 8 hours PRN.
□ Oxybutynin 5 mg PO every 12 hours PRN.
□ Urinalysis.
□ Discontinue Foley catheter if present.
Other ____________________________________________________________________.
___________________________ ____________ ____________ ____________
Physician Signature ID Number Date Time
Continued on page 5
PALLIATIVE CARE ORDER (#5300) - page 5 of 5 1/21/10 (new)
NEBRASKA PULMONARY SPECIALTIES
l. Hiccups
□ Prochlorperazine 10 mg PO every 4 hours PRN.
□ Haloperidol 0.5-2 mg PO or IV every 4 hours PRN.
□ Metoclopramide 10 mg PO or IV every 6 hours PRN (avoid if gastrointestinal obstruction)
□ Chlorpromazine 25 mg PO every 6 hours PRN.
Other_____________________________________________________________________.
m. Diarrhea
□ Loperamide 2 mg PO every 6 hours PRN.
Avoid if C. difficile colitis is present.
□ Fecal containment bag PRN.
□ Cholestyramine 4 gm packet PO daily.
Other _____________________________________________________________________.
n. Constipation
□ Bisacodyl (Dulcolax) PO or PR every 12 hours PRN.
□ Senna 1 tablet every 8 hours PO scheduled.
□ Magnesium hydroxide (MOM) 30 ml PO every 24 hours scheduled.
□ Docusate 100 mg PO every 12 hours scheduled.
□ Polyethylene glycol (Miralax) 17 grams in 8 ounces of water daily PO.
* Hold all constipation medications if stools are loose.
Other _____________________________________________________________________.
o. Acid Reflux
□ Aluminum magnesium hydroxide/simethicone 15-30 mL PO every 6 hours PRN.
□ Lansoprazole 30 mg PO every 12 hours PRN.
Other _____________________________________________________________________.
p. Insomnia
□ Zolpidem 5-10 mg PO at HS PRN.
□ Temazepam 15-30 mg PO at HS PRN.
Other _____________________________________________________________________.
q. Pruritis
□ Diphenhydramine 25-50 mg IV or PO every 12 hours PRN.
□ Hydrocortisone 1% cream to affected sites every 6 hours PRN.
□ Loratadine 10 mg PO every 24 hours PRN.
Other _____________________________________________________________________.
r. Perineal candidiasis
□ Clotrimazole lotion BID to affected area topically.
□ Nystatin powder to affected area BID.
Other: ____________________________________________________________________.
s. Dry Eyes
□ Artificial Tears 1-2 drops each eye every hour PRN.
t. Additional Orders
________________________________________________________________________
________________________________________________________________________
__________________________ __________ __________ __________
Physician Signature ID Number Date Time
COMMITTEE REVIEW DATE: 12/09
END OF LIFE ORDER (#5299) - page 1 of 4 1/21/10 (new)
NEBRASKA PULMONARY SPECIALTIES
Drs. Mansur, Chakraborty, Fiedler, Johnson, Miller, Rudersdorf, Trapp, Reichmuth, Jarrett
* Orders with a box are optional and must be checked to activate. If a line appears in the order it must be filled in to complete and activate the order. Orders without boxes are automatically done unless crossed through *
1. Allow Natural Death.
▫ deactivate AICD
2. Consultation Orders
□ Palliative Care Consult (Specify below)
a. Nebraska Pulmonary Specialties Inpatient Palliative Care MD.
Pastoral Care Consult (patient/family preference)
□ Specific spiritual advisor as requested by patient/family.
□ BryanLGH spiritual advisor.
Social Work/Care Management Consult
□ New evaluation.
□ Notification of initiation of end of life orders.
□ Hospice Consult.
3. Nursing Orders
□ Initiate nursing care plans for Dying/Terminal Care and Grief/Bereavement.
□ Notify physicians of plans.
□ Pain, dyspnea, and anxiety assessment every 2 hours.
□ Foley catheter PRN.
□ Bladder scan PRN if possible urinary retention.
□ Saline Lock IV and follow vascular access flushing guidelines.
□ Do not replace IV catheter if fails.
□ Discontinue monitoring devices.
□ Notify NORS of imminent death.
□ Reposition patient every two hours and PRN patient comfort.
□ Head of bed elevated 30 degrees.
□ Remove sequential compression devices/TED hose.
□ May remove any restrictive devices/articles.
□ Vital signs per shift or PRN request or change in status.
□ General Care Status.
Other _____________________________________________________________________.
4. Current Medication Orders
□ Discontinue all current medication except:
¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬_________________________________________________________________
_________________________________________________________________
5. Respiratory Orders
□ Oxygen 0.5 to 4 LPM PRN via canula or other comfortable delivery device.
May discontinue once unresponsive.
□ BiPAP protocol PRN comfort.
□ Albuterol aerosol 0.083% every 2 hours PRN dyspnea.
□ May gently orotracheal or nasotracheal suction PRN secretions.
□ Place Compassionate Extubation Order #5301 on chart.
Other _____________________________________________________________________.
__________________________ __________ __________ __________
Physician Signature ID Number Date Time
Continued on page 2
END OF LIFE ORDER (#5299) - page 2 of 4 1/21/10 (new)
NEBRASKA PULMONARY SPECIALTIES
Drs. Mansur, Chakraborty, Fiedler, Johnson, Miller, Rudersdorf, Trapp, Reichmuth, Jarrett
6. Laboratory/Radiology Orders
□ Discontinue all laboratory, radiology and glucose monitoring orders.
7. Ancillary Orders
□ Discontinue physical therapy, occupational therapy and speech therapy.
□ Activity as patient’s condition allows.
8. Ambient Orders
□ Calming music PRN □ Fan PRN □ Pets PRN □ Warm blanket or K pad PRN Discomfort.
□ Private room of adequate size to comfortably accommodate the family.
9. Nutrition Orders
□ Discontinue tube feedings, water flushes and parenteral nutrition.
□ Evacuate/suction gastric contents once feedings discontinued.
□ Discontinue orogastric or nasogastric tube (if gastrointestinal obstruction is present- leave to suction).
□ Diet as desired by patient (Aspiration precautions).
10. Symptom Relief Orders
a. Dyspnea
□ See Respiratory Orders.
□ Liquid Morphine/Roxanol (20 mg/mL) 0.25 mL SL or PO q 6 hours scheduled.
□ Liquid Morphine /Roxanol (20 mg/mL) 0.25-0.5 mL SL or PO every 1 hour PRN.
□ Liquid Oxycodone (20 mg/mL) 0.2 mL SL or PO every 6 hours scheduled.
□ Liquid Oxycodone (20 mg/mL) 0.2-0.4 mL SL or PO every 1 hour PRN.
□ Morphine Sulfate 1-4 mg IV every 2 hours PRN.
□ If dyspnea is not controlled:
□ Increase scheduled Morphine (20 mg/mL) to 0.5 mL SL or PO every 6 hours.
□ Increase schedule Oxydodone (20 mg/mL) to 0.4 mL SL or PO every 6 hours.
Other __________________________________________________________________.
b. Pain
□ Acetaminophen 650 mg (tablet/liquid) every 4 hours PO PRN pain.
□ Ibuprofen 400 mg (tablet/liquid) every 6 hours PO PRN pain.
□ Liquid Morphine/Roxanol (20 mg/mL) 0.25 mL PO or SL every 6 hours scheduled.
□ Liquid Morphine/Roxanol (20 mg/mL) 0.25-0.5 mL q 1 hours PO or SL PRN.
□ Morphine Sulfate 1-8 mg IV every 1 hour PRN.
□ Contact physician if pain is uncontrolled.
□ Morphine Allergic/Other preferred opioid:
_____________________________________________________________________.
c. Secretion Clearance
□ Atropine 1% ophthalmic drops SL or PO 2 drops every 2 hours PRN.
□ Atropine 1% ophthalmic drops SL or PO 2 drops every 4 hours scheduled.
□ Scopolamine 1.5 mg patch; 1 or 2 patches applied to skin and change every 3 days.
□ Glycopyrrolate 0.2 IV or subcutaneously every 6 hours PRN.
Other _____________________________________________________________________.
__________________________ __________ __________ __________
Physician Signature ID Number Date Time
Continued on page 3
END OF LIFE ORDER (#5299) - page 3 of 4 1/21/10 (new)
NEBRASKA PULMONARY SPECIALTIES
Drs. Mansur, Chakraborty, Fiedler, Johnson, Miller, Rudersdorf, Trapp, Reichmuth, Jarrett
d. Delirium/Agitation
□ Haloperidol 1-2 mg IV every 4 hours PRN.
□ Haloperidol 1 mg PO every 1 hour PRN.
□ Lorazepam (Ativan) 0.5-2 mg PO or SL every 4 hours PRN.
□ Lorazepam (Ativan) 1-2 mg IV every 2 hours PRN.
□ Diazepam (Valium) 5 mg IV or PO every 6 hours.
Other _____________________________________________________________________.
e. Apprehension/Anxiety
□ Lorazepam (Ativan) 1-2 mg SL or PO every 4 hours PRN.
□ Lorazepam (Ativan) 2 mg IV every 2 hours PRN.
Other _____________________________________________________________________.
f. Fever
□ Acetaminophen 650 mg PO/PR every 4 hours PRN.
□ Ibuprofen 400 mg PO every 8 hours PRN.
□ Ketorolac 5 mg IV every 6 hours PRN.
g. Seizure/Myoclonus
□ Lorazepam (Ativan) 2-4 mg IV PRN.
□ Diazepam (Valium) 5 mg IV PRN.
Other __________¬¬__________________________________________________________.
h. Nausea/Vomiting
□ Haloperidol 1 mg PO or 2 mg IV every 2 hours PRN.
□ Prochlorperazine 5-10 mg IV every 4 hours PRN.
□ Prochlorperazine 25 mg suppository PR every 12 hours PRN.
□ Ondansetron 4 mg IV every 4 hours PRN.
□ Dexamethasone 4 mg IV every 12 hours PRN.
Other _____________________________________________________________________.
i. Wound Care
□ Cleanse affected areas with sterile saline PRN.
□ Apply dry absorptive dressing PRN.
□ Apply non adherent gauze if bleeding or if dry dressings adhere PRN.
□ Continue to follow Wound Care Nursing orders.
Other _____________________________________________________________________.
j. Oral Care
□ Moistened swabs PRN.
□ Artificial saliva PRN.
□ Magic Mouthwash (Maalox/Benadryl/Viscous Lidocaine) 5-10 mL swish and swallow
every 6 hours PRN.
□ Baking soda 1 teaspoon in 8 ounces of warm water, 5-15 mL swish and spit PRN.
□ Chlorhexadine oral protocol PRN.
Other____________________________________________________________________.
__________________________ __________ __________ __________
Physician Signature ID Number Date Time
Continued on page 4
END OF LIFE ORDER (#5299) - page 4 of 4 1/21/10 (new)
NEBRASKA PULMONARY SPECIALTIES
Drs. Mansur, Chakraborty, Fiedler, Johnson, Miller, Rudersdorf, Trapp, Reichmuth, Jarrett
k. Bladder Spasm
□ Belladonna/opium (B and O) 1 suppository PR every 8 hours PRN.
□ Oxybutynin 5 mg PO every 12 hours PRN.
Other ____________________________________________________________________.
l. Hiccups
□ Prochlorperazine 10 mg PO every 4 hours PRN.
□ Haloperidol 0.5-2 mg PO or IV every 4 hours PRN.
□ Metoclopramide 10 mg PO or IV every 6 hours PRN (avoid if gastrointestinal obstruction)
Other_____________________________________________________________________.
m. Diarrhea
□ Loperamide 2 mg PO with each loose stool, max dose 16 mg/day.
Avoid if C. difficile colitis is present.
□ Fecal containment bag PRN.
Other _____________________________________________________________________.
n. Constipation
□ Bisacodyl (Dulcolax) PR every 12 hours PRN.
□ Senna 1 tab PO every 8 hours PRN.
Other _____________________________________________________________________.
o. Acid Reflux
□ Aluminum magnesium hydroxide/simethicone 15-30 mL PO every 6 hours PRN.
□ Lansoprazole 30 mg PO every 12 hours PRN.
Other _____________________________________________________________________.
p. Insomnia
□ Zolpidem 5-10 mg PO at HS PRN.
□ Temazepam 15-30 mg PO at HS PRN.
Other _____________________________________________________________________.
q. Pruritis
□ Diphenhydramine 25-50 mg IV or PO every 12 hours PRN.
□ Hydrocortisone 1% cream to affected sites every 6 hours PRN.
□ Loratadine (Claritin) 10 mg PO every 24 hours PRN.
Other _____________________________________________________________________.
r. Dry Eyes
□ Artificial Tears 1-2 drops each eye every hour PRN.
s. Additional Orders
________________________________________________________________________
________________________________________________________________________
t. Place Bereavement Order Set #5302 on chart.
__________________________ __________ __________ __________
Physician Signature ID Number Date Time
COMMITTEE REVIEW DATE: 12/09
Our hospital is considering starting an inpatient palliative care program. I would very much appreciate it if you could email the order sets to me.
Thanks,
Sue Endter, LCSW
Daya LaCavera APN CNS
Maureen Swiderski RN OCNS CHPN
lacaverad@alexian.net