REFERENCE. Admit to: Program/Service: Diagnosis: Droplet/ Contact Airborne/ Contact

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1 Weight (kg) REFER TO THE ALLERGY SCREEN IN MEDITECH FOR ALLERGY INFORMATION To complete the order form, fill in the required blanks and/or check the appropriate boxes. To delete orders, draw one line through the item and initial. Admit to: Program/Service: Diagnosis: Infection Control Precautions: Date: Time: Contact Airborne THIS PPO MUST BE FAXED TO PHARMACY Droplet/ Contact Airborne/ Contact Initial Clinical Institute Withdrawal Assessment Alcohol (CIWA-Ar) Score (refer to page ): Initial Sedation Score (refer to page 4): Consults: Psychiatry OT Re: Dietitian: assess and implement nutrition therapy Other: Diet: Regular Diet Other Diet: Activity: AAT, Ambulation with assistance if Clinical Institute Withdrawal Assessment Alcohol (CIWA-Ar) is less Assessments and Monitoring: Vital signs (Temp, HR, RR, BP, SpO), CIWA-Ar score and sedation score Vital signs q1h if on PO diazepam or SL LORazepam until CIWA-Ar score is less for two consecutive assessments and then vital signs q4h and PRN Vital signs q 0 minutes if on IV diazepam or IV LORazepam until CIWA-Ar score is less for two consecutive assessments and then vital signs q4h and PRN Titrate O to keep SpO greater than or equal to 9% or Notify RT if O requirements exceed FiO greater than 40% or L/minute Intake and Output q shift Initial Lab Investigations (if not already done): CBC, Lytes, Glucose (GLU), Creatinine, GGT, Mg, PO4, Corrected Calcium (includes Calcium and Albumin), AST, ALT, ALP, Bilirubin (TBILI) Blood Alcohol (ETHYL), Serum osmolality (OSMO) Urine Drug Screen (URDRUGSCR) Other: PT Re: SW Re: Capillary glucose q INR, PT, aptt (PTT) before each dose of diazepam or LORazepam IV Fluids: Saline Lock 0.9% NaCl / + 1/ DW Other: Rate: ml/h for hours then then Saline Lock Additive: With 0 mmol KCl/L of IV fluid With 40 mmol KCl/L of IV fluid Other: Discontinue IV when drinking well. Other: Complete additional orders on page PRESCRIBER SIGNATURE 00 D HR (December/01) Page 1 of

2 Clinical Institute Withdrawal Assessment Alcohol (CIWA-Ar) Score Nausea & Vomiting: Ask Do you feel sick to your stomach? Have you vomited? 0 No nausea & no vomiting 1 Mild nausea with no vomiting 4 Intermittent nausea & dry heaves 7 Constant nausea, frequent dry heaves Tremor: Ask patient to extend arms and spread fingers apart. Observation: 0 No tremor 1 Tremor not visible but can be felt, finger tip to finger tip 4 Moderate tremor with arms extended 7 Severe tremor, even with arms extended Paroxysmal sweats: Observation 0 No sweat visible 1 Barely perceptible sweating; palms moist 4 Beads of sweat obvious on forehead 7 Drenching sweats Anxiety: Ask Do you feel anxious? 0 No anxiety 1 Mildly anxious 4 Moderately anxious or guarded, so anxiety is inferred 7 Equivalent to acute panic states as occur in severe delirium or acute schizophrenic reactions Agitation: Observation 0 Normal activity 1 Somewhat more than normal activity 4 Moderately fidgety and restless 7 Paces back and forth during most of the interview or constantly thrashes about Tactile Disturbances: Ask Do you have any itching, pins-&-needles sensations, burning, or numbness, or do you feel like bugs are crawling on or under your skin? 0 None 1 Very mild itching, pins-&-needles, burning or numbness sensations Mild itching, pins-&-needles, burning, numbness sensation Moderate 4 Moderately severe hallucinations Severe hallucinations Extremely severe hallucinations 7 Continuous hallucinations Auditory Disturbances: Ask Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing you? Are you hearing things you know are not there? 0 Not present 1 Very mild harshness or ability to frighten Mild harshness or ability to frighten Moderate harshness or ability to frighten 4 Moderately severe hallucinations Severe hallucinations Extremely severe hallucinations 7 Continuous hallucinations The Clinical Institute Withdrawal Assessment Alcohol (CIWA-Ar) is a quantification score of patients who are at high risk for developing alcohol withdrawal and or the development of seizures and delirium. Scores of less than 10 usually are not at risk Scores of indicate moderate withdrawal Scores of greater than or equal to 1 indicate severe withdrawal Visual Disturbances: Does the light appear to be too bright? Is its colour different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there? 0 Not present 1 Very mild sensitivity Mild sensitivity Moderate sensitivity 4 Moderately severe hallucinations Severe hallucinations Extremely severe hallucinations 7 Continuous hallucinations Headache, Fullness in Head: Does your head feel different? Does it feel like there is a band around your head 0 Not present 1 Very mild Mild Moderate 4 Moderately severe Severe Very severe 7 Extremely severe Orientation & Clouding of Sensorium: 0 Orientated and can do serial additions 1 Cannot do serial additions or is uncertain about rate Date disorientation by no more than calendar days Date disorientation by more than calendar days 4 Disorientated for place and/or person Total Score = 00 D HR (December/01) Page of

3 Weight (kg) REFER TO THE ALLERGY SCREEN IN MEDITECH FOR ALLERGY INFORMATION To complete the order form, fill in the required blanks and/or check the appropriate boxes. To delete orders, draw one line through the item and initial. Medication Orders: Prior to instituting medication orders review for possible medication interactions with benzodiazepines and consider discontinuing or reducing the dose of other classes of sedatives or narcotics. If patient greater than years of age in addition to using LORazepam as per the chart below consider reducing the dose. Notify MRP if there are THREE consecutive CIWA-Ar scores greater than 10, despite 1 hours of therapy (may give next dose of Diazepam or LORazepam) Notify MRP if patient experiences RR less than 10, systolic BP less than 90 mmhg, sedation score of 4 or shows new presence of jaundice. Discontinue Diazepam, LORazepam, Haloperidol if CIWA-Ar is less than 10 for 4 hours. Date: Patients Initial CIWA-Ar Score Less than years of age Greater than years of age Severe liver disease Severe asthma Respiratory failure Diazepam 10 mg PO/IV q1h PRN to maintain CIWA-Ar score of less greater than LORazepam mg SL/IV q1h PRN to maintain CIWA-Ar score of less greater than Time: Initial CIWA-Ar Score 1 or greater Diazepam 0 mg PO/IV STAT then 10 mg PO/IV q0 minutes PRN to maintain CIWA-Ar score of less greater than LORazepam 4 mg SL/IV STAT then mg IV/SL q0 minutes PRN to maintain CIWA-Ar score of less greater than ** Maximum Diazepam dose is 00 mg in 4 hours ** Maximum LORazepam dose is 0 mg in 4 hours Thiamine 100 mg PO/IV daily x days ( doses total) Multivitamin 1 tablet PO daily Renal Multivitamin 1 tablet PO daily For severe hallucinations/ or agitation: Haloperidol mg PO/ IM/ IV q1-4h PRN until sedated for a maximum of doses/day Note: Haloperidol lowers seizure threshold. Use with caution in first three days. Give doses of diazpeman 0 mg as seizure prophylaxis unless sedation score greater than Venous Thromboembolism Prophylaxis: If not ordered Day 1, MD to reassess starting DVT prophylaxis hospital day Dalteparin,000 units Subcutaneous daily Dalteparin,00 units Subcutaneous daily (if greater than 80 years old or weight less than 40 kg) Heparin,000 units Subcutaneous q8h If Heparin ordered: CBC, APTT, Creatinine prior to initiating therapy if not already ordered and CBC weekly while on therapy Anti-thrombotic compression stockings (if pharmacological prophylaxis contraindicated and reassess for pharmacological prophylaxis daily.) Specify Reason: No DVT Prophylaxis (Specify Reason): Fully mobile Expected length of stay less than days and non-surgical Other: Any history of alcohol withdrawal related seizure Diazepam 0 mg PO/IV q1h x doses greater than Diazepam 10 mg PO/IV q0 minutes PRN to maintain CIWA-Ar score of less greater than LORazepam 4 mg SL/IV q1h x doses greater than LORazepam mg IV/SL q0 minutes PRN to maintain CIWA-Ar score of less greater than Complete additional orders on page PRESCRIBER SIGNATURE 00 D HR (December/01) Page of THIS PPO MUST BE FAXED TO PHARMACY

4 Sedation Score Assessment Documented Recommended Action Level of Sedation S 1 4 Sleep, easy to arouse Alert, easy to arouse Occasionally drowsy, easy to arouse Frequently drowsy, falls asleep mid-sentence Somnolent, difficult to arouse No action No action No action Increase monitoring and hold benzodiazepines Hold benzodiazepines and notify MRP 00 D HR (December/01) Page 4 of

5 Weight (kg) REFER TO THE ALLERGY SCREEN IN MEDITECH FOR ALLERGY INFORMATION To complete the order form, fill in the required blanks and/or check the appropriate boxes. To delete orders, draw one line through the item and initial. Hypoglycemia Management Blood glucose testing if patient exhibits signs or symptoms of hypoglycemia PATIENT IS ABLE TO SWALLOW If blood glucose is between.8mmol/l - 4 mmol/l: Give 4 glucose tablets (1mg total)or 17 ml of juice If blood glucose is less than.8 mmol/l: Give glucose tablets (0mg total) OR ml of juice Recheck blood glucose in 1 min and repeat above treatment x 1 if blood glucose remains less than 4 mmol/l Notify MD to reassess glucose lowering therapy PATIENT IS UNABLE TO SWALLOW If blood glucose is less than 4 mmol/l With IV access: Give D0W 0 ml IV push Without IV access: Give Glucagon 1 mg subcutaneous or IM Recheck blood glucose in 1 min Notify MD if blood glucose remains less than 4 mmol/l Additional Orders: Date: Time: PRESCRIBER SIGNATURE 00 D HR (December/01) Page of THIS PPO MUST BE FAXED TO PHARMACY

6 THIS PAGE BLANK IS 00 D HR (December/01) Page of

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