FHS ED 1ST Trimester Pregnancy Vaginal Bleeding/Spotting and/or Pelvic/Abdominal Pain [ ]

Transcription

1 FHS ED 1ST Trimester Pregnancy Pelvic/Abdominal Pain Height Weight Allergies General Vital Signs [222942] [ ] Cardiac monitoring [NUR436], Until discontinued, Starting S For Until specified Nursing Interventions [222943] [X] Set Up for Pelvic Exam [NUR133], Once For 1 Occurrences [ ] Fetal Heart Tones [NUR185], Once For 1 Occurrences [ ] Place ED Ultrasound at Bedside [NUR185], Once For 1 Occurrences [ ] Continuous Pulse Oximetry [NUR586], Until discontinued, Starting S Keep O2 saturation greater than or equal to: Physician Consults [222944] [ ] Inpatient consult to Obstetrics / Gynecology [CON46] REQUIRED Reason for Consult? RN/Secretary to contact the consulting provider? Yes Labs Labs [222927] [X] hcg, quantitative, pregnancy [LAB143] [X] Urinalysis with culture, if indicated [LAB3205] For 1 Occurrences For 1 Occurrences, Urinalysis with Culture if indicated reflex to Urine Microscopic when: cloudy appearance that does not clear when warming, color other than yellow, pale yellow, or colorless, protein present in any amount, blood present in any amount, positive nitrite, positive WBC screen (leukocyte esterase); also Urine Culture when: positive nitrate, positive yeast, leukocyte esterase >Trace, more than 10 WBC's, or bacteria >10 Page 1 of 5 Vaginal Bleeding/Spotting and/or

2 [X] POCT Chemistry 8 Panel [POC347], Once For 1 Occurrences [ ] ABO/Rh type [LAB3185] For 1 Occurrences [ ] Rhogam Workup [222930] [X] rho(d) immune globulin (RHOPHYLAC) injection [38072] [X] Rhogam product order [from Lab] [LAB4104] [X] Rhogam Workup (PSBC) [LAB4161] 300 mcg, IntraMuscular, Once (immunizations), For 1 Doses ASAP For 1 Occurrences, Starting S For 1 Occurrences Rhogam workup is not required, if patient is less than 19 weeks gestation or antepartum [ ] Hepatic function panel (LFT) [LAB20] For 1 Occurrences [ ] CBC and differential [LAB293] For 1 Occurrences [ ] GC/Chlamydia [LAB1376] For 1 Occurrences [ ] Wet prep, genital- Trichomonas [LAB252] For 1 Occurrences [ ] POCT pregnancy, urine [POC7], For 1 Occurrences, Not indicated for women >55 years of age or patients with a history of hysterectomies. [ ] POCT urinalysis dipstick [POC5], For 1 Occurrences [ ] POCT ProTime INR [POC358], For 1 Occurrences [ ] Protime-INR [LAB320] For 1 Occurrences [ ] Type and screen [LAB276] For 1 Occurrences Labs [222932] [ ] hcg, quantitative, pregnancy [LAB143] For 1 Occurrences [ ] Urinalysis with culture, if indicated [LAB3205] For 1 Occurrences, Urinalysis with Culture if indicated reflex to Urine Microscopic when: cloudy appearance that does not clear when warming, color other than yellow, pale yellow, or colorless, protein present in any amount, blood present in any amount, positive nitrite, positive WBC screen (leukocyte esterase); also Urine Culture when: positive nitrate, positive yeast, leukocyte esterase >Trace, more than 10 WBC's, or bacteria >10 Page 2 of 5

3 [ ] POCT Chemistry 8 Panel [POC347], Once For 1 Occurrences [ ] ABO/Rh type [LAB3185] For 1 Occurrences [ ] Rhogam Workup [165783] [ ] rho(d) immune globulin (RHOPHYLAC) injection [38072] 300 mcg, IntraMuscular, Once (immunizations), For 1 Doses [ ] Rhogam product order [from Lab] [LAB4104] ASAP For 1 Occurrences [ ] Rhogam workup [LAB3434], Starting S For 1 Occurrences Rhogam workup is not required, if patient is less than 19 weeks gestation or antepartum [ ] Hepatic function panel (LFT) [LAB20] For 1 Occurrences [ ] CBC and differential [LAB293] For 1 Occurrences [ ] GC/Chlamydia [LAB1376] REQUIRED For 1 Occurrences [ ] Wet prep, genital- Trichomonas [LAB252] REQUIRED For 1 Occurrences [ ] POCT pregnancy, urine [POC7], For 1 Occurrences, Not indicated for women >55 years of age or patients with a history of hysterectomies. [ ] POCT urinalysis dipstick [POC5], For 1 Occurrences [ ] POCT ProTime INR [POC358], For 1 Occurrences [ ] Protime-INR [LAB320] For 1 Occurrences [ ] Type and screen [LAB276] REQUIRED For 1 Occurrences Imaging Imaging [222945] [ ] ED Bedside Ultrasound [IMG ] REQUIRED, 1 time imaging For 1 Occurrences Reason for Exam: Is the patient pregnant? Page 3 of 5

4 [ ] Ultrasound OB Less than 14 weeks Transabdominal Single Gestation [IMG530] REQUIRED, 1 time imaging For 1 Occurrences Reason for Exam: Is the patient pregnant? IV Fluids IV Fluids [222928] [ ] Saline Lock and Flush Panel [ ] [X] sodium chloride 0.9 % syringe [7319] 10 ml, IntraVENous, Once (expires in 36 hours), For 1 [X] Saline lock IV [IVT11] [ ] sodium chloride 0.9% (NORMAL SALINE) bolus [400291], Continuous REQUIRED 1,000 ml, IntraVENous, Once (expires in 36 hours), For 1 Medications 1st TRIMESTER PREGNANCY VAGINAL BLEEDING/SPOTTING and/or PELVIC/ABDOMINAL PAIN [222929] [ ] ondansetron (ZOFRAN-ODT) disintegrating tablet [27697] 4 mg, Oral, Once (expires in 36 hours), For 1 Doses, [ ] ondansetron (ZOFRAN) 4 mg/2 ml injection [106348] IntraVENous, Once (expires in 36 hours), For 1 Doses, [ ] promethazine (PHENERGAN) injection [6618] 12.5 mg, IntraVENous, Once (expires in 36 hours), For 1 [ ] diphenhydramine (BENADRYL) injection [2508] 25 mg, IntraVENous, Once (expires in 36 hours), For 1 [ ] naproxen (NAPROSYN) tablet [5391] 250 mg, Oral, Once (expires in 36 hours), For 1 Doses, [ ] hydromorphone IV [222955] "Followed by" Linked Panel [ ] hydromorphone IV once [420079] 0.5 mg, IntraVENous, Now (expires in 36 hours), For 1 [ ] hydromorphone 0.5 mg IV repeat dose in 30 minutes PRN pain [420079] 0.5 mg, IntraVENous, Once, when indicated (remains on MAR), breakthrough pain, For 7 Days Give at least 30 minutes after first dose Page 4 of 5

5 [ ] morphine IV [ ] "Followed by" Linked Panel [ ] morphine 4 mg IV once [420065] 4 mg, IntraVENous, Now (expires in 36 hours), For 1 [ ] morphine 4 mg IV repeat dose in 30 minutes PRN pain [420065] 4 mg, IntraVENous, Once, when indicated (remains on MAR), pain Give at least 30 minutes after 1st dose [ ] acetaminophen (TYLENOL) tablet [101] 650 mg, Oral, Once (expires in 36 hours), For 1 Doses, DATE TIME ORDERING PROVIDER PRINT NAME PROVIDER SIGNATURE DATE TIME RN ACKNOWLEDGED Page 5 of 5