General PROVIDER INITIALS: PHYSICIAN ORDERS

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1 Height Weight Allergies If appropriate for patient condition, please consider the following order sets: Initiate Electrolyte Replcement: Med/Surg, Med/Surg Tele Physician Order #842 General Vital Signs [X] Vital signs every 4 hours - During use of Prophylaxis or Taper Regimen [X] Vital signs every 4 hours - During use of Mild/Moderate Alcohol Withdrawal Regimen [X] Vital signs every 2 hours while awake and every 4 hour while sleep - During use of Mild/Moderate Alcohol Withdrawal Regimen Notify Provider [X] Notify provider, Every 4 hours, Starting today, During use of Prophylaxis or Taper Regimen, obtain vital signs and monitor for symptoms of alcohol withdrawal using CIWA-Ar scale every 4 hours, Every 4 hours, Starting today For Until specified, During use of Mild/Moderate Alcohol Withdrawal Regimen obtain vital signs every 4 hours and monitor for symptoms of alcohol withdrawal using Pasero-McCaffery Sedation Score., Every 4 hours, Starting today For Until specified, During use of Mild/Moderate Alcohol Withdrawal Regimen obtain vital signs and monitor for symptoms of alcohol withdrawal using CIWA-Ar scale every 2 hours while awake and every 4 hours while sleep. STAT, Until discontinued, Starting today Respiratory rate greater than: 24 Respiratory rate less than: 10 O2 saturation less than (%): 90 Pulse greater than: 120 Pulse less than: 50 Systolic BP greater than: 160 Systolic BP less than: 90 If seizures present, not arousable, ataxia, slurred/garbled speech, pasero- McCaffery Sedation Score of 3 or greater, maximum lorazepam (Ativan) dose reached and symptoms are not controlled (20 mg for Regimen A, B, C), CIWA-Ar score greater than or equal to 8, blood alcohol level is less than 0.25 g/dl, of upgrade to Regimen A. any CIWA-Ar score greater than 20,and an upgrade to Regimen C. SAH, SCH, SFH, SJMC Nursing Assessments Page 1 of 8

2 [X] Cardiac monitoring [X] Continuous pulse oximetry Highline Nursing Assessment [X] Cardiac monitoring, Until discontinued, Starting today, Monitor for symptoms of alcohol withdrawl using CIWA-Ar scale. GOAL: CIWA-Ar score less than 8. Assess CIWA-Ar score minutes after each IV lorazepam (Ativan) dose, and minutes after each PO dose. Also assess at least: 1. Every 2 hours while patient is awake on Mild/Moderate regimen 2. Every 4 hours during prophylaxis, taper, and while patient is sleeping on Mild/Moderate regimen 3. Every 15 minutes while on Regimen C 4. DISCONTINUE SCORING WHEN TAPER COMPLETE, Until discontinued, Starting today, Monitor for symptoms of alcohol withdrawal using Pasero-McCaffery scale. 1. Every 2 hours while patient is awake 2. Every 4 hours while patient is sleeping 3. DISCONTINUE SCORING WHEN TAPER COMPLETE, Until discontinued, Starting today, If IV lorazepam (Ativan) is initiated., Until discontinued, Starting today Keep O2 saturation greater than or equal to: If IV lorazepam (Ativan) is initiated., Until discontinued, Starting today, Monitor for symptoms of alcohol withdrawl using CIWA-Ar scale. GOAL: CIWA-Ar score less than 8. Assess CIWA-Ar score minutes after each IV lorazepam (Ativan) dose, and minutes after each PO dose. Also assess at least: 1. Every 2 hours while patient is awake on Mild/Moderate regimen 2. Every 4 hours during prophylaxis, taper, and while patient is sleeping on Mild/Moderate regimen 3. Every 15 minutes while on Regimen C 4. DISCONTINUE SCORING WHEN TAPER COMPLETE, Until discontinued, Starting today, Monitor for symptoms of alcohol withdrawal using Pasero-McCaffery scale. 1. Every 2 hours while patient is awake 2. Every 4 hours while patient is sleeping 3. DISCONTINUE SCORING WHEN TAPER COMPLETE, Until discontinued, Starting today, If IV lorazepam (Ativan) is initiated. Nursing Interventions Regimen A = Lorazapam 1mg PO/IV every hour time two doses and then 1mg every 2-4 hours to keep CIWA-Ar score less than 8 for 24 hours, Until discontinued, Starting today, If CIWA-Ar score greater than or equal to 8, and blood alcohol level is less than 0.25 g/dl, upgrade patient to Regimen A and notify physician., Until discontinued, Starting today, When Regimen A is started, discontinue scheduled lorazepam (Ativan) doses (prophylaxis regimen). Page 2 of 8

3 - HOLD lorazepam (Ativan) and Contact Physician for signs of oversedation - CONTINUE lorazepam and contact Physician for elevated vital signs Ancillary Consults [X] Pharmacy general consult - Ativan [X] Inpatient consult to Care Management, Until discontinued, Starting today, If CIWA-Ar score or failed A regimen, upgrade patient to Regimen B., Until discontinued, Starting today, If CIWA-Ar score is greater than 20 or failed Regimen B, upgrade patient to Regimen C. - Notify MD and initiate dosing while arranging immediate transfer to ICU/PCU - Consider initiation of Rapid Response Team - Initiate 1:1 RN monitoring - CIWA-Ar scoring and vital signs every 15 minutes - Cardiac monitoring with continuous Pulse Oximetry - Initiate Alcohol Withdrawal, Severe (for only ICU/PCU only) Physician order #823 STAT, Until discontinued, Starting today, If patient develops any of the following signs of oversedation, HOLD lorazepam (Ativan) and contact physician: - Respirations less than or equal to 10 breaths/minute - Sustained oxygen saturation less than 90% - Heart rate less than 50 beats per minute - Systolic blood pressure less than or equal to 90 mmhg - Not arousalable, ataxia or slurred/garbled speech - Pasero-McCaffery Sedation Score 3 or greater STAT, Until discontinued, Starting today, If patient develops any of the following symptoms/signs, CONTINUE lorazepam (Ativan) and contact physician: - Respirations greater than or equal to 24 breaths/minute - Heart rate greater than 120 beats per minute - Systolic blood pressure greater than or equal to 160 mmhg, Once, Starting today, Verify all prior dose of ativan are discontinued EXCEPT IV dosing for PRN seizures Reason for Consult? To assess potential for admittance to support groups and treatment programs upon discharge RN/Secretary to contact the consulting provider? Yes Labs Chemistry [ ] TPN panel 10 Once, Starting today For Until specified Substance Level IV Fluids IV Fluids [X] IV Fluids Taper, Once, Starting today For 1 Occurrences, If blood alcohol greater than 250 mg/dl, draw blood alcohol level PRN every 4 hours until level is less than 250 mg/dl. Page 3 of 8

4 [X] 1000ml 5% dextrose in 0.45% sodium cloride (D5 1/2 Normal Saline) + Thiamine 100mg + Folic Acid 1mg + Magnesium Sulfate 2 g + MVI [X] 1000ml 5% dextrose in 0.45% sodium cloride (D5 1/2 Normal Saline) + Magnesium Sulfate 2g [X] dextrose 5 % and NaCl 0.45 % infusion Medications Vitamins [ ] Prenatal multivitamin with folic acid 1 PO daily [X] Vitamins [X] Thiamine 100mg IV daily times 2 doses (if not previously ordered) even if included in maintenance IV (May give IM if no IV access) [X] Thiamine 100mg PO daily Antacids [ ] aluminum/magnesium hydroxide & simethicone (MAALOX MAX) oral suspension [ ] Other 100 ml/hr, IntraVENous, Continuous, For 10 Hours 1 bag ONLY. Initiate IV fluids ONLY after first thiamine is given. 100 ml/hr, IntraVENous, Continuous, For 10 Hours 1 bag ONLY. Rountine 100 ml/hr, IntraVENous, Continuous 1 tablet, Oral, Daily, 100 mg, IntraVENous, for 30 Minutes, Daily, Starting today, For 2 Doses Administer Thiamine as soon as possible, especially before any meals or dextrose infusions, in order to avoid precipitation of Wernicke's encephalopathy. STAT 100 mg, Oral, Daily, Starting 6/5/14, 30 ml, Oral, Every 4 hours PRN, indigestion "Shake Well" Do not use if serum creatinine greater than 1.8 mg/dl Antihypertensive (Single Response) ( ) clonidine (CATAPRES) tablet 0.1 mg, Oral, Every 6 hours PRN, other, sweating, itching, nausea, tremors PRN adrenergic symptoms (ie sweating,itching,nausea,tremors). Hold for systolic BP less than 90mmHg. ( ) clonidine (CATAPRES) patch 0.1 mg/24 hr 1 patch, TransDermal, for 7 Days, As needed, other, sweating, itching, nausea, tremors If unable to tolerate oral Clonidine apply patch every 7 days as needed for adrenergic symptoms.. Hold for systolic BP less than 90 mmhg. Antipsychotic [ ] Haloperidol (Haldol) 1mg IV every 30 minutes PRN hallucinations 1 mg, IntraVENous, Every 30 min PRN, other, hallucinations Not to exceed 4mg in 4 hours. Page 4 of 8

5 Benzodiapine Regimens Benzodiazepine Prophylaxis Regimens (Single Response) Consider prophylaxis dosing for positive CAGE score with CIWA-Ar score less than 8. Use low dose prophylaxis regimen if no risk factors. Use high dose prophylaxis regimen for at least one positive risk factor (caution for patients age 65 years and older). Choose One Regimen (X) Benzodiazapine Low Dose Prophylaxis Regimen Consider if positive CAGE score & no risk factors. Discontinue all lorazepam (Ativan) doses written prior to initiation of withdrawal regimen, except IV dosing for PRN seizures. [X] Lorazepam (Ativan) Low dose Prophylaxis 0.5 mg PO every 6 hours times 4 doses [X] Lorazepam (Ativan) Low dose Prophylaxis 0.5 mg PO every 8 hours times 3 doses [X] Lorazepam (Ativan) Low dose Prophylaxis 0.5 mg PO every 12 hours times 2 doses [X] Lorazepam (Ativan) Low dose Prophylaxis 0.5 mg PO every 24 hours times 1 doses ( ) Benzodiazapine High Dose Prophylaxis Regimen 0.5 mg, Oral, Every 6 hours, For 4 Doses 0.5 mg, Oral, Every 8 hours, For 3 Doses 0.5 mg, Oral, Every 12 hours, For 2 Doses 0.5 mg, Oral, Every 24 hours interval, For 1 Doses THEN STOP Page 5 of 8

6 Consider if positive CAGE score & at least 1 positive risk factor. Use caution for patients age 65 years and older. Discontinue all lorazepam (Ativan) doses written prior to initiation of withdrawal regimen, except IV dosing for PRN seizures. [ ] Lorazepam (Ativan) High Dose Prophylaxis Regimen1 mg PO every 6 hours times 4 doses [ ] Lorazepam (Ativan) High Dose Prophylaxis Regimen1 mg PO every 8 hours times 3 doses [ ] Lorazepam (Ativan) High Dose Prophylaxis Regimen1 mg PO every 12 hours times 2 doses [ ] Lorazepam (Ativan) High Dose Prophylaxis Regimen1 mg PO every 24 hours times 1 doses ( ) Alcohol Withdrawal Regimen A - PO Panel 1 mg, Oral, Every 6 hours, For 4 Doses 1 mg, Oral, Every 8 hours, For 3 Doses 1 mg, Oral, Every 12 hours, For 2 Doses 1 mg, Oral, Every 24 hours interval, For 1 Doses THEN STOP Page 6 of 8

7 [ ] LORazepam (ATIVAN) tablet - Regimen (A) PO every 1 hour times 2 doses [ ] LORazepam (ATIVAN) tablet - Regimen (A) PO every 2-4 hours for 24 hours ( ) Alcohol Withdrawal Regimen A - IV Panel Use if patient is NPO or unable to tolerate PO 1 mg, Oral, Every 1 hour, For 2 Doses Regimen A - CIWA-Ar score 8-14 If CIWA-Ar score increases by 2 or more, go immediately to Regimen (B).Max total daily dose of Lorazepam (Ativan) IV is 20 mg. Notify physician if maximum daily dose is reached and symptoms are not controlled. Lorazepam is to be given oral unless patient is NPO or unable to tolerate PO. 1 mg, Oral, As needed, anxiety Regimen A - CIWA-Ar score Give PO Every 2-4 hours to keep CIWA-Ar score less than 8 for 24 hours.[ THEN BEGIN LOW TAPER.] If CIWA-Ar score increases by 2 or more, go immediately to Regimen (B).Max total daily dose of Lorazepam (Ativan) IV is 20 mg. Notify physician if maximum daily dose is reached and symptoms are not controlled. Lorazepam is to be given oral unless patient is NPO or unable to tolerate PO. [ ] LORazepam (ATIVAN) tablet - Regimen (A) IV every 1 hour times 2 doses 1 mg, IntraVENous, Every 1 hour, For 2 Doses Regimen A - CIWA-Ar score 8-14 If CIWA-Ar score increases by 2 or more, go immediately to Regimen (B).Max total daily dose of Lorazepam (Ativan) IV is 20 mg. Notify physician if maximum daily dose is reached and symptoms are not controlled. Lorazepam is to be given oral unless patient is NPO or unable to tolerate PO. Page 7 of 8

8 [ ] LORazepam (ATIVAN) tablet - Regimen (A) IV every 2-4 hours for 24 hours 1 mg, IntraVENous, As needed, anxiety Regimen A - CIWA-Ar score Give IV Every 2-4 hours to keep CIWA-Ar score less than 8 for 24 hours.[ THEN BEGIN LOW TAPER.] If CIWA-Ar score increases by 2 or more, go immediately to Regimen (B).Max total daily dose of Lorazepam (Ativan) IV is 20 mg. Notify physician if maximum daily dose is reached and symptoms are not controlled. Lorazepam is to be given oral unless patient is NPO or unable to tolerate PO. Upgrade Patient to Mild/Moderate Alcohol Withdrawl Regimen - Enter order for Mild/Moderate Alcohol Withdrawal Regimen and UPGRADE patient Regimen [X] Notify provider when Mild/ Moderate Alcohol withdrawal regimen is INITIATED, Once, Starting today For 1 Occurrences, If CIWA-AR score is greater than or equal to 8 and the blood alcohol level is less than 0.25 g/dl, Enter order for Mild/Moderate Alcohol Withdrawal Regimen and UPGRADE patient to Mild/Moderate Alcohol Withdrawal Regimen When Mild/Moderate Alcohol Withdrawal Regimen is started discontinue all Prophylaxis (scheduled) Regimens and/ or current Ativan., Once, Starting today For 1 Occurrences Pulse greater than: Respiratory rate less than: Respiratory rate greater than: Temperature greater than (celsius): Urine output less than (ml/hr): Systolic BP greater than: Systolic BP less than: Diastolic BP greater than: Diastolic BP less than: Other: Date: Time: Printed Name of Ordering Provider: Provider Signature: Date: Time: RN Acknowledged: Page 8 of 8

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