PLACE LABEL HERE

HYPEREMESIS GRAVIDARUM

ADMISSION ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

  1. Diagnosis Admit as Inpatient  IUP at _____ wks. Gestation  Other: ______(reason for admission)

and Place in Observation  IUP at _____ wks. Gestation  Other: ______(reason for observation)

Status: Place in Outpatient  IUP at _____ wks. Gestation  Other: ______(diagnosis)

To: High Risk Pregnancy Unit Other: ______

  1. Consults:Nutrition Servicesto recommend calorie needs and meal plan

Social Work Services evaluation if indicated

 With: ______Concerning: ______ Routine Urgent

  1. Lab/ Diagnostics:

Comprehensive metabolic profile daily

CBC Repeat CBC in 7 days if on heparin or Lovenox (enoxaparin)

Magnesium level daily

 UA daily until ketones negative  Liver function profile  Other: ______

 Glucose monitoring:  FBS q AM  2 hrs postprandial  at Bedtime  at 3 AM  ______

 Ultrasound for ______by:  Radiology  Maternal-Fetal Medicine

  1. Fetal heart tones daily if greater than 12 weeks gestation.  EFM with toco x ______daily
  2. Vital signs q shift (12 hrs)
  3. Obtain daily weights before breakfast
  4. Intake & Output q shift, including emesis
  5. Diet: Hyperemesis diet OR

Consistent carbohydrate gestational diabetic diet, no juice or fruit at breakfastOther: ______

  1. Activity:Up ad lib Darken room and limit visitors  Other: ______
  2. Hygiene:Shower/tubBed bath
  3. If OSA score ≥ 75 or pt history of OSA, initiate OSA in Pregnancy Orders (form # 32839).
  4. Vaccination screening (form # 26423)
  5. Implement Electrolyte Replacement Protocol (form # 21340)
  6. VTE Prophylaxis: Plexi-pulses  with TEDs OR  Sequential Compression Device (SCDs) with TEDs

 Mechanical prophylaxis contraindicated because: ______

SCHEDULED MEDICATIONS:

  1. IV Access Pain: Lidocaine 0.5%, 0.1 ml intradermally prior to IV start per patient request
  2. IV Fluids:LR 1,000 ml with Thiamine (vitamin B1) 50 mg at 500 ml/hr X 2 liters via IV pump, then D5 ½NS 1,000 ml at 125 ml/hr X 2 liters via IV pump, then NS1,000 ml withKCl 20 mEq and Pyridoxine (vitamin B6) 25 mg at 125 ml/hr via IV pump

Add Thiamine (vitamin B1) 100 mg to 1 bag on Day 2 and Day 3 only

Add multivitamins 10 ml plus folic acid 0.4 mg (for a total of 1 mg of folic acid) to 1 bag IV fluids daily

  1. Antiemetics:Zofran (ondansetron) 8 mg IV q 8 hrs

If nausea/vomiting persist, add Reglan (metoclopramide) 10 mg IV q 6 hrs

  1. Pepcid (famotidine) 20 mg IV q 12 hours
  2. VTE Prophylaxis: Must select one option:

 Heparin 5,000 units SQ q 12 hrs (if patient has/had epidural, do not begin heparin until epidural has been out for 2 hrs)

 Lovenox (enoxaparin) 40 mg SQ q 24 hrs at 1700; if CrCl < 30, give 30 mg SQ q 24 hrs (do not begin enoxaparin until epidural has been out for 12 hrs)

 Chemical prophylaxis contraindicated because: ______

  1. Insulin:  Implement Insulin Subcutaneous for Obstetrics orders (form # 21502)
  2. Oral antihyperglycemics: ______
  3. For Blood Glucose < 60, initiate Hypoglycemia Treatment Standing Orders (form # 2513)
  4. Corticosteroids: (if greater than 10 weeks pregnant):  Methylprednisolone 16 mg poor IV q 8 hrs for 3 days; Then call physician for orders to taper dose

PRN MEDICATIONS(See policy 520-06 for range orders and pain intensity guidelines):

  1. Pain/Headache: Tylenol (acetaminophen) 650 mg po or per rectum q 4 hrs prn
  2. Sleep: Ambien (zolpidem) 5-10mg po at HS prn. If 5 mg given, may repeat x 1 dose after 2 hrs.

or  Benadryl (diphenhydramine) 25 - 50 mg po q 4 hrs prn. Cancel Ambien (zolpidem) order.

or Benadryl (diphenhydramine) 12.5 - 25 mg IV q 4 hrs prn. Cancel Ambien (zolpidem) order.

  1. Indigestion:Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
  2. Stool softener: Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
  3. Constipation: Milk of Magnesia (MOM) 30 ml po daily prn

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

*2-17363* FORM 2-17363 REV. 05/2014 Page 1 of 2

PLACE LABEL HERE

HYPEREMESIS GRAVIDARUM

ADMISSION ORDERS

Reference Page

Recommended Thromboprophylaxis for Pregnancies Complicated by Inherited Thrombophilias*
Clinical Scenario / Antepartum Management / Postpartum Management
Low-risk thrombophilia† without previous VTE / Surveillance without anticoagulation therapy or prophylactic LMWH or UFH / Surveillance without anticoagulation therapy or postpartum anticoagulation therapy if the patient has additional risks factors‡
Low-risk thrombophilia† with a single previous episode of VTE—Not receiving long-term anticoagulation therapy / Prophylactic or intermediate-dose LMWH/UFH or surveillance without anticoagulation therapy / Postpartum anticoagulation therapy or intermediate-dose LMWH/UFH
High-risk thrombophilia§ without previous VTE / Prophylactic LMWH or UFH / Postpartum anticoagulation therapy
High-risk thrombophilia§ with a single previous episode of VTE—Not receiving long-term anticoagulation therapy / Prophylactic, intermediate-dose, or adjusted-dose LMWH/UFH regimen / Postpartum anticoagulation therapy or intermediate or adjusted-dose LMWH/UFH for 6 weeks (therapy level should be at least as high as antepartum treatment)
No thrombophilia with previous single episode of VTE associated with transient risk factor that is no longer present—Excludes pregnancy- or estrogen-related risk factor / Surveillance without anticoagulation therapy / Postpartum anticoagulation therapy||
No thrombophilia with previous single episode episode of VTE associated with transient risk factor that was pregnancy- or estrogen-related / Prophylactic-dose LMWH or UFH|| / Postpartum anticoagulation therapy
No thrombophilia with previous single episode of VTE without an associated risk factor (idiopathic)—Not receiving long-termanticoagulation therapy / Prophylactic-dose LMWH or UFH|| / Postpartum anticoagulation therapy
Thrombophilia or no thrombophilia with two or more episodes of VTE—Not receiving long-term anticoagulation therapy / Prophylactic or therapeutic-dose LMWH
or
Prophylactic or therapeutic-dose UFH / Postpartum anticoagulation therapy
or
Therapeutic-dose LMWH/UFH for 6 weeks
Thrombophilia or no thrombophilia with two or more episodes of VTE—Receiving long-term anticoagulation therapy / Therapeutic-dose LMWH or UFH / Resumption of long-term anticoagulation therapy
Abbreviations: LMWH, low molecular weight heparin; UFH, unfractionated heparin; VTE, venous thromboembolism.
*Postpartum treatment levels should be greater or equal to antepartum treatment. Treatment of acute VTE and management of antiphospholipid syndrome are addressed in other Practice Bulletins.
†Low-risk thrombophilia: factor V Leiden heterozygous; prothrombin G20210A heterozygous; protein C or protein S deficiency.
‡First-degree relative with a history of a thrombotic episode before age 50 years, or other major thrombotic risk factors (eg, obesity, prolonged immobility).
§High-risk thrombophilia: antithrombin deficiency; double heterozygous for prothrombin G20210A mutation and factor V Leiden; factor V Leiden homozygous or prothrombin G20210A mutation homozygous.
||Surveillance without anticoagulation is supported as an alternative approach by some experts.

FORM 2-17363 REV. 05/2014 Reference Page Page 1 of 2

PLACE LABEL HERE

HYPEREMESIS GRAVIDARUM

ADMISSION ORDERS

Reference Page

Attachment

Run all IVF on pump

Keep this sheet in the medication section of chart. For reference only. Not a part of the Medical Record.

After each bag is finished, check the checkbox to indicate it has completed. This helps keep track of which bag is due next.

Bag # / IV Fluid
1000 mL / Additives / Rate / Cumm Time
 1 / LR / Thiamine 50 mg / 500 mL/hr / 2 hrs
 2 / LR / Thiamine 50 mg / 500 mL/hr / 4 hrs
 3 / D5 ½ NS / MVI 10 mL, and folic acid 0.4 mg / 125 mL/hr / 12 hrs
 4 / D5 ½ NS / None / 125 mL/hr / 20 hrs
 5 / NS / KCl 20 mEq and Pyridoxine (Vit B6) 25 mg / 125 mL/hr / 28 hrs
 6 / NS / KCl 20 mEq, Pyridoxine (Vit B6) 25 mg, Thiamine 100 mg, MVI 10 mL, and folic acid 0.4 mg / 125 mL/hr / Day 2
 7 / NS / KCl 20 mEq and Pyridoxine (Vit B6) 25 mg / 125 mL/hr
 8 / NS / KCl 20 mEq and Pyridoxine (Vit B6) 25 mg / 125 mL/hr
 9 / NS / KCl 20 mEq, Pyridoxine (Vit B6) 25 mg, Thiamine 100 mg, MVI 10 mL, and folic acid 0.4 mg / 125 mL/hr / Day 3
 10 / NS / KCl 20 mEq and Pyridoxine (Vit B6) 25 mg / 125 mL/hr
 11 / NS / KCl 20 mEq and Pyridoxine (Vit B6) 25 mg / 125 mL/hr
 12 / NS / KCl 20 mEq, Pyridoxine (Vit B6) 25 mg, MVI 10 mL, and folic acid 0.4 mg / 125 mL/hr / Day 4
 13 / NS / KCl 20 mEq and Pyridoxine (Vit B6) 25 mg / 125 mL/hr
 14 / NS / KCl 20 mEq and Pyridoxine (Vit B6) 25 mg / 125 mL/hr
 15 / NS / KCl 20 mEq, Pyridoxine (Vit B6) 25 mg, MVI 10 mL, and folic acid 0.4 mg / 125 mL/hr / Day 5
 16 / NS / KCl 20 mEq and Pyridoxine (Vit B6) 25 mg / 125 mL/hr
 17 / NS / KCl 20 mEq and Pyridoxine (Vit B6) 25 mg / 125 mL/hr
Repeat 15-17 until changed or discontinued

Not a part of permanent medical record.

FORM 2-17363 REV. 05/2014 Reference Attachment Page 1 of 1