Draft Order Set – (Source – Ridgeview Medical Center, Waconia)

Pain Control

Mild pain

Acetaminophen 650 mg po every 4 hours as needed for mild pain or fever. (Maximum acetaminophen dose is 4000 mg per day= 6 doses daily)

Acetaminophen 300 mg + codeine 30 mg (Tylenol #3), 1 tablet po every 4 hours as needed for pain. May increase to 2 tablets if ineffective or if pain rated moderate. (Maximum acetaminophen dose is 4000 mg per day= 12 tablets per day)

Ibuprofen 600 mg po every 6 hours as needed for bone pain/muscle aches. Take with food. May also use as needed for fever or malignant bone pain.

Naproxen 250 mg by mouth twice a day for mild pain (maximum dose is 1,500 mg per day)

Tramadol ___ mg (25-100 mg) by mouth 4 times daily as needed for pain (Reduce dose in patients with renal dysfunction: maximum dose 400 mg/day)

Moderate to severe pain

Norco (hydrocodone 5 mg + acetaminophen 325 mg) 1 tablet po every 4 hours as needed for moderate pain. May increase to 2 tablets every 4 hours if ineffective or pain rated severe. (Maximum acetaminophen dose is 4,000 mg per day= 8 tablets)

Norco-10 (hydrocodone 10 mg + acetaminophen 325 mg) one tablet po every 4 hours as needed for moderate or severe pain (Maximum acetaminophen dose is 4,000 mg per day) Notify MD for new orders if ineffective

Percocet (oxycodone 5 mg + acetaminophen 325 mg) 1 tablet po every 4 hours as needed for moderate pain. May increase to 2 tablets every 4 hours if ineefective or pain rated severe. (Maximum acetaminophen dose equals 12 tablets per day)

Percolone (oxycodone immediate release) 5 mg po every 4 hours as needed for severe, breakthrough pain. Notify MD for new orders if ineffective.

Oxycontin (oxycodone controlled release) 10 mg po every 12 hours scheduled. Notify MD if ineffective

MS contin (morphine controlled release) 15 mg po every 12 hoursscheduled. Notify MD if ineffective

Paternal narcotic agents

Morphine 2 mg IV every 5 min as needed for acute, severe, pain. May increase by 2 mg to a max of 10 mg in 1 hour. Notify MD for new orders if ineffective

Dilaudid (hydromorphone) 0.2 mg IV every 5 min as needed for acute, severe pain. May increase by 0.2 mg to a max dose of 2 mg in 1 hour. Notify MD for new orders if ineffective

Buprenex (buprenorphine) 0.15 mg IV every 30 min as needed for acute, severe, pain. May increase by 0.15 mg to a max of 0.6 mg in 2 hours. Notify MD for new orders if ineffective.

Fentanyl 20 mcg IV every 15 minutes as needed for sever pain. Evaluate after each dose

REVERSAL AGENT FOR CNS DEPRESSION (< 6 respirations per minute or obtundation): Naloxone (narcan) 0.4 mg IV. Notify ordering physician or physician on call STAT. May repeat naloxone every 3 minutes until findings reversed.

Malignant bone pain

Consider naproxen or ibuprofen as above or

Dexamethasone___ mg (2-6 mg) by mouth daily for malignant bone pain (maximum dose 6 mg per day) Evaluate after 7 days

Neuropathic Pain Management

Amitriptyline __ mg (10-25 mg) by mouth daily at bedtime as needed for neuropathic pain (Avoid in elderly patients)

Nortiptyline ___ mg (10-25 mg) by mouth daily at bedtime as needed for neuropathic pain (Avoid in elderly patients)

Desipramine ___ mg (10-25 mg) by mouth daily at bedtime as needed for neuropathic pain (Avoid use in elderly patients)

Gabapentin (reduce dose in patients with renal dysfunction)

For elderly patients, 100 mg by mouth daily at bedtime. Titrate up to 100 mg twice daily and then 100 mg 3 times a day as needed for comfort

For non-elderly patient, 100 mg by mouth daily at bedtime. Titrate up to 300 mg twice daily and then 300 mg 3 times a day as needed for comfort

Pregabalin 50 mg by mouth 3 times daily for neuropathic pain. Evaluate in 7 days. (Reduce dose in patients with renal dysfunction)

Transdermal lidocaine patch (1-3 patches) for neuropathic pain. Apply for 12 hours, remove for 12 hours.

Fever- Acetaminophen or ibuprofen as indicated in pain protocol. See pain management protocol

Cough Management

Elevate head of bed to 30 degrees

Add room humidifier

Benzonatate (Tessalon perles) 200 mg by mouth 3 times a day as needed for cough

Lidocaine ___ mg (20 mg in 2 mL premixed) by nebulizer every 4 hours as needed for cough (do not give within 2 hours of eating to decrease aspiration risk)

Promethazine/codeine 6.25 mg/10 mg per 5 mL, 5 mL PO every 4-6 hours as needed for cough.

Dry Eyes/Dry Nose

Artificial tears, 1-2 drops each eye as needed for dry eyes

Saline nasal spray in each nostril as needed for dry nose

Oral Care Management

Topical viscous lidocaine 2% 5 mL every 4 hours by mouth. Swish and spit as needed for mouth pain

Magic mouth wash/hematology mouthwash (viscous lidocaine 2%-60 mL, dipehnhydramine elixir 60 mL, aluminum hydroxide/magnesium hydroxide 60 mL) 1-2 tsp by mouth. Swish and swallow or swish and spit 3-4 times per day as needed for mouth pain

Candida treatment

Clotrimazole 10 mg troche, dissolve in mouth 5 times a day for candida. Discontinue after 14 days of treatment

Nystatin (100,000 units/ 1 mL) 5 mL for candida. Swish and swallow 4 times a day for 7 days, then evaluate

Fluconazole 200 mg by mouth initially for candida, then 100 mg by mouth daily for 7 days, then evaluate

Dyspnea

Add fan to the room

Oxygen 2 liters per minute by nasal canula. Titrate up for comfort (Caution with COPD patients)

Morphine 2.5 mg ___ by mouth ___ sublingual every hour as needed for dyspnea, do not need to order if already treating with morphine for pain management (maximum dose is 10 mg/hour). Evaluate after each dose.

If rales present

Furosemide ___ mg ___ by mouth ____ sublingual every hour as needed for dyspnea (maximum dose is 40 mg/hour)

If wheezing present

Albuterol 2.5 mg in 3 mL by nebulizer every 4 hours as needed for wheezing

Ipratropium 0.5 mg in 3 mL by nebulizer every 4 hours as needed for wheezing

Albuterol + Ipatropium 3 mL by nebulizer every 4 hours as needed for wheezing

Fatigue Management

Dextroamphetamine 5 mg by mouth twice daily for fatigue (maximum dose is 60 mg per day). Evaluate in 7 days

Prednisone ___ mg (7.5-10 mg) by mouth daily for fatigue. Evaluate in 7 days

Megestrol acetate see anorexia/cachexia management

Methylphenidate ____ mg (5-10 mg) by mouth twice daily 30 minutes before breakfast and lunch for fatigue (Maximum dose is 20 mg per day). Evaluate in 7 days.

Hiccup Management

Chlorpromazine __ mg (25-50 mg) ___ by mouth ___ by IV every 6 hours as needed for hiccups

Baclofen 5 mg by mouth every 8 hours as needed for hiccups (reduce dose for patients with renal dysfunction)

Nausea

Droperidol ___ mg (0.625-1.25 mg) IV every 6 hours as needed for nausea/vomiting

Prochlorperazine ___ mg (5-10 mg) by mouth 4 times daily 30 minutes before meals and at bedtime as needed for nausea/vomiting

Prochlorperazine ___ mg by rectal suppository every 12 hours as needed for nausea/vomiting

Promethazine ___ mg (6.25-25 mg) ____ by mouth ____ IV every 6 hours as needed for nausea/vomiting

Agitation, Anxiety, Delirium, Depression

Alprazolam ____ mg (0.25-0.5 mg) by mouth 3 times daily prn anxiety

Escitalopram ____mg (5-10 mg) by mouth daily for depression

Mirtazapine _____mg (7.5-15 mg) by mouth daily for depression

Sertaline 25 mg (25-200 mg) by mouth daily for anxiety or depression

Haloperidol 0.5 mg ___ by mouth ____ subcutaneous ____ IV titrate up to 5.0 mg every hour until a daily requirement is established and then administered in 2-3 divided doses per day as needed for agitation, anxiety, physical aggression with potential harm, or hallucinations or delusions that are causing the patient distress (Maximum dose is 30 mg/day). Evaluate after each dose.

Citalopram ___ mg (10-40 mg) by mouth daily for anxiety or depression

Lorazepam ___ mg (0.25-2 mg) ____ by mouth ____ sublingual ____ IV every 4 hours as needed for anxiety

Anorexia/Cachexia Management

Dexamethasone ___ mg (2-6 mg) by mouth daily for anorexia/cachexia (maximum dose 6 mg per day) Evaluate after 7 days.

Megestrol acetate 160 mg by mouth as needed for anorexia/cachexia (maximum dose 800 mg per day)

Metoclopramide ___ (10-20 mg) by mouth 30 minutes before meals and at bedtime for nausea/vomiting or anorexia/cachexia. (max dose 80 mg every 24 hours)

Constipation/Bowel Care (*Required if opioid use*)

Docusate ___ mg (100-400 mg) by mouth twice daily for constipation (max dose is 800 mg daily)

Senna ____ tablets (1-4 tablets) by mouth twice daily for constipation

Docusate/Senna ___ tablets (1-4 tablets) twice daily for constipation

Bisacodyl ___ mg (5-10 mg) by mouth as needed for constipation (maximum dose is 10 mg per day)

Sorbitol (70%) ___ mL (15-30 mL) by mouth daily as needed for constipation

Glycerin rectal suppository 1 every day as needed for constipation

Magnesium hydroxide (Milk of Magnesia) 30 mL by mouth daily as needed for constipation

Diarrhea Management

Cholestyramine 4 grams by mouth _____ (3-4) times daily for diarrhea

Loperamide 4 mg by mouth initially; then 2 mg after each loose stool (maximum dose is 16 mg daily)

Secretions

□Atropine (1% ophthalmic drops) _____ (1-4) drops sublingual every 2 hours as needed for excess secretions

□Glycopyrrolate _____ (1-2mg)

□By mouth every 8 hours as needed for excess secretions

□Sublingual every 8 hours as needed for excess secretions

□Hyoscyamine _____ (0.125-0.25 mg) sublingual every 6 hours as needed for excess secretions.

□Scopolamine _____ (1.5 mg) transdermal patch behind ear every 72 hours as needed. May increased up to 3 patches in 72 hours.

Seizure Management

□Diazepam _____ (5-10mg) IV every 10-15 min up to 30mg as needed for seizures

□Diazepam _____ (0.2 mg/kg) rectally as needed for seizures. May repeat once in 4 hours as needed to stop seizure. (Maximum is one treatment course every 5 days).

□Lorazepam _____ (2-4) mg IV as needed for seizures. May repeat in 15 minutes as needed if a seizure continues (Maximum 8 mg in 12 hours)

Skin and Wound Management

□Metronidazole (0.75% cream) applied to wound daily for odors. Discontinue after 7 days and assess wound

□Metronidazole 500mg by mouth 3 time a day for odors. Discontinue after 7 days and assess wound.

□Metronidazole 500 mg crushed and sprinkled directly on wound daily for odors. Discontinue after 7 days and assess wound.

□Silver sulfadiazine cream (1%) applied to wound surface daily to control odor. Reassess wound in 7 days.

Ostomy/Wound nurse consult and recommendations for treatment

□Morphine 1 mg in 1 gram hydrogel applied to cover would surface daily for wound pain

Pruritus

□Hydroxyzine _____ (10-25mg) by mouth every 6 hours as needed for irritation.

□Doxepin_____ (10-25mg) by mouth at bedtime for pruritus. Use daily for 7 days, then evaluate.

□Diphenhydramine _____ 25 mg by mouth every 4 hours as needed for itching. Avoid in elderly (Maximum dose is 300 mg per day).

□Camphor/menthol (Sarna) lotion applied as needed for irritation.

□Hydrocortisone 1% cream or lotion applied 2-3 times per day as needed for irritation

□Triamcinolone 0.1% cream applied 2-3 times per day as needed for irritation.

Sleep Disturbance/Insomnia Management

□Temazepam _____ (15 mg) by mouth at bedtime as needed for sleep. May repeat 1 dose

□Trazodone _____ (25-100mg) by mouth at bedtime. May repeat 1 dose (Maximum is 200 mg per day)

□Zolpidem _____ (5-10mg) by mouth at bedtime as needed for sleep

Urinary Incontinence and Retention Management

□Oxybutynin 2.5 (2.5-5 mg) by mouth 2-4 times daily as needed for bladder spasms. (Maximum dose is 20mg/day).

Consults

Dietary Consult

Social Services Consult

Chaplain Consult