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