PLACE LABEL HERE
DRUG OVERDOSE
ORDERS
Emergency Department
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.
2.
3.
4.
5.
6.
Diagnosis & Status: Place in Observation for ____________________________ Drug Overdose
Private Physician:  None  ___________________________ Time Contacted: ______________
 Consult _________________________ regarding _________________ Time contacted: ____________
 Mental Health Consult
 Security to watch patient
Laboratory: CBC, CMP and CTS if not done in ED
 Other toxicology studies ____________________
 Repeat Acetaminophen level at 4 hrs post ingestion ______________
 Repeat Salicylate level at 6 hrs post ingestion ___________________
 Other: ____________________________________________________________________________
7. Radiology:  CXR
 KUB Clinical indication: _____________________________
8.  Continuous cardiac monitoring
9.  May be off telemetry for tests and transport
10.  EKG
11.  Pulse oximetry q 8 hrs
12. Vital signs:  per routine
 q ______ hrs
13. Notify physician for abnormal laboratory results or toxicology results, EKG changes or arrhythmias,
abnormal vital signs, uncooperative or agitated patient, or changes in mental status
14. Diet:  NPO
 Clear liquids
 Regular
 Other: ________________________________
15. Activity:  Bedrest
 Bedside Commode  Bathroom privileges
 Up ad lib  Up with assistance
16. IVF _________________________ at ____________________ ml/hr
SCHEDULED MEDICATIONS:
17.  Decontamination: Repeat activated charcoal _________ grams po q 4 hrs X ___________ doses
18.  Tylenol (acetaminophen) overdose: Initiate Acetaminophen Overdose Orders (form # 20583)
19. Antidote __________________________________________________________________________
PRN MEDICATIONS:
20. Nausea:
(Choose one if needed)
 Phenergan (promethazine) 12.5 - 25 mg po or per rectum q 4 hrs prn
 Reglan (metoclopramide) 10 mg po or IV q 6 hrs prn (5 mg if greater than 65 y/o)
 Zofran (ondansetron) 4 mg IV q 6 hrs prn
 Other: ___________________________________________________________
____________ ____________
Date
Time
_______________________________________
Physician Signature
____________
PID Number
Send copy to pharmacy
*1-16344*
FORM 1-16344 REV. 07/2012
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