PLACE LABEL HERE
RENAL COLIC (kidney stone)
OBSERVATION 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.
Status:  Place in Observation for: _________________________________ 
2.
Level of Care: Acute Care
3.
4.
 Telemetry: If patient Medical/Surgical, must complete form # 36084
 Isolation:  Contact  Droplet  Airborne For: _________________
5.
Consults:______________________________________________  Notified by physician
Location/Specialty Unit Preference 5 South
______________________________________________  Notified by physician
 CBC
 Urinalysis
 Urine C&S
 Uric Acid
 Other______________________________________________
 KUB in the AM, Reason: Back Pain/Kidney Stone
 KUB at _______ Reason: Back Pain/Kidney Stone
6.
Diagnostics:
7.
Radiology:
8.
Strain all urine
9.
If calculus passed, notify physician; place order in HEO for stone analysis and send calculus to laboratory
for analysis
10. Vital signs per unit routine or q ____ hrs
11. Notify physician if fever > 100°F, persistent pain or obstruction at 8 hr post injection of IV push film
12. Diet:  Clear liquid diet
 Cardiac
13. Activity:  Bed Rest
 Up ad lib
 Full liquid diet  Regular
 Diabetic ______ calorie
 Renal
 Other: _______
 Bedside commode
 Up with assistance
 Bathroom privileges
SCHEDULED MEDICATIONS:
14. IVF:  NS
 LR
 D5NS
 D5 ½ NS with 20 KCl
at ___________ ml/hr
15.  Cipro (ciprofloxacin) 400 mg IV q 12 hrs
or  Cipro (ciprofloxacin) 500 mg po bid
16. VTE Prophylaxis: Initiate Venous Thromboembolism (VTE) Prophylaxis Orders (form # 33058)
 Low risk: No pharmacologic or mechanical prophylaxis, ambulate 3 times daily
 Heparin 5,000 units SQ q 8 hrs (q 12 hrs if wt < 50 kg or age > 75)
or
 Lovenox (enoxaparin) 40 mg SQ daily at 1700 (30 mg if CrCl < 30 ml/min)
and/or  Mechanical devices: SCDs
Order writer’s initials _________
Copy to pharmacy
*3-37201*
FORM 3-37201 REV. 12/2014
Page 1 of 2
PLACE LABEL HERE
RENAL COLIC (kidney stone)
OBSERVATION 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).
PRN MEDICATIONS
See policy 520-06 for range orders and pain intensity guidelines.
17.  Electrolyte Replacement Protocol (form # 21340)
18. Mild Pain, Temp >100.5F, HA:  Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
19. Moderate Pain:
 Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered.
or  If patient can not take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po
q 4 hrs prn intead of Norco. DC if Percocet ordered.
or  Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Norco ordered.
and/or  Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (15 mg if CrCl 31-50, > 65 y/o old or < 50
kg) or 10 mg po q 6 hrs prn (max combined duration of IV and po ketorolac is 5 days). DC if CrCl < 30.
20. Severe Pain (Begin when Epidural or PCA has been discontinued)
 Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered.
or  Dilaudid (HYDROmorphone) 0.25-0.5 mg IV q 3 hrs prn. If CrCl < 30, dose at 0.25 mg. Hold for
excessive sedation. DC if Morphine ordered.
21. Nausea/Vomiting:  Zofran (ondansetron) 4 mg IV or po q 6 hrs prn
 If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)
22. Sleep:
 Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn
23. Indigestion:
 Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
24. Stool Softener:
 Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
25. Constipation:
If no BM after 48 hrs
and/or
 Milk of Magnesia (MOM) 30 ml po daily prn
 Dulcolax (biscodyl) 10 mg per rectum daily prn
 Senokot-S (docusate/senna) 2 tablets po at bedtime nightly
26. Cough:
 Robitussin (guaifenesin) 15 ml po q 4 hrs prn
27. Sore Throat:
 Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn
ADDITIONAL ORDERS:
______________________________________________________________________________________
______________________________________________________________________________________
______________
Date
_______________
Time
_________________________________
Physician Signature
___________
PID Number
Copy to pharmacy
FORM 3-37201 REV. 12/2014
Page 2 of 2