PLACE LABEL HERE
ALLERGIC REACTION
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 indicate (multipage).
1. Status:  Place in Observation for: __________________________________
2. Level of Care:  Acute Care
Location/Specialty Unit Preference 5 South
3.  Telemetry: If patient Medical/Surgical, must complete form # 36084
4.  Isolation:  Contact  Droplet  Airborne For: _________________
5.
Consults: ______________________________________________  Notified by physician
______________________________________________  Notified by physician
6.
Diagnostics:
 Chem 7
 CBC
 Other: ___________________________________________________
7.
 CXR,  Portable  PA/Lat Reason: __________________
8.
Respiratory:
 O2 per Protocol (form # 34431)
 Micronephrine (racemic EPInephrine) nebulizer treatment 0.5 ml in NS q 2 hrs prn for stridor
9.
Notify physician for stridor, SaO2 < 90%, SBP < 100 mmHg, RR > 24 BPM
10. Vital signs per unit routine or q ______ hrs
11. Diet:  Regular  Clear Liquids  Cardiac  Diabetic ____ calorie
12. Activity:  Bedrest
 Up ad lib
 Bedside commode
 Renal
 Other: ______
 Bathroom privileges
 Up with assistance
SCHEDULED MEDICATIONS:
13. IVF:  NS
 LR
 D5NS
 D5 ½ NS with 20 KCl
at ___________ ml/hr
14.  Solumedrol (methylprednisolone) 40 mg IV push q 6 hrs
15.  Benadryl (diphenhydramine) 25 mg IVP q 6 hrs
or  Benadryl (diphenhydramine) 25 mg po q 6 hrs
16.  Pepcid (famotidine) 20 mg IV q 12 hrs
or  Pepcid (famotidine) 20 mg po q 12 hrs
17.
VTE prophylaxis, Initiate Venous Thromboembolism (VTE) Prophylaxis Orders (form # 33058)
 Low risk: No pharmacologic or mechanical prophylaxis, ambulate 3 times daily
or
 Heparin 5,000 units SQ q 8 hrs (q 12 hrs if wt < 50 kg or age > 75)
 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
*3-37188*
FORM 3-37188 REV. 12/2014
Page 1 of 2
PLACE LABEL HERE
ALLERGIC REACTION
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 indicate (multipage).
PRN MEDICATIONS See policy 520-06 for range orders and pain intensity guidelines.
18.  Electrolyte Replacement Protocol (form # 21340)
19. Mild Pain, Temp >100.5F, HA:  Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
20. 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.
21. 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.
22. 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)
23. Sleep:
 Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn
24. Indigestion:
 Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
25. Stool Softener:
 Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
26. 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
27. Cough:
 Robitussin (guaifenesin) 15 ml po q 4 hrs prn
28. Sore Throat:
 Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn
ADDITIONAL ORDERS:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________
Date
_______________
Time
_________________________________
Physician Signature
___________
PID Number
Copy to pharmacy
FORM 3-37188 REV. 12/2014
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