PLACE LABEL HERE
ALLERGIC REACTION
ORDERS
Pediatric Observation
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Intital all handwritten order modifications and the bottom of each pae when indicated (multipage).
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Diagnosis
and Status: Place in Observation ______________________________________________(reason for observation)
Primary Care Physician:  None  ________________________________
Allergies: ___________________________________________________________________________
Weight: ________ kg
Vital signs q ___ hrs x ____, then q 4 hrs
Diet:
 NPO x ______ hrs, then advance as tolerated
 Clear liquids, then advance as tolerated
 Regular for age
Activity as tolerated in room
 Pulse oximetry checks q ____ hrs
 Continuous pulse oximetry
 INT
SCHEDULED MEDICATIONS
10.  IV fluids _____________________ IV at ___________ ml/hr
11. Antihistamine (choose one from each route if needed):
 Benadryl (diphenhydramine) ______ mg po q 6 hrs
 Benadryl (diphenhydramine) ______ mg IV q 6 hrs
 Atarax (hydroxyzine) ______ mg po q 6 hrs
12.  Pepcid (famotidine) ______ po q12 hrs
 Pepcid (famotidine) _______ IV q 12 hrs
13. Steroid (choose one from each route if needed):
 Solu-Medrol (methylprednisolone) _____ mg IV q 6 hrs
 Prednisolone _______ mg po q 12 hrs
 Prednisone _______ po q day
PRN MEDICATIONS
14. Mild Pain/temp >100.5F:
 Tylenol (acetaminophen) ____ mg (consider 15 mg/kg, max 650 mg) po or per rectum q 4 hrs prn
or  Ibuprofen ____ mg (consider 10 mg/kg) po q 6 hrs prn
15. Wheezing:
 Albuterol 2.5 mg per inhalation q _____ hrs prn
 Albuterol 5 mg per inhalation q _____ hrs prn
16. Wheezing, diffuse urticaria with difficult breathing and swallowing: Notify physician, and give:
 EPInephrine 1:1000, 0.15 ml IM x 1 dose prn
 EPInephrine 1:1000, 0.3 ml IM x 1 dose prn
17. Nausea/Vomiting:
 Zofran (ondansetron) _____ mg po q 6 hrs prn
 Zofran (ondansetron) _____ mg IV q 6 hrs prn
18. Itching/Urticaria, GI Reflux:  Zantac (ranitidine) _____ mg po q 12 hrs prn
19. Notify physician if EPInephrine treatments are required, increased work of breathing, difficulty swallowing or altered
level of consciousness
ADDITIONAL ORDERS:
_______________________________________________________________________________________
_______________________________________________________________________________________
______________
Date
___________________
Time
_________________________________
Physician Signature
__________
PID Number
Send copy to pharmacy
*1-27519*
FORM 1-27519 REV. 07/2012
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