Pancreatitis CDU Admission Order Sheet
Orders with a “” are choices and are
NOT ordered unless checked. All may be
altered at physician’s discretion.
Diagnosis: Pancreatitis
1. Admit: CDU
2. Private MD: None 
Time contacted
3.  Consult Dr.
Reason: Pancreatitis
4. Laboratory: CBC, CMP, Amylase, Lipase, and Mg if not done in ER
 Repeat CBC, Amylase, Lipase in 12 Hrs
 Repeat Chem 7 every 6 Hrs
 Other________________________________
5. Radiology:
 Abdominal series: Clinical indication: pancreatitis, rule out small bowel obstruction
 CT abdomen/pelvis: Clinical indication: pancreatitis, rule out pseudo cyst
 Abdominal U/S: Clinical indication: pancreatitis, rule out pseudo cyst, biliary tract disease
6. Vital Signs:  Per routine
 Every ____Hrs
7. I & O recorded every 8 Hours
8.  NG tube to low intermittent suction (if persistent vomiting, obstruction, severe ileus)
9. Notify MD for fever >101, WBC >16,000, Calcium <8mg/dl, unstable vital signs or worsening condition
10. Diet: NPO until vomiting resolves and NGT discontinued, then advance to clear liquid diet
11. Activity:  Bedrest
 BSC
 BRP
 Up ad lib
 Up with assistance
12. IVF____________________________ml/Hr
Scheduled Medications:
13. Pepcid 20 mg IVP every 12 Hrs
14.  Other
15.  Patient may take own home medications:
Home Medication
Dose
Route
Frequency
Indication
PRN Medications:
16. Severe pain:
(Choose one if needed)
 Morphine 1-4 mg IV every 3 Hrs prn
 Dilaudid 0.5-1 mg IV every 3 Hrs prn
 Other: ___________________________________________
17. Moderate pain: (Choose one if needed)
 Lortab 5 mg, 1-2 tablets po every 4 Hrs prn
 Percocet 5 mg, 1-2 tablets po every 4 Hrs prn
 Toradol 30 mg IV (or IM if no IV access) every 6 Hrs prn (if pt >65 years old, give 15 mg)
 Other: ___________________________________________
Orders continued on next page
*3-16352*
3-16352
Seq. # 3-16352 Rev. 8/2005
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Pancreatitis CDU Admission Order Sheet
18. Mild pain/temp
>100.5F/HA:
19. Nausea:
20. Sleep:
21. Indigestion:
22. Stool softener:
23. Constipation:
25. Anxiety:
_______________
Date
Orders with a “” are choices and are
NOT ordered unless checked. All may
be altered at physician’s discretion.
 Tylenol 650 mg po every 4 Hrs
 Other____________________________________
(Choose one if needed)
 Phenergan 6.25 – 25 mg IV every 4 Hrs prn, may use
IM if no IV access
 Zofran 4 mg IV every 8 Hrs prn
 Other_____________________________________________________________
(Choose one if needed)
 Restoril 30 mg po at bedtime prn (7.5 mg if greater than 65 years old, may repeat x 1 dose)
 Ambien 10 mg po at bedtime prn (5 mg if greater than 65 years old, may repeat x 1 dose)
 Other: ____________________________________________________
 Maalox XS 30 ml po four times daily prn
 Other: ________________________________________________________________________
 Colace (docusate) 100 mg po two times daily prn; if no bowel movement.
 Other: ________________________________________________________________________
 Milk of Magnesia (MOM) 30 ml po daily prn
 Other________________________________________________________________________
(Choose one if needed)
 Ativan 0.5-1 mg po every 8 Hrs prn
 Xanax 0.25-0.5 mg po every 6 Hrs prn
 Other: ________________________________________________________________________
________________
Time
_______________________________
Physician Signature
________
MD Number
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