PLACE LABEL HERE
LASIX (furosemide) for
RENAL SCAN
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).
ALLERGIES: _____________________________________________________________________
1. Start INT
2. Obtain vital signs pre and post administration of Lasix (furosemide)
3. Lasix (furosemide) 0.5 mg/kg IV push over 2 – 3 min
Patient weight = ______ kg x 0.5 mg/kg = _______ mg (maximum dose 40 mg)
4. Remove INT prior to discharge
5. Discharge home if criteria met (Outpatients)
OR
Return to floor (Inpatients)
ADDITIONAL ORDERS:
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Date
___________________
Time
_________________________________
Physician Signature
__________
PID Number
Send copy to pharmacy
*1-33216*
FORM 1-33216 INITIATED 04/2013
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