Franciscan hospice

PLEASE REVIEW. LINE OUT AND INITIAL ANY UNWANTED ORDERS.
PATIENT NAME:
PRIMARY PHYSICIAN NAME:
GENERAL ORDERS
• May administer medication rectally, topically, or via feeding tube if unable to take medications orally
• May hold medications/treatments if death is imminent • If patient has signs and symptoms of UTI, obtain a urine sample and request the lab perform a urinalysis with a culture • Insert retention catheter as needed, replacing each month. Irrigate with 50ml of sterile normal saline as needed. • Artificial tears as needed for dry eyes • Artificial saliva as needed for dry mouth • Triple Antibiotic ointment topically 2 times daily to minor skin scratches and/or abrasions
• Thick-It – Slowly mix the recommended amount with liquids to form nectar, honey, or pudding consistency
• Permission to release the body to funeral home PAIN – Pain Level 1- 4 And/Or As Adjuvant To Opioid Therapy (Contact Primary Prescriber If Pain Over 4)
Oral Medication
1
Acetaminophen (Tylenol) 325 mg orally or 650 mg rectally every 4 hours as needed, not to exceed total dose of 2000
mg per day. If ineffective or not tolerated go to # 2.
2. Ibuprofen (Motrin) 400 mg orally every 4 hours. May increase to 600 mg every 4 hours for unrelieved pain. Maximum
Topical Medication (For Patient Unable To Take Oral Anti-Inflammatories)
1. Ketoprofen 10% Pluronic-Lecithin Oil Gel (PLO) – Apply 1 ml topically to inner wrist every 6 hours. If ineffective or
2. Ketoprofen 10%/Prednisone 1.25% Pluronic-Lecithin Oil Gel (PLO) – Apply 1 ml topically to inner wrist every 6
ANXIETY / TERMINAL RESTLESSNESS
Lorazepam
(Ativan) 0.5 mg 1-2 tablets orally/sublingually or Lorazepam (Ativan) PLO 1 mg topically every hour if
needed. If not comfortable after 2 doses, call Hospice. DO NOT exceed 2 mg orally in 4 hours. If ineffective or not
tolerated, discontinue Lorazepam and contact primary prescriber.
DELIRIUM
Haloperidol
(Haldol) 1 mg orally or Haloperidol PLO 2 mg topically, may repeat in 1 hour, then every 4 hours if
needed. If ineffective or not tolerated, contact primary prescriber. FEVER – Greater Than 102° Fahrenheit
Oral Medication
1. Acetaminophen (Tylenol) 325 mg orally or 650 mg rectally every 4 hours as needed, not to exceed total dose of 2000
mg per day. If ineffective or not tolerated go to #2. 2. Ibuprofen (Motrin) 400 mg orally every 6 hours as needed
Topical Medication (For patient unable to take oral antipyretic)
Ketoprofen 10% PLO – Apply 1 ml topically to inner wrist every 6 hours
OXYGEN THERAPY
• Obtain pulse oximetry to assess need for oxygen (89% or less on room air/activity)
• Obtain pulse oximetry to establish effectiveness of therapy for patients on oxylite (oxygen conservation device, OCD). If oxygen saturation goes below 89% with activity, may increase in 1 liter increments. If the need is greater than 4 liters per minute and still below 89% saturation, replace oxylite (OCD) with a continuous flow portable. • Oxygen 2 liters per minute continuously via nasal cannula. May increase to 3 liters per minute continuously for unrelieved dyspnea. If dyspnea remains unrelieved, increase to 4 liters per minute continuously. Patient may use oxygen intermittently. WHITE to MD for signature, then to medical record YELLOW to medical record, replaced by white when signed by MD PINK to originator. PHYSICIAN ORDERS
FRANCISCAN HOSPICE (NOT FOR
HOSPITAL USE)
PATIENT NAME:
SECRETIONS: ORAL/PHARANGEAL
Excess Secretions
1. Atropine Sulfate 1% ophthalmic solution – Instill 2 drops sublingually every 4 hours if needed for secretions. If
2. Hyoscyamine (Levsin) 0.25 mg orally or sublingually every 4 hours if needed (maximum daily dose -1.5 mg or 12
tablets). If ineffective or not tolerated contact primary prescriber. 3. Glycopyrrolate (Robinul) 0.4 mg subcutaneously or intravenously every 4 hours if needed for secretions (Hospice
House only)
Thick Secretions
1. Guaifenesin (Robitussin) 400 mg (400 mg/20 ml) orally every 4 hours as needed. If ineffective or not tolerated go to # 2.
2. Guaifenesin (Mucinex) 600 mg sustained release, 1 tablet orally every 12 hours. May increase to 1200 mg sustained
release orally every 12 hours if 600 mg dose ineffective. If ineffective after 48 hours or not tolerated go to # 3. 3. 0.9% sodium chloride (Normal Saline) 2.5 ml in a small volume nebulizer every 4 hours
4. If no relief after 72 hours, contact primary prescriber
Albuterol unit dose (2.5 mg/3 ml) every 4 hours as needed. If ineffective or not tolerated go to # 2.
ipratropium bromide (Atrovent) unit dose (0.5 mg/2.5 ml) every 4 hours if needed. Use with
Albuterol. If ineffective or not tolerated, contact primary prescriber.
RESPIRATORY DISTRESS with lung crackles
Furosemide
40 mg orally times 1 dose. Assess effectiveness and contact primary prescriber. COUGH
1. Guaifenesin/Dextromethorphan (Robitussin DM) (100 mg/10 mg/5 ml), 10 ml orally every 4 hours as needed for
cough. May increase to 20 ml orally every 4 hours as needed if 10 ml dose ineffective or not tolerated. Maximum dose of 60 ml/day. If ineffective or not tolerated go to # 2. 2. Benzonatate
(Tessalon
Perles)100 mg orally three times daily. May increase to 200 mg three times daily if 100 mg
dose ineffective. Maximum dose of 600 mg/day. If ineffective or not tolerated, contact primary prescriber. SLEEP DISTURBANCE
Temazepam
(Restoril)
15 mg orally each night at bedtime. May repeat in one hour if still awake. If ineffective or not NAUSEA AND VOMITING
1. Prochlorperazine (Compazine) 10 mg orally every 6 hours as needed. If unable to tolerate oral medications give 25
mg suppository per rectum every 12 hours as needed. If ineffective or not tolerated go to # 2. 2. Haloperidol (Haldol) 0.5 mg orally, or Haloperidol PLO 1 mg topically, two times daily if needed for nausea. If
ineffective or not tolerated, contact primary prescriber. HICCOUGH
1. Chlorpromazine (Thorazine) 25 mg orally every 6 hours if needed. If ineffective or not tolerated go to # 2.
2. Baclofen 5 mg orally three times daily if needed. If unable to tolerate oral medications use Baclofen PLO 10 mg
topically three times daily if needed. If ineffective or not tolerated, contact primary prescriber. STOMATITIS
May use a mixture of diphenhydramine (Benadryl), Viscous Lidocaine, and Formulary Antacid in a
1:1:1 solution - Swish and swallow 5 ml every 4 hours if needed. DO NOT exceed 5 doses per day.
WHITE to MD for signature, then to medical record YELLOW to medical record, replaced by white when signed by MD PHYSICIAN ORDERS
FRANCISCAN HOSPICE (NOT FOR
HOSPITAL USE)
PATIENT NAME:
CANDIDIASIS
Oral:
Nystatin
suspension
– Swish and swallow 5 ml (500,000 units) 4 times daily for 7 days Cutaneous:
Clotrimazole
cream – Apply topically to affected area 2 times daily for 7 days
Vaginal:
Clotrimazole
– Insert 1 applicatorful vaginally each night at bedtime for 7 nights PRURITIS
1. Sarna lotion, or equivalent – Apply topically 2 times daily to affected area. If ineffective or not tolerated go to # 2.
2. Hydroxyzine (Vistaril) 25 mg orally 3 times daily as needed. Not for use in patients age 65 and over.
3. May
Sarna lotion, or equivalent, in combination with hydroxyzine (Vistaril)
SKIN IRRITATION
Calmoseptine
ointment, or equivalent – Apply topically 2 to 4 times daily if needed or after incontinent episode
BOWEL REGIME (if no other regime is in place) PRN with initiation of opioids or constipation
1. Begin with gentle laxative: senna (Senokot) 8.6 mg orally, 1-4 tablets 2 times daily as recommended below:
• Give1 tablet per 4 mg of hydromorphone (Dilaudid), 30 mg morphine, 30 mg oxycodone, or
50 mcg fentanyl (Duragesic)
2. If needed secondary to hard stools, add docusate sodium (Colace) 250 mg orally two times daily
3. If no bowel movement in any 48 hour period, add:
A. Milk of Magnesia (MOM) 30-60 ml two times daily. If ineffective or not tolerated go to # B.
B. Bisacodyl (Dulcolax) 10 mg per rectum
4. If no bowel movement by 72 hours, and no bowel impaction present, give phosphate enema times 1. If ineffective,
BOWEL IMPACTION
1. If stool is soft enough, manually disimpact patient. If ineffective or not tolerated go to # 2.
2. Soften
Mineral oil retention enema, then manually disimpact patient. Follow with a Phosphate enema for
cleansing of oil retention enema times 1. If ineffective, contact primary prescriber. DIARRHEA
1. Loperamide (Imodium) 2 mg, 2 capsules orally every 2 hours as needed or after each diarrhea stool up to 8 capsules
in 24 hours. If ineffective go to step # 2. 2. Diphenoxylate 2.5 mg/Atropine 0.025 mg (Lomotil) – 2 tablets orally every 6 hours or after each diarrhea stool.
DO
INDIGESTION/
1. Formulary
30 ml orally every hour if needed for nausea/indigestion. Maximum total dose of 210 ml/24 hours. If ineffective or not tolerated go to # 2. 2. Simethicone
80 mg orally four times daily if needed, after meals and at bedtime WHITE to MD for signature, then to medical record YELLOW to medical record, replaced by white when signed by MD PHYSICIAN ORDERS
FRANCISCAN HOSPICE (NOT FOR
HOSPITAL USE)
PATIENT NAME:
INTRAVENOUS CATHETER CARE
1. PICC or Midline catheter
A.
Heparinized
• IN USE – Flush each lumen with 10 ml 0.9% sodium chloride (Normal Saline), then infuse
medication, then flush with 10 ml 0.9% sodium chloride (Normal Saline), finally flush with 2.5 ml of
10 unit/ml Heparin. 0.9% sodium chloride and Heparin will be drawn up in a 10 ml or larger syringe.
• NOT IN USE – Flush each lumen daily with 2.5 ml 10 unit/ml Heparin drawn up in a 10 ml or larger syringe
B. Groshong
• IN USE – Flush each lumen with 10 ml 0.9% sodium chloride (Normal Saline), then infuse medication, then
flush with 10 ml 0.9% sodium chloride (Normal Saline), finally flush with 5 ml 0.9% sodium chloride (Normal
Saline). 0.9% sodium chloride will be drawn up in a 10 ml or larger syringe.
• NOT IN USE – Flush each lumen every 7 days with 5 ml 0.9% sodium chloride (Normal Saline) drawn up in a
2. Hickman
Catheter
• IN USE – Flush each lumen with 10 ml 0.9% sodium chloride (Normal Saline), then infuse medication, then flush
with 10 ml 0.9% sodium chloride (Normal Saline), finally flush with 2.5 ml 100 unit/ml Heparin. 0.9% sodium
chloride and Heparin will be drawn up in 10 ml or larger syringe.
• NOT IN USE – Flush each lumen daily with 2.5 ml 100 unit/ml Heparin drawn up in a 10 ml or larger syringe
- Dressing change daily for first 14 days after placement, then 3 times per week 3. Portacath
• IN USE – Flush with 10 ml 0.9% sodium chloride (Normal Saline), then infuse medication, then flush with 10 ml
0.9% sodium chloride (Normal Saline), finally flush with 5 ml of 100 unit/ml Heparin. 0.9% sodium chloride and
Heparin will be drawn up in 10 ml or larger syringe.
• NOT IN USE – Flush monthly with 5 ml 100 unit/ml Heparin drawn up in a 10 ml or larger syringe
I, ________________RN, have received preliminary authorization from _____________________MD, to initiate the above pre-printed orders, pending the review and return of signed pre-printed orders by the patient’s primary physician. Patient Name:
NOTE: Please review these orders, appropriately modify for the individual patient, date, time and sign below.
If upon a thorough clinical assessment the Licensed Nurse determines the greater dose is necessary to
adequately manage the patient’s condition, the medication may be administered in the higher dose initially
or for subsequent doses.

Another brand of drug, identical in form and content, may be dispensed unless checked. … WHITE to MD for signature, then to medical record YELLOW to medical record, replaced by white when signed by MD PHYSICIAN ORDERS
FRANCISCAN HOSPICE (NOT FOR
HOSPITAL USE)

Source: http://fhs.ecrossingsmedia.com/uploadedFiles/For_Physicians/Provider_Orders/PHYORDER.140.pdf