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PALLIATIVE CARE (ADULT 0609)
PALLIATIVE CARE (ADULT 0609)
Page 1 of 7
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This is a stand alone module and should not be used with an Admission module
General Orders
Other_________________________________________________________________________ Patient Category Status_____________________________________________________________ Assess for signs of inadequate symptom control every 1 to 4 hours as needed Nursing to place completed document on chart Consult Pastoral Care to assist patient/family with completion Nursing to place completed document on chartConsult Pastoral Care to assist patient/family with completion Vital Signs
Every____________hours as agreed upon by patient or family IV Fluids
________________at_______________milliliter/hour Physician's Signature
Print Name:
PALLIATIVE CARE (ADULT 0609)
PALLIATIVE CARE (ADULT 0609)
Page 2 of 7
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Activity
Out of bed as toleratedOut of bed to chair Up with assistanceOther___________________________________________________________________________ Regular DietComfort Feedings_________________________________________________________________ Enteral Nutrition___________________________________________________________________ Other___________________________________________________________________________ Discontinue the Following Medications/Therapies (LEAVE INTRAVENOUS LINE UNLESS
OTHERWISE ORDERED)
Daily labs/weightsFingerstick glucose checksPulse oximetry Vasopressor/Vasoactive medicationsNeuromuscular blockers Physician's Signature
Print Name:
PALLIATIVE CARE (ADULT 0609)
PALLIATIVE CARE (ADULT 0609)
Page 3 of 7
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) are active orders. Items with a ( ) must be checked to become an active order.
Symptom Control
Dyspnea (Shortness of Breath or Air Hunger)
morphine sulfate 2-5 milligram intravenously every 30 minutes as needed for shortness of breath Mouth Ulcers/Pain
Magic Mouthwash 15 milliliter swish and swallow every 4 hours as needed for mouth pain Constipation
lactulose 15 milliliter orally every 8 hours as needed for constipation bisacodyl 10 milligram suppository rectally every 12 hours as needed for constipationdocusate sodium 100 milligram orally 2 times a day Fleets enema rectally every 8 hours as needed for constipation methylnaltrexone 4 milligram subcutaneously every other day as needed for constipation(less than 38 kilogram) methylnaltrexone 8 milligram subcutaneously every other day as needed for constipation(38 kilogram - 61 kilogram) methylnaltrexone 12 milligram subcutaneously every other day as needed for constipation(62 kilogram - 114 kilograms) methylnaltrexone 16 milligram subcutaneously every other day as needed for constipation(greater than 114 kilograms) Upper Airway Secretions
glycopyrrolate 0.1-0.2 milligram intravenously every 6 hours as needed for secretions
(MAX DOSE: 0.8 MILLIGRAMS/DAY)
scopolamine 1.5 milligram disc applied topically every 72 hours as needed for secretions
(Remove old patch when replacing with new one)
atropine 1% eye drops 2 drop sublingually every 3 hours as neeeded Nausea and Vomiting
In patients with suspected bowel obstruction, do not use metoclopramide. Consider the use ofhaloperidol instead.
Renal adjustment (metoclopramide) 5 milligrams (Creatinine Clearance (CrCl) less than 40 mL/min) metoclopramide 5 milligram intravenously every 6 hours as needed for nausea/vomiting metoclopramide 5 milligram orally every 6 hours as needed for nausea/vomitingmetoclopramide 10 miligram intravenously every 6 hours as needed for nausea/vomiting metoclopramide 10 milligram orally every 6 hours as needed for nausea/vomiting Physician's Signature
Print Name:
PALLIATIVE CARE (ADULT 0609)
PALLIATIVE CARE (ADULT 0609)
Page 4 of 7
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Symptom Control (continued)
Nausea and Vomiting (continued)
dexamethasone 4 milligram intravenously every 6 hours as needed for nausea/vomiting diphenhydrAMINE 200 milligram/lorazepam 8 milligram/dexamethasone 20 milligram (B.A.D. pump)in NaCl 0.9% 40 milliliter intravenously at 4 milliliter/hour ondansetron 4 milligram intravenously every 4 hours as needed for nausea/vomiting ondansetron odt 8 milligram sublingually every 6 hours as needed for nausea/vomitingABHR (lorazepam, diphenhydramine, haloperidol, metoclopramide) topical gel 1 mL to inner wristevery 4-6 hours as needed for nausea and vomiting. For GHS inpatients ONLY.
Physician instructions for obtaining ABHR Gel:
A written outpatient prescription is required (bundled).
Complete and deliver to Central Pharmacy (ground floor level at Memorial Campus).
Do NOT scan or fax outpatient prescription
Write for refills (5 suggested) so that GHS Pharmacy may obtain a resupply if needed
during hospitalization
NOTE: ABHR prescription must be compounded from an outside pharmacy; a delay up to
72 hours or longer should be expected in order to obtain the product for inpatient use
Nursing Instructions for administering ABHR Gel:
ABHR is to be administered topically to inner wrist
Gloves must be worn when applying the product on the patient
Do not cover medication administration site after application
ABHR gel to be continued upon discharge and any remaining supply to be sent home with patient,UNLESS discontinuation order written and scanned to Pharmacy during hospitalization Do NOT continue ABHR gel upon discharge and do NOT send remaining supply home with patient Agitation
haloperidol 0.5 milligram-5 milligram intravenously every hour as needed for agitation haloperidol 0.5 milligram-5 milligram orally every hour as needed for agitation LORazepam 0.5 milligram-2 milligram intravenously every 2 hours as needed for agitation LORazepam 0.5 milligram-2 milligram tablet orally or sublingually every 2 hours as needed for agitation Physician's Signature
Print Name:
PALLIATIVE CARE (ADULT 0609)
PALLIATIVE CARE (ADULT 0609)
Page 5 of 7
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) are active orders. Items with a ( ) must be checked to become an active order.
Symptom Control (continued)
Pain: SET PAIN GOAL (USE NUMERICAL RATING SYSTEM (NRS))
Refer to Opiate Dose Conversions (Equianalgesic Dosing) as needed (bundled) Print PCA Order Set for Physician completion - M10526 (bundled)Ice packs as needed morphine sulfate (2 mg/1 mL) intravenously begin at 1 mg/hrmorphine sulfate (2 mg/1 mL) intravenously begin at________________mg/hrHYDROmorphone (0.4 mg/1 mL) intravenously begin at 0.25 mg/hrHYDROmorphone (0.4 mg/1 mL) intravenously begin at______________mg/hrfentaNYL (50 micrograms/1 mL) intravenously begin at 12.5 micrograms/hr (PALLIATIVE CARE UNIT/ICU ONLY) fentaNYL (50 micrograms/1 mL) intravenously begin at__________micrograms/hr (PALLIATIVE CARE UNIT/ICU ONLY) fentaNYL 25 microgram patch transdermally every 3 days MS CONTIN 30 milligram orally every 12 hoursOxyCONTIN 10 milligram orally every 12 hours oxyCODONE 5-10 milligram orally every 4 hours as needed for pain Morphine Sulfate Immediate Release (MSIR) 15 milligram orally every 4 hours as needed for pain HYDROmorphone 0.25-1 milligram intravenously every hour as needed for pain morphine sulfate 1-5 milligram intravenously every hour as needed for pain Neuropathic (Nerve) Pain
desipramine 50 milligram orally at bedtime gabapentin 100 milligram orally 3 times a day Medications
Complete Medication Transfer Reconciliation form Complete Medication Review Reconciliation form Physician's Signature
Print Name:
PALLIATIVE CARE (ADULT 0609)
PALLIATIVE CARE (ADULT 0609)
Page 6 of 7
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) are active orders. Items with a ( ) must be checked to become an active order.
Other Medications/Orders
_________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ TELEPHONE ORDERS MUST BE READ BACK AND CONFIRMED
Physician's Signature
Print Name:
PALLIATIVE CARE (ADULT 0609)
PALLIATIVE CARE (ADULT 0609)
Page 7 of 7
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) are active orders. Items with a ( ) must be checked to become an active order.
Greenville Hospital System
701 Grove Road
Greenville, SC 29605
ABHR Gel Prescription for GHS Inpatients ONLY
ALL SECTIONS MUST BE COMPLETED, OR PRESCRIPTION CANNOT BE FILLED.
Physician Name & Degree Classification (MD, DO, etc):________________________________________Physician License Number:_____________________________________________ Physician DEA Number:________________________________________________ Physician Address: Greenville Hospital System (GHS), 701 Grove Rd, Greenville, SC 29605 Physician Pager Number:_______________________________________________ Patient Name:__________________________________________________________ Patient GHS Account #:__________________________________________________ Patient Date of Birth:__________________________________ Patient Address (GHS Inpatient Room Number):_______________________________ Patient Allergies & Reaction (if known):________________________________________ Date of Issue:__________________________________ ABHR Topical Gel 1 mL applied to inner wrist every 4 to 6 hours as needed for nausea and vomiting Gel to deliver the following amounts of drug per 1 mL: Lorazepam 1 mgDiphenhydramine 25 mgHaloperidol 1 mgMetoclopramide 10 mg Dispense Quantity #: 30 syringes (5mL size) Physician Signature:__________________________________________________________________

Source: http://healthstream.greenvillehealthsystem.net/End%20of%20Life/Order%20Set.pdf