Check box to activate orders below if applicable. Cross off non-applicable orders with a single line. ALLERGIES: None Known Yes
Psychiatric Consult “Suicide Risk Assessment Tool” post withdrawal (required for all patients once withdrawal completed)
Implement Withdrawal Syndrome Precautions. Score patient using Richmond Agitation Sedation Scale. Desired RASS score is 0 to -1.
Thiamine 100 mg po daily x 3 days Folic Acid 1 mg po daily x 3 days Multivitamin 1 tablet po daily If patient unable to take PO: Thiamine 100 mg & Folic Acid 1 mg IV in 100 ml Normal Saline over 1 hour x 3 days
1 liter D5NS with 20meq KCL at __________/hour. (Start after first piggyback of Thiamine and Folic Acid finishes or patient has taken PO vitamins.
Obtain a serum magnesium and potassium on admit and daily while on withdrawal protocol and treat per Potassium Magnesium Replacement Protocol. Select either 5a or 5b and check appropriate boxes: Low Risk for Alcohol Withdrawal Delirium: *1
(This regimen preferred for patients with COPD or respiratory illness) Lorazepam 1 mg PO or IV every 1 hour PRN early withdrawal symptoms
High Risk for Alcohol Withdrawal Delirium: *2
Lorazepam 2 mg PO or IV every 4 hours x 12 doses then Lorazepam 1 mg PO or IV every 6 hours x 6 doses then discontinue order and give Lorazepam 1 mg PO or IV every 1 hour PRN early withdrawal symptoms.
For Acute Alcohol Withdrawal Delirium Treatment Regimen:*3 (Notify the attending physician and the hospitalist of acute alcohol withdrawal and inquire regarding ICU transfer.) 6. Lorazepam 2 mg IV every 15 minutes PRN. (If patient needs 8mg in 1 hour OR if severe agitation continues
with Richmond score of +3 or greater contact physician for medication order that will treat delirium and transfer the patient to ICU.)
Haldol _____mg IV is for sedation every 4 hours PRN (ICU only) and check QTc interval prior to administration of drug, notify physician and hold Haldol if QTc 500 msec or greater.
8. Recheck QTc 2 hours after first dose of Haldol and every 8 hours. Notify physician if QTc is greater than 500 msec
or there is a change of greater than 80 msec and discontinue Haldol.
G:\FORMS\Forms for EMR\BAR CODED Forms\ORDER\Alcohol Withdraw Physician Standing Order.doc Last printed 2/5/2013 3:38:00 PM
POLICY: Share (G):\ Dept P&Ps \ Nursing \ Alcohol Withdrawal Syndrome-Screen Assess Treat.doc (Attachment B)
Note: This page does not require a patient label
Alcohol Withdrawal Syndrome PHYSICIAN Pre-Printed Orders
Acute Alcohol Withdrawal Syndrome occurs when early alcohol withdrawal symptoms are not promptly recognized and treated. Treatment with benzodiazepines should reduce or eliminate withdrawal symptoms.
Early alcohol withdrawal symptoms to monitor all patients for include:
GI Complaints: Nausea, vomiting, anorexia Peripheral Nervous System Hyperactivity: Tremor, tachycardia, tachypnea, hypertension, fever, and
Central Nervous System Complaints: anxiety, insomnia, restlessness, light/sound sensitivity, headache
No prior history of alcohol withdrawal symptoms (“shakes”) or history of acute alcohol withdrawal, patient consumes minimal (less than or equal to 2 drinks per day) alcohol, patient is not exhibiting any signs/symptoms of early alcohol withdrawal.
Prior history of acute alcohol withdrawal syndrome, history of withdrawal seizures, daily consumption of large quantities (more than 2 drinks per day) of alcohol, patient exhibits signs/symptoms of early alcohol withdrawal.
*3Acute alcohol withdrawal delirium requiring physician notification:
Early alcohol symptoms (see above) and, dry heaves, drenching sweats, agitation, panic, seizures, visual, tactile, and/or auditory hallucinations confusion, disorientation, agitation and/or marked tremor.
All patients will be scored using Richmond Sedation Scale. The goal of sedation will be a 0 to –1 on the scale below: Richmond Agitation Sedation Scale Combative Overtly combative, violent, immediate danger to staff Very agitated Pulls or removes tube(s) or catheter(s); aggressive Agitated Frequent non-purposeful movement, fights ventilator Restless Anxious but movements not aggressive or vigorous Alert and calm Not fully alert, but has sustained awakening (Eye- -1 Drowsy opening/contact) to voice (≥ 10 seconds) sedation Briefly awakens with eye contact to voice (< 10seconds) Moderate sedation Movement or eye-opening to voice (but no eye contact) No response to voice, but movement or eye opening to physical sedation stimulation Unarousable No response to voice or physical stimulation
G:\FORMS\Forms for EMR\BAR CODED Forms\ORDER\Alcohol Withdraw Physician Standing Order.docLast printed 2/5/2013 3:38:00 PM Rev/Appd 5/11
R………………………… Receiving Officer OMBI LA KUTAKA PASPOTI YA KENYA APPLICATION FOR A KENYA PASSPORT Signature.………………………. Stamp …………………………. Majina Kamili } Full Names Indexing Officer Tafadhali soma maagizo kwa makini kabla ya kujaza fomu Please read instructions carefully before completing the form Signa
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