Diagnosis:



DIAGNOSIS: ___________________________________________________________________________

ALLERGIES: ___________________________________________ NKDA

PHYSICIAN / PROVIDER: Bullet point orders implemented automatically. Line through and initial any inapplicable orders. Check (√) appropriate order boxes where given choice. To reinstate or add additional orders after signing, timing and dating this set, use a new preprinted order set. Sign or initial any other (internal) pages of the order set where selections or changes have been made.

NURSE: Verify all orders before faxing to pharmacy.

Orders added to a preprinted order set after it has been signed, timed, dated, and noted will not be honored.

VITAL SIGNS AND RASS SCORE:

• Every 4 Hours with pulse oximetry or more often per unit routine

• Assess Richmond Agitation Sedation Scale (RASS) prior to any Lorazepam (ATIVAN) dose

CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT FOR ALCOHOL-REVISED (CIWA-Ar)

• Assess once upon admission and then as indicated below according to score

• Discontinue CIWA-Ar assessment when CIWA-Ar is less than 8 for 72 Hours

CALL PHYSICIAN FOR:

• Notify physician for vital signs outside of range and/or need to transfer to higher level of care: Pulse greater than 120 beats per minute; SBP greater than 160 mmHg or less than 100 mmHg; DBP greater than 100 mmHg or less than 60 mmHg; Respiratory rate greater than 30 breaths per minute or less than 10 breaths per minute; Temperature greater than 38.5 Centigrade

• Notify physician when initial CIWA is greater than or equal to 9 and medication will be administered

• RASS Score of -2 to -5

• Restraints are required

• Evaluation for transfer from Med/Surg to Progressive Care Unit

o RASS -2 to -3

o CIWA-Ar severity score of 9 on more than 2 consecutive assessments

• Evaluation for transfer to ICU

o Seizure activity

o CIWA-Ar score increases of more than 10 over previous measurement

o Score exceeding 15 on 4 consecutive measurements

o Patient has required 14 mg or more of Lorazepam (ATIVAN) within 2 hours

o RASS -4 to -5

Clinical Laboratory-Upon Admission (if not already done)

Blood alcohol level

Liver Function Test Panel

PTT / PT / INR

Hemogram

Magnesium

Phosphorus

Potassium

MEDICATION ORDERS:

ROUTINE: IV formulations should only be used for those patients where it is absolutely necessary, as in patient is unable to take PO medications.

Oral Medications:

Folic acid 1 mg PO DAILY until discharge.

Multivitamin 1 tablet PO DAILY until discharge. If patient is on tube feeds, Notify MD when tube feeds are at goal rate to consider discontinuing.

Thiamine 300 mg in 50 mL 0.9% Sodium Chloride IV EVERY 8 HOURS for 3 days, then 100mg PO DAILY until discharge.

IV/Oral Medications:(For ICU or NPO patients)

Folic acid 1 mg in 50 mL 0.9% Sodium Chloride IV ONCE every morning over 30 minutes for 3 days, then 1mg PO Daily until discharge.

Multivitamin solution, 5 mL PO or via NG Tube DAILY until discharge. If patient is on tube feeds, Notify MD when tube feeds are at goal rate to consider discontinuing.

Thiamine 300 mg in 50 mL 0.9% Sodium Chloride IV EVERY 8 HOURS for 3 days, then 100 mg PO DAILY until discharge.

Lorazepam

SCHEDULED DOSE: For patients with PAWSS greater than or equal to 4 and without symptoms of alcohol withdrawal. If GCS is less than 13, discuss with attending physician.

Lorazepam (ATIVAN) 1mg PO every 4 hours. Notfiy MD if CIWA-Ar is less than or equal to 8 for 24 hours to consider tapering.

SYMPTOM TRIGGERED:

Lorazepam (ATIVAN) administered as below if CIWA-Ar score greater than 8 until score less than or equal to 8 for at least 24 hours

Hold for respiratory rate less than 10 breaths per minute or lethargy (RASS Score of --2 to -5)

|CIWA – Ar | |Lorazepam (ATIVAN) Dosage |CIWA - Ar |

|Severity | |Score |PO |IV |Monitoring |

|Mild | |0-8 |None |None |Monitor every H until CIWA-Ar less than or equal to 8 x 4|

| | | | | |H consecutively, then every 4 Hours |

|Moderate** | |9-15 |2 mg or mg |2 mg or mg |Monitor every 30 minutes prn per CIWA-Ar until CIWA-Ar is |

| | | | | |less than or equal to 8 |

|Severe |Greater than 15 |none |4 mg or mg |Monitor every 15 minutes prn per CIWA-Ar until CIWA-Ar is |

| | | | |less than or equal to 15 |

** Always administer p.o. Lorazepam (ATIVAN) unless NPO or severe alcohol withdrawal

SEIZURE:

Lorazepam (ATIVAN) 2 mg IV every 5 minutes PRN active seizures. Notify MD for seizures and possible transfer to a higher level of care.

CONSULT:

Inpatient Consult to Social Work:

General Social Work SBI CRMC Only

Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)

|PAROXYSMAL SWEATS -- Observation. |TREMOR -- Arms extended and fingers spread apart. Observation. |

|0 no sweat visible |0 no tremor |

|1 barely perceptible sweating, palms moist 2 |1 not visible, but can be felt fingertip to fingertip 2 |

|3 |3 |

|4 beads of sweat obvious on forehead 5 |4 moderate, with patient's arms extended 5 |

|6 |6 |

|7 drenching sweats |7 severe, even with arms not extended |

|NAUSEA AND VOMITING -- Ask "Do you feel sick to your stomach? Have you vomited?" |AUDITORY DISTURBANCES -- Ask "Are you more aware of sounds around you? Are they |

|Observation. |harsh? Do they frighten you? Are you hearing anything that is disturbing to you? |

|0 no nausea and no vomiting |Are you hearing things you know are not there?" Observation. 0 not present |

|1 mild nausea with no vomiting 2 |1 very mild harshness or ability to frighten 2 mild harshness or ability to |

|3 |frighten |

|4 intermittent nausea with dry heaves 5 |moderate harshness or ability to frighten |

|6 |moderately severe hallucinations 5 severe hallucinations |

|7 constant nausea, frequent dry heaves and vomiting |extremely severe hallucinations |

| |continuous hallucinations |

|TACTILE DISTURBANCES -- Ask "Have you any itching, pins and needles sensations, any |VISUAL DISTURBANCES -- Ask "Does the light appear to be too bright? Is its color |

|burning, any numbness, or do you feel bugs crawling on or under your skin?" |different? Does it hurt your eyes? Are you seeing anything that is disturbing to |

|Observation. |you? Are you seeing things you know are not there?" Observation. |

|0 none |0 not present |

|1 very mild itching, pins and needles, burning or numbness 2 mild itching, pins and |1 very mild sensitivity 2 mild sensitivity |

|needles, burning or numbness |moderate sensitivity |

|3 moderate itching, pins and needles, burning or numbness 4 moderately severe |moderately severe hallucinations 5 severe hallucinations |

|hallucinations |6 extremely severe hallucinations 7 continuous hallucinations |

|severe hallucinations | |

|extremely severe hallucinations 7 continuous hallucinations | |

|ANXIETY -- Ask "Do you feel nervous?" Observation. |HEADACHE, FULLNESS IN HEAD -- Ask "Does your head feel different? Does it feel |

|0 no anxiety, at ease |like there is a band around your head?" Do not rate for dizziness or |

|1 mild anxious |lightheadedness. Otherwise, rate severity. |

|2 |0 not present |

|3 |very mild |

|4 moderately anxious, or guarded, so anxiety is inferred |mild |

|5 |moderate |

|6 |moderately severe |

|7 equivalent to acute panic states as seen in severe delirium or acute schizophrenic |severe |

|reactions |very severe |

| |extremely severe |

|AGITATION -- Observation. |ORIENTATION AND CLOUDING OF SENSORIUM -- Ask "What day is |

|0 normal activity |this? Where are you? Who am I?" |

|1 somewhat more than normal activity |0 oriented and can do serial additions |

|2 |1 cannot do serial additions or is uncertain about date 2 disoriented for date by|

|3 |no more than 2 calendar days 3 disoriented for date by more than 2 calendar days |

|4 moderately fidgety and restless 5 |4 disoriented for place/or person |

|6 | |

|7 paces back and forth during most of the interview, or constantly thrashes about | |

|Maximum Possible Score 67 |Total CIWA-Ar Score ________________ |

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