Floor pages/calls: Symptoms

Abdominal cramping: (Hx of IBD: Crohn’s/UC; IBS)

  • Bentyl (Dicyclomine) 10mg PO 4X/day PRN abdominal cramping
  • Levsin (Hyoscyamine sulfate) 0.125mg sublingual tid (q4-6hr) PRN [Tx: GI hypermotility, IBS]
    1. Tx IBS: Bentyl, exercise, limit caffeine, limit stress.

Agitation/Delirium:

Management of delirium:

  1. Treat reversible causes (ex: antibiotics if infection, narcotic if secondary to uncontrolled pain)
  2. Non-pharmacologic measures: Frequent verbal patient orientation, reassurance, touch by a familiar (family) member or trained sitter at bedside, environmental modification.

If non-pharm strategies fail or the patient is a harm to self or others:

3. Trial of pharmacotherapy is indicated:

1st: Typical antipsychotics (Haloperidol) or Atypical antipsychotics (Seroquel, Risperidone, or Olanzapine)

  1. Last resort: Physical restraints – can cause worsening agitation, can result in impaired mobility and pressure ulcers.
    • Redirect patient verbally, visual cues, family at bedside
    • May need to place the patient in restraints overnight (try to avoid as this may exacerbate agitation).
    • Haldol (Haloperidol) [ADR: QT prolongation] – Do NOT give if QTc > 500!!! Look back at EKGs, get updated.
      1. IM lactate (prompt-acting): 2-5mg IM X 1 dose (q4-8hrs PRN); may require q1hr in acute agitation. Or 1 MG = 1 TAB PO Q6HPRN AGITATION
        1. ***Haloperidol (Haldol) lactate 2mg IM q6hrs PRN agitation***
    • ***Quetiapine (Seroquel) 50mg PO tid PRN agitation/psychosis***
      1. Seroquel 12.5mg PO qHS (can go through NG tube).
      2. Seroquel 100mg tablets: Take 1/2 tablet (50mg) for the first 2 days. Then take 1 whole (100mg) tablet for the next 2 days. Then take 2 tablets (200mg) every day after that
  • CAM: Confusion Assessment Method
    1. Used to diagnose delirium
    • Lorazepam (Ativan) 1mg PO q4hr PRN Ex: anxiety, agitation, diaphoresis, tremulousness, SBP>150mmHg, DBP>90mmHg, and/or HR>100bpm.
  • Agitation PO:
  1. Ativan (lorazepam): 1mg PO q6hr PRN moderate agitation and 2mg PO q6hr PRN severe agitation
  2. Haloperidol 5mg PO q4hr PRN agitation
  3. Olanzapine 5mg sublingual tid
  • Agitation IM
    1. Aripiprazole IM (Abilify): 9.75mg IM q8hr PRN severe agitation
    1. Lorazepam (Ativan) 1mg IM q6hr PRN moderate agitation, 2mg IM q6hr PRN severe agitation
    2. Ziprasidone IM (Geodon): (NOT to exceed 40mg/24 hours)
      1. Ziprasidone 10mg IM q6hr PRN mild/moderate agitation and/or geriatric status
      2. Ziprasidone 20mg IM q8hr PRM severe agitation
    1. Haloperidol IM: 2-5mg IM q4-8hr (may require q1hr) moderate/severe agitation.

Anxiety: (If night float, consider doing only X 1 dose now.)

  • Hydroxyzine Pamoate (Vistaril): antihistamine (Tx: anxiety, tension, nervousness, N/V, allergies, skin rash, pruritis, hives) (do NOT use in elderly)
    1. 50mg IM/PO
  • Buspirone (Buspar): Start 15mg “dividose” daily (7.5mg PO bid, increase by 5g/day q 2-3 days to usual effective dose of 30mg/day (Max dose: 60mg/day).
  • Ativan (Lorazepam): benzodiazepine (Tx: anxiety, anxiety with depression, and insomnia)
    1. 0.5 – 2mg IV/IM/PO (may worsen confusion in the elderly)
      1. ***Lorazepam (Ativan) 0.5mg IV q4hrs PRN anxiety.***
    2. Do NOT give if COPD: Because pts with COPD retain CO2, do not give them sedatives (like Ativan) because it will exacerbate their CO2 retention (may lead to intubation).
  • Geodon 10mg IM
  • Seroquel 12.5-25mg PO (use 12.5mg in elderly)
  • Hypertension, tachycardia, likely secondary to severe anxiety:
    1. Klonopin (Clonazepam) 1 mg X 1 dose stat (treats panic)
    2. Also give: Metoprolol 25 mg PO bid
  • Other meds…use with caution: Xanax

Bradycardia:

  • Symptomatic: lightheaded, syncope, chest pain, SOB, palpitations
    1. Hold 1 dose of currently prescribed HR meds (Beta-blocker, Calcium channel blocker)
  • Order EKG for all patients with bradycardia: (look for pauses or heart blocks) [Consult Cardiology!]
    1. If sinus pauses <2.5s and asymptomatic: No intervention needed.
    2. If sinus pauses 2.5-3s and asymptomatic: Consider trial of Atropine.
    3. If sinus pauses >3s and asymptomatic: External pacer.
      1. Atropine 0.5-1mg IV q3-5 minutes.
      2. Dopamine 5-20mcg/kg/min
      3. Dobutamine (+beta 1 and beta 2 receptors): 2.5mcg/kg/min?
  • Ex scenario: Pt just had a carotid endarterectomy, which may lead to vagus nerve injury -> low HR

Chest pain:

  • Vital signs, serial troponin X3, serial EKG, CBC, BMP
  • Give Aspirin, Nitroglycerin, and Oxygen. (MONA!) – may need morphine too.
  • Consider underlying etiology: MI, GERD, PE, AAA, pneumothorax, arrhythmia.
  • High BP may also be underlying etiology of HTN; correct HTN, which may mitigate chest discomfort.
  • Plavix: anticoagulant and anti-anginal
    1. Discontinue Omeprazole if on Plavix because Omeprazole can inactivate Plavix. Change to Ranitidine to treat acid reflux while on Plavix.
  • Imdur: long-acting nitrate (ADR: headache)
  • Ranexa: use if resistant angina

Constipation:

  • Metamucil 1tsp daily (bulk laxative)
  • Miralax (polyethylene glycol) 17g (1 packet) PO qd – 3350 oral powder – mix 1 capful (17g) in 8oz
  • Milk of Magnesia 30cc (osmotic)
  • Dulcolax 5mg (stimulant) – Dulcolax stool softener. – suppository
  • Bisacodyl 10mg rtl once PRN – suppository
  • Magnesium Citrate liquid – oral 1 bottle (10oz) PO once.
  • Colace (Docusate sodium) 100mg PO bid
  • Fleet enema [Phosphate enema sodium/bisodium phosphate] (do NOT use in: renal failure, hypernatremia, hyperphosphatemia), soap suds enema, tap water enema
  • Senokot (Senna 50/8.6) 5-15mg (useful in narcotic induced constipation): 1-2 tab PO q12hrs
  • Fiber tablets/capsules.
  • Eat plenty of fiber.
  • Drink more water.
    1. Example bowel regimen in patient on narcotics:
      1. Miralax scheduled qd
      2. Bisacondyl 10mg rectal suppository now and PRN
      3. Magnesium Citrate liquid – 1 bottle (10oz) PO once.
  • FDA approved meds for Narcotic induced constipation:
    1. Relistor – do NOT use if small bowel obstruction (SBO) is suspected.
    2. Amitiza (Lubiprostone) 24mcg PO bi

Cough/Congestion:

  • Tessalon perles (Benzonatate) 100-200mg PO tid PRN cough [max 600mg/day]
  • Guaifenesin 100-400mg PO q4hr
    1. Guaifenesin-Codeine 100-10 mg/5ml oral syrup – Take 1-2 teaspoons q4-6 hours PRN
  • Robitussin 10cc q4hr
  • Pseudoephedrine 60mg PO q4hr
  • Dextromethorphan

Diarrhea:

  • Check stool for C. diff, WBCs (lactoferrin), ova and parasites.
  • Fluid replacement to avoid dehydration.
  • If C. diff negative, consider trying: (only after ruling out other causes for the diarrhea, gastroenteritis diarrhea treated)
    1. Lomotil PRN for Diarrhea
    2. Imodium 2 tablets now and then 1 tab after each loose stool.
  • If unknown C. diff: Order Kaopectate (Bismuth subsalicylate) and probiotics (lactobacillus)

Dysphagia:

  • Make pt NPO (except for sips of water with meds until cleared by ST)
  • Speech therapy consult to perform a modified Barium Swallow.

Fall: Place on fall precautions.

  • Evaluate for injury. Write a note in the patient’s chart documented the incident and your PE and/or workup after the incident. Ex: CT head without contrast to rule out intracranial hemorrhage.
  • Restraints if necessary (confused patient).

Fever: (+100.4 to be a true fever)

    1. Unknown etiology: Order pan cultures: UA with urine culture, Blood culture, sputum culture – can repeat blood culture at fever spikes, sputum culture.***
    2. CBC
    3. Chest x-ray
  • Tylenol 650mg PO or PR q4hrs for fever.
  • Consider a cooling blanket if temp >102.5.
  • Post-op:
    1. Wind (1st couple days after surgery): Atelectasis vs. PNA: Encourage incentive spirometer!
    2. Water ( X days after surgery): UTI
    3. Wound (Y days after surgery): wound infection
    4. Walking (Z days after surgery): DVT à PE

Glucose: Dx DM: HgA1C > 6.5! (pre-diabetic: HgA1C 5.7 – 6.4; ideal: HgA1C < 5.7)

  • Glucose > 400:
    1. Give 12 U of regular insulin and recheck blood glucose in 1 hour.
    2. Consider starting an Insulin Sliding Scale to determine how much insulin they require.
  • Glucose < 60:
    1. Hypoglycemia protocol: Give 1 Amp D50 (IV dextrose) if unable to take PO.
    2. Glucose 50-70: Give 15ml, then recheck blood glucose in 15 minutes.
    3. Glucose 30-49: Give 25ml, then recheck blood glucose in 5-15 minutes.
    4. If the patient is able to take PO: Give 4 glucose tabs or 1 tube of glucose gel.
    5. Hold DM medications if pt is currently taking any until blood glucose rises to a normal range.

Headache: (see Pain)

  • Order: CT head without contrast (assess for bleeding).
  • Meds for intractable headache:
    1. Immitrex, Topamax,
    2. Compazine 10mg PO q6hr PRN N/V
    3. Solu-Medrol 125mg IV X1 dose
    4. Dexamethasone (Decadron) 10mg IV X1 dose
    5. Stadol (Butorphanol) 1mg IV X1 dose
    6. Magnesium sulfate 2g IV X1 dose – over 2 hrs
    7. Benadryl 25mg IV X 1 dose
    8. Metoclopramide (Reglan) 10mg IV X1 dose
    9. Pain: Morphine 2-4mg IV, Tramadol 50mg PO q8hr PRN pain
    10. Nausea: Zofran
    11. Anxiety: Valium 5mg PO q12hr PRN anxiety
  • Tylenol
  • Imitrex (Sumatriptan) 25mg PO q2hrs PRN headache – rescue med!
  • Excedrin: contains Tylenol, Aspirin, and Caffeine.
  • Consider controlled BP: may be underlying etiology.
  • Lidocaine (Lidoderm) 5% patch 1 patch transdermal qd

Heartburn:

  • GI cocktail:
    1. Maalox X-ST (ALOH/MGOH/Simet) 30ml PO X 1 dose
      1. Magnesium Hydroxide (MOM) oral suspension
    2. Lidocaine (Xylocaine) 2% viscous 15ml PO X 1 dose
  • Maalox 30cc, Mylanta, Protonix, Ranitidine

Hemorrhoids: (External hemorrhoids with rectal itching)

  • Started Hydrocortisone5% rectal cream (Anusol) today.
  • Patient is encouraged to eat plenty of fiber to avoid constipation, which would aggravate her hemorrhoids.

Hypertension:

  • Have nurse recheck vitals (confirm measurement). Also assess for pain as underlying etiology if no Hx of HTN. Consider pre-poning HTN meds if already ordered (“Give now” rather than wait a couple hours for scheduled dose.)
  • Nitroglycerin 2% ointment 1 inch (Nitropaste) = 1pkt topical. Recheck vitals in 30 minutes.
  • Labetalol 20mg IV, may repeat q10min, double dose each time, max: 300mg
  • Lopressor (Metoprolol) 5mg IV q5min. (Hold for bradycardia.)
  • Lisinopril or other ACE-I (Vasotec = Enalapril IV)
  • Hydralazine (Apresoline) 10mg IV q8hr PRN BP
  • If COPD or Asthma (lungs: B2, bronchoconstriction if B2 blocked via B1 blocker, no B-blocker use):
    1. Vasotec (Enalapril) IV 0.625mg over 5 minutes. Repeat in 1 hour and then go to q6hours.
  • Hypertensive crisis: Nitroprusside – avoid Nitroprusside b/c poor outcomes, especially if intracranial hemorrhage!!!
    1. Initial: 0.25-0.3 mcg/kg/min IV infusion; may increase by 0.5 mcg/kg/min every few minutes to achieve desired results
    2. Usual range: 3-4 mcg/kg/min IV infusion, not to exceed 10 mcg/kg/min
    3. Do NOT use in patient with renal failure.

Insomnia:

  • ****Melatonin 3mg PO X 1 dose at bedtime
  • Benadryl 50mg PO or 12.5mg IV (If pt cannot swallow)
  • Ambien (Zolpidem) 5-10mg PO qd at bedtime PRN for insomnia
  • Restoril (Temazepam) 7.5-30mg PO qHS (for short term (7-10 day) treatment of insomnia)
  • Rozarem 8mg
  • *Trazodone 100mg PO qHS
    1. If insomnia secondary to depression.
  • ***Hydroxyzine Pamoate (Vistaril): antihistamine
    1. If insomnia secondary to anxiety. (Tx: anxiety, tension, nervousness, N/V, allergies, skin rash, pruritis, hives) (do NOT use in elderly)
    2. 50mg IM/PO
  • NSAID or Tramadol
    1. If insomnia secondary to pain.

Nausea/Vomiting:

  • Zofran (Ondansetron) 2-8mg PO/IV q6-8hrs PRN for N/V [Do NOT use if prolonged QT interval!]
  • Phenergan (Promethazine) 12.5-25mg IV/PO/PR/IM q4-6hr PRN for N/V (careful in elderly and peds)
    1. Use this if pt has prolonged QT interval!)
  • Compazine (Prochlorperazine) 5-10mg PO q8hrs or 5mg IV X 1 dose
  • Tigan (peds)
  • Meclozine: (antihistamine) Tx/prevent nausea, vomiting, and dizziness caused by motion sickness
    1. Also treats vertigo (dizziness/lightheadedness) caused by inner ear problems.

Pain: (in general: i.e. headache)

  • Mild-Moderate pain:
    1. Tylenol 325-650mg PO q4-6hrs PRN mild pain or fever > +101 F.
    2. Ibuprofen (Motrin: NSAID: GI BLEED!) 600mg PO q6hrs PRN for mild pain
      1. Meloxicam – less risk of bleeding with GERD!!!
        1. Stop Ibuprofen and change to Meloxicam (less acid reflux).
  • Moderate pain:
    1. Lidocaine (Lidoderm) 5% patch 1 patch transdermal qd
    2. Fentanyl patch – 1 patch transdermal qd
    3. Toradol (Ketorolac – NSAID: GI BLEED!): 15-30mg PO/IM/IV q6hrs (no more than 5 days)
    4. Darvocet N100 1 tab PO q4hrs
    5. Tramadol (Ultram) 50-100mg PO q4-8hrs (Opioid)
    6. Oxycodone 10mg PO q4hrs
    7. Percocet 5/325 (oxycodone/acetaminophen) 1-2 tabs PO q4hrs
    8. Lortab 5/325 1-2 tabs PO q4hrs
  • Moderate-Severe pain:
    1. Morphine 1-2mg IM/IV X 1 dose for severe pain (use sparingly) or q3-4hrs PRN
    2. Dilaudid (1mg Dilaudid = 7mg Morphine) 0.5-2mg IM/IV – use sparingly.

Morphine Equivalents:

morphine equivalents

 

 

 

Pain (arthritic):

  • Voltaren Gel (NSAID) used for the relief of joint pain of osteoarthritis in the knees, ankles, feet, elbows, wrists, etc.
    1. Voltaren 1% transdermal gel: apply sparingly to affected areas bid.

Pain post-op (patient started on PCA pump by surgery):

  • Surgery will start these orders and may want to maintain their own PCA pump orders. If you are paged by a nurse about PCA pump questions/issues/pain control or lack thereof/wild vitals secondary to lack of pain control, consider asking the nurse to:
    1. Recheck vitals (if they were abnormal).
    2. Contact surgery so that they may manage the PCA pump orders that the initiated or manage the pumped yourself:
      1. Ex: Dilaudid PCA. Basal rate: 0.3mg/hr (7.5mg/day) Bolus rate: 0.1mg q20min (7.5mg/day). Lockout at 2mg/hr.
      2. Make sure that you also have: Naloxone (opioid antagonist): Give if signs of resp. failure.
      3. Cocaine is NOT an opioid. Cocaine is derived from the coca plant whereas opiates (and thus opioids) are derived from the opium poppy.
    3. Contact that nurse 30min-1hr later for an update on the patient and/or go by the patient’s room.

Pain/stiffness secondary to muscle spasms/cramps:

  • Cyclobenzaprine (Flexeril) 10mg 1 tab PO q8hr PRN (muscle relaxer)
  • Methocarbamol (Robaxin)
  • Metaxalone (Skelaxin)
  • Tizanidine (Zanaflex)

Shortness of Breath (SOB):

  • Assess patient. Page Respiratory Therapy to set up breathing treatment (DuoNebs).
  • Consider: Acute MI, PE, CHF, COPD exacerbation.
  • Check Troponins, EKG, ABG, BNP. If likelihood of PE is high (high Wells score), get CT chest with contrast to r/o PE.
  • Stat portable chest x-ray.
  • CHF:
    1. Lasix 40mg IV X 1 dose
  • COPD:
    1. Solu-Medrol (methylprednisolone) 60mg IV X 1 dose
    2. DueNeb 2.5mg breathing treatment
    3. Flovent HFA 220mg – inhale 2 puffs q 6hrs
  • PE: Start anticoagulation (therapeutic Lovenox vs Heparin).

Sinusitis:

  • Flonase (Fluticasone): steroid nasal spray 0.1mg spray each nostril qd
  • Cetirizine (Zyrtec): anti-histamine 10mg 1 tab PO qd
  • May also need Augmentin 875/125 1 tab PO q12hrs (covers sinusitis and CAP): if persistent
  • Cough: Montelukast (Singular) 10mg PO qd
    • Guaifenesin-Codeine 100-10 mg/5ml oral syrup – Take 1-2 teaspoons q4-6 hours PRN

Smoker:

  • Nicotine patch, Nicorette gum, education/encourage smoking cessation.
  • Consider beginning cessation medication: (if no contraindications: seizures) – outpatient
    1. Wellbutrin (Bupropion) Zyban ER 150mg PO bid
      1. Take 1 tablet once a day for 3 days and then take 1 tablet bid then on.
      2. Recommended to take the evening dose earlier in the afternoon (5pm-7pm) due to the evening dose of the medication possibly causing him to stay awake at night and causing difficulty with sleep.
    2. Chantix
  • Nortriptyline and Amitriptyline can be used for smoking cessation.

Sore throat: Salt water gargle is encouraged. Chloraseptic lozenges encouraged.

  • Chloraseptic 1.4 % Mouth/Throat Liquid

Tachycardia: If a cardiology group is already following patient, consider contacting them before intervening.

  • Check vital signs.
  • Stat EKG: look for arrhythmia as underlying etiology
  • Place patient on a telemetry monitor if not already on one.
  • Beta-blocker:
    1. Labatolol 20mg IV stat X 1 dose
    2. Metoprolol 5mg IV stat X 1 dose
  • Calcium channel blocker:
    1. Cardiazem 10mg IV stat X 1 dose
  • Correct underlying cause:
    1. Look at fluid status/IV fluids. Check BP: If low, may be underlying etiology: correct that 1st via IV fluid bolus.
    2. Fever/infection. Check temperature. Consider collecting UA, Urine culture, Blood culture, Chest x-ray.
    3. Thyroid (hyperthyroidism as underlying etiology): Check TSH.

Thrush:

  • Fluconazole 100-200mg PO qd for 7-14 days.
  • Nystatin (Mycostatin) suspension 500,000 U (5ml) PO q6hrs (swish and swallow/spit) miracle mouth wash (1.5ml q6hrs)

Unresponsive patient (but NOT in arrest!!!):

  • Check Code Status, vital signs, blood sugar, and pulse ox.
  • Stat EKG: Look for arrhythmia or heart block.
  • Order a CMP plus magnesium level.
  • Check a urine drug screen (UDS).
  • Overdose of OPIATES: Look for pinpoint pupils!
    1. Narcan (Naloxone) 0.2-2mg IV/IM
  • Overdose of BENZODIAZEPINES:
    1. Flumazenil 0.2mg IV (be careful because this may cause seizures)

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