CHN5140 Magnesium Sulfate for Preterm Labor.pdf - Carondelet

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CARONDELET HEALTH NETWORK
HOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERS
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MAGNESIUM SULFATE FOR PRETERM LABOR
* LIST ALL ALLERGIES: (Medication, food, latex and/or Contrast Dye) * Required on Admission Orders
PATIENT STATUS: Inpatient Observation Outpatient (check if applicable)
1. Admit to Care Management Protocol
2. Vital Signs:
Vital Signs on admission, then BP, Pulse, Respirations every 15 minutes x 1 hour, then every hour if stable
Maternal temperature every 4 hours. If rupture of membranes, maternal temperature every 2 hours
Continuous fetal monitoring
3. Activity: Bedrest
4. Nursing:
Assess breath sounds, edema and DTRs hourly
Complete I&O hourly – total fluid intake not to exceed 125 ml/hour
Foley catheter: See Urinary Catheter Insertion & Maintenance Orders
SCDs bilaterally - knee high
5. Diet:
NPO Clear Liquids Ice Chips
Regular diet as tolerated ______________(specify) diet as tolerated
6. IV Fluid:
Mainline IV D5LR 1000 ml at ________ ml/hour
7. Medications:
IV Bolus _____gm Magnesium Sulfate. Infuse over 20 minutes via IV pump
After bolus, infuse Magnesium Sulfate 20 gm in 500 ml Sterile Water (premix) at ____ gm/hour via IV pump
with Buretrol
8. Labs:
BUN and Creatinine prior to starting Magnesium Sulfate
Serum Magnesium level at 4 hours after bolus
Then every 6 hours
Then every ________ hours
9. Diagnostic Tests:
Vaginal exam for indications of uterine activity and if no suspected placenta previa or bright red vaginal
bleeding
10. Contact physician for:
Magnesium level greater than 6 mg/dl
Magnesium level greater than 8 mg/dl
Contractions greater than ________/hour
Physician Signature: Date Signed: Time Signed:
Physician Printed Name / License # / Telephone #:
PATIENT IDENTIFICATION
MEC Approval CSJ – 02/25/14 CHC – 02/25/14
CHN5140 Expires – 02/2017
Copy 10.28.14
UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED

USE BALL POINT PEN – PRESS FIRMLY
CARONDELET HEALTH NETWORK
HOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERS
STAT/NOW
(Check Box to Left)
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URINARY CATHETER INSERTION/MAINTENANCE ORDERS
Urinary Catheter Insertion/Maintenance Options
1. Urinary Catheter Insertion OR Urinary Catheter to Dependent Drainage
Select urinary catheter indication:
GU/GYN/Perineal Procedure
Gross hematuria
Acute urinary retention
Bladder outlet obstruction
Continuous IV infusion of diuretic
Continuous IV infusion of paralytic
Continuous IV infusion of vasopressor/inotropic
Mechanical ventilation with order for deep sedation (RASS = -4 or -5)
Prolonged immobility potentially related to unstable thoracic or lumbar spine, multiple traumatic injuries,
hip fractures, etc
End of life/comfort care
Urinary catheter placed by urologist
Urinary incontinence with Stage III or greater pressure ulcers
Other: _______________________________________________________________
Urinary Catheter Removal Options
2. Discontinue Urinary Catheter if no indication for use per protocol
Discontinue Urinary Catheter on Date: ______________ at Time: _____________
Do Not Discontinue Urinary Catheter until further orders from provider
When urinary catheter discontinued:
Initiate Bladder Scan Protocol
Perform Bladder Scan 4 hours after removal if no void. Straight cath if volume greater than _____ mL.
Nursing Tasks
3. Assess and document Urinary Catheter Indication now and qshift (0900 and 2100) thereafter
CSJ Only:
If unable to place urinary catheter after one attempt, activate RN Foley Team and initiate protocol as needed
Medications
4. Lidocaine 2% gel transurethral.
- Fill urethra 10 to 15 minutes prior to urinary catheter insertion. May repeat x 1.
Physician Signature: Date Signed: Time Signed:
Physician Printed Name / License # / Telephone #:
PATIENT IDENTIFICATION
Approved 8/28/14
CHN2212 Expires – 08/2017
UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED