Medicine

2007 Edition

Paul D. Chan, MD

Executive Editor

Peter J. Winkle, MD

Associate Editor

Copyright © 2007 Current Clinical Strategies Publishing.

All rights reserved.

This book, or any parts thereof, may not be reproduced or

stored in an information retrieval network without the

written permission of the publisher. The admitting order

format of this book is protected by copyright law. The

reader is advised to consult the package insert and other

references before using any therapeutic agent. The

publisher disclaims any liability, loss, injury, or damage

incurred as a consequence, directly or indirectly, of the use

and application of any of the contents of this text.

Medical Documentation

History and Physical Examination

Identifying Data: Patient's name; age, race, sex. List the

patient's significant medical problems. Name of

informant (patient, relative).

Chief Compliant: Reason given by patient for seeking

medical care and the duration of the symptom. List all of

the patients medical problems.

History of Present Illness (HPI): Describe the course of

the patient's illness, including when it began, character

of the symptoms, location where the symptoms began;

aggravating or alleviating factors; pertinent positives and

negatives. Describe past illnesses or surgeries, and past

diagnostic testing.

Past Medical History (PMH): Past diseases, surgeries,

hospitalizations; medical problems; history of diabetes,

hypertension, peptic ulcer disease, asthma, myocardial

infarction, cancer. In children include birth history,

prenatal history, immunizations, and type of feedings.

Medications:

Allergies: Penicillin, codeine?

Family History: Medical problems in family, including the

patient's disorder. Asthma, coronary artery disease,

heart failure, cancer, tuberculosis.

Social History: Alcohol, smoking, drug usage. Marital

status, employment situation. Level of education.

Review of Systems (ROS):

General: Weight gain or loss, loss of appetite, fever,

chills, fatigue, night sweats.

Skin: Rashes, skin discolorations.

Head: Headaches, dizziness, masses, seizures.

Eyes: Visual changes, eye pain.

Ears: Tinnitus, vertigo, hearing loss.

Nose: Nose bleeds, discharge, sinus diseases.

Mouth and Throat: Dental disease, hoarseness,

throat pain.

Respiratory: Cough, shortness of breath, sputum

(color).

Cardiovascular: Chest pain, orthopnea, paroxysmal

nocturnal dyspnea; dyspnea on exertion, claudication,

edema, valvular disease.

Gastrointestinal: Dysphagia, abdominal pain, nausea,

vomiting, hematemesis, diarrhea, constipation, melena

(black tarry stools), hematochezia (bright red blood per

rectum).

Genitourinary: Dysuria, frequency, hesitancy,

hematuria, discharge.

Gynecological: Gravida/para, abortions, last

menstrual period (frequency, duration), age of

menarche, menopause; dysmenorrhea, contraception,

vaginal bleeding, breast masses.

Endocrine: Polyuria, polydipsia, skin or hair changes,

heat intolerance.

Musculoskeletal: Joint pain or swelling, arthritis,

myalgias.

Skin and Lymphatics: Easy bruising,

lymphadenopathy.

Neuropsychiatric: Weakness, seizures, memory

changes, depression.

Physical Examination

General appearance: Note whether the patient appears

ill, well, or malnourished.

Vital Signs: Temperature, heart rate, respirations, blood

pressure.

Skin: Rashes, scars, moles, capillary refill (in seconds).

Lymph Nodes: Cervical, supraclavicular, axillary, inguinal

nodes; size, tenderness.

Head: Bruising, masses. Check fontanels in pediatric

patients.

Eyes: Pupils equal round and react to light and

accommodation (PERRLA); extra ocular movements

intact (EOMI), and visual fields. Funduscopy

(papilledema, arteriovenous nicking, hemorrhages,

exudates); scleral icterus, ptosis.

Ears: Acuity, tympanic membranes (dull, shiny, intact,

injected, bulging).

Mouth and Throat: Mucus membrane color and moisture;

oral lesions, dentition, pharynx, tonsils.

Neck: Jugulovenous distention (JVD) at a 45 degree

incline, thyromegaly, lymphadenopathy, masses, bruits,

abdominojugular reflux.

Chest: Equal expansion, tactile fremitus, percussion,

auscultation, rhonchi, crackles, rubs, breath sounds,

egophony, whispered pectoriloquy.

Heart: Point of maximal impulse (PMI), thrills (palpable

turbulence); regular rate and rhythm (RRR), first and

second heart sounds (S1, S2); gallops (S3, S4),

murmurs (grade 1-6), pulses (graded 0-2+).

Breast: Dimpling, tenderness, masses, nipple discharge;

axillary masses.

Abdomen: Contour (flat, scaphoid, obese, distended);

scars, bowel sounds, bruits, tenderness, masses, liver

span by percussion; hepatomegaly, splenomegaly;

guarding, rebound, percussion note (tympanic),

costovertebral angle tenderness (CVAT), suprapubic

tenderness.

Genitourinary: Inguinal masses, hernias, scrotum,

testicles, varicoceles.

Pelvic Examination: Vaginal mucosa, cervical discharge,

uterine size, masses, adnexal masses, ovaries.

Extremities: Joint swelling, range of motion, edema

(grade 1-4+); cyanosis, clubbing, edema (CCE); pulses

(radial, ulnar, femoral, popliteal, posterior tibial, dorsalis

pedis; simultaneous palpation of radial and femoral

pulses).

Rectal Examination: Sphincter tone, masses, fissures;

test for occult blood, prostate (nodules, tenderness,

size).

Neurological: Mental status and affect; gait, strength

(graded 0-5); touch sensation, pressure, pain, position

and vibration; deep tendon reflexes (biceps, triceps,

patellar, ankle; graded 0-4+); Romberg test (ability to

stand erect with arms outstretched and eyes closed).

Cranial Nerve Examination:

I: Smell

II: Vision and visual fields

III, IV, VI: Pupil responses to light, extraocular eye

movements, ptosis

V: Facial sensation, ability to open jaw against

resistance, corneal reflex.

VII: Close eyes tightly, smile, show teeth

VIII: Hears watch tic; Weber test (lateralization of

sound when tuning fork is placed on top of head);

Rinne test (air conduction last longer than bone

conduction when tuning fork is placed on mastoid

process)

IX, X: Palette moves in midline when patient says "ah,"

speech

XI: Shoulder shrug and turns head against resistance

XII: Stick out tongue in midline

Labs: Electrolytes (sodium, potassium, bicarbonate,

chloride, BUN, creatinine), CBC (hemoglobin,

hematocrit, WBC count, platelets, differential); X-rays,

ECG, urine analysis (UA), liver function tests (LFTs).

Assessment (Impression): Assign a number to each

problem and discuss separately. Discuss differential

diagnosis and give reasons that support the working

diagnosis; give reasons for excluding other diagnoses.

Plan: Describe therapeutic plan for each numbered

problem, including testing, laboratory studies,

medications, and antibiotics.

Admission Check List

1. Call and request old chart, ECG, and X-rays.

2. Stat labs: CBC, Chem 7, cardiac enzymes (myoglobin,

troponin, CPK), INR, PTT, C&S, ABG, UA.

3. Labs: Toxicology screens and drug levels.

4. Cultures: Blood culture x 2, urine and sputum culture

(before initiating antibiotics), sputum Gram stain,

urinalysis.

5. CXR, ECG, diagnostic studies.

6. Discuss case with resident, attending, and family.

Progress Notes

Daily progress notes should summarize developments in

a patient's hospital course, problems that remain active,

plans to treat those problems, and arrangements for

discharge. Progress notes should address every

element of the problem list.

Progress Note

Date/time:

Subjective: Any problems and symptoms of the

patient should be charted. Appetite, pain,

headaches or insomnia may be included.

Objective:

General appearance.

Vitals, including highest temperature over past 24

hours. Fluid I/O (inputs and outputs), including oral,

parenteral, urine, and stool volumes.

Physical exam, including chest and abdomen, with

particular attention to active problems. Emphasize

changes from previous physical exams.

Labs: Include new test results and circle abnormal

values.

Current medications: List all medications and

dosages.

Assessment and Plan: This section should be

organized by problem. A separate assessment

and plan should be written for each problem.

Procedure Note

A procedure note should be written in the chart when a

procedure is performed. Procedure notes are brief

operative notes.

Procedure Note

Date and time:

Procedure:

Indications:

Patient Consent: Document that the indications and

risks were explained to the patient and that the

patient consented: "The patient understands the

risks of the procedure and consents in writing."

Lab tests: Relevant labs, such as the INR and CBC,

chemistry.

Anesthesia: Local with 2% lidocaine.

Description of Procedure: Briefly describe the

procedure, including sterile prep, anesthesia

method, patient position, devices used, anatomic

location of procedure, and outcome.

Complications and Estimated Blood Loss (EBL):

Disposition: Describe how the patient tolerated the

procedure.

Specimens: Describe any specimens obtained and

labs tests which were ordered.

Discharge Note

The discharge note should be written in the patient's chart

prior to discharge.

Discharge Note

Date/time:

Diagnoses:

Treatment: Briefly describe treatment provided

during hospitalization, including surgical

procedures and antibiotic therapy.

Studies Performed: Electrocardiograms, CT scans.

Discharge Medications:

Follow-up Arrangements:

Discharge Summary

Patient's Name and Medical Record Number:

Date of Admission:

Date of Discharge:

Admitting Diagnosis:

Discharge Diagnosis:

Attending or Ward Team Responsible for Patient:

Surgical Procedures, Diagnostic Tests, Invasive

Procedures:

Brief History, Pertinent Physical Examination, and

Laboratory Data: Describe the course of the patient's

disease up until the time that the patient came to the

hospital, including physical exam and laboratory data.

Hospital Course: Describe the course of the patient's

illness while in the hospital, including evaluation,

treatment, medications, and outcome of treatment.

Discharged Condition: Describe improvement or

deterioration in the patient's condition, and describe

present status of the patient.

Disposition: Describe the situation to which the patient

will be discharged (home, nursing home), and indicate

who will take care of patient.

Discharged Medications: List medications and

instructions for patient on taking the medications.

Discharged Instructions and Follow-up Care: Date of

return for follow-up care at clinic; diet, exercise.

Problem List: List all active and past problems.

Copies: Send copies to attending, clinic, consultants.

Prescription Writing

• Patient's name:

• Date:

• Drug name, dosage form, dose, route, frequency

(include concentration for oral liquids or mg strength for

oral solids): Amoxicillin 125mg/5mL 5 mL PO tid

• Quantity to dispense: mL for oral liquids, # of oral solids

• Refills: If appropriate

• Signature

Cardiovascular Disorders

ST-Segment Elevation Myocardial

Infarction

1. Admit to: Coronary care unit

2. Diagnosis: Rule out myocardial infarction

3 Condition:

4. Vital Signs: q1h. Call physician if pulse >90,<60; BP

>150/90, <90/60; R>25, <12; T >38.5°C.

5. Activity: Bed rest with bedside commode.

7. Nursing: Guaiac stools. If patient has chest pain,

obtain 12-lead ECG and call physician.

8. Diet: Cardiac diet, 1-2 gm sodium, low-fat, lowcholesterol

diet. No caffeine or temperature extremes.

9. IV Fluids: D5W at TKO

10. Special Medications:

-Oxygen 2-4 L/min by NC.

-Aspirin 325 mg PO, chew and swallow immediately,

then aspirin EC 162 mg PO qd OR Clopidogrel

(Plavix) 75 mg PO qd (if allergic to aspirin).

-Nitroglycerin 10 mcg/min infusion (50 mg in 250-500

mL D5W, 100-200 mcg/mL). Titrate to control symptoms

in 5-10 mcg/min steps, up to 1-3 mcg/kg/min;

maintain systolic BP >90 OR

-Nitroglycerin SL, 0.4 mg (0.15-0.6 mg) SL q5min until

pain free (up to 3 tabs) OR

-Nitroglycerin spray (0.4 mg/aerosol spray) 1-2 sprays

under the tongue q 5min; may repeat x 2.

-Heparin 60 U/kg IV (max 4000 U) push, then 12

U/kg/hr (max 1000 U/hr) by continuous IV infusion

for 48 hours to maintain aPTT of 50-70 seconds.

Check aPTTq6h x 4, then qd. Repeat aPTT 6 hours

after each heparin dosage change.

Thrombolytic Therapy (within first 6 hours of onset of

chest pain)

Absolute Contraindications to Thrombolytics: Active

internal bleeding, suspected aortic dissection, known

intracranial neoplasm, previous intracranial

hemorrhagic stroke at any time, other strokes or

cerebrovascular events within 1 year, head trauma,

pregnancy, recent non-compressible vascular puncture,

uncontrolled hypertension (>180/110 mm Hg).

Relative Contraindications to Thrombolytics: Severe

hypertension, cerebrovascular disease, recent surgery

(within 2 weeks), cardiopulmonary resuscitation.

A. Alteplase (tPA, tissue plasminogen activator,

Activase):

1. 15 mg IV push over 2 min, followed by 0.75 mg/kg

(max 50 mg) IV infusion over 30 min, followed by 0.5

mg/kg (max 35 mg) IV infusion over 60 min (max

total dose 100 mg).

2. Labs: INR/PTT, CBC, fibrinogen.

B. Reteplase (Retavase):

1. 10 U IV push over 2 min; repeat second 10 U IV

push after 30 min.

2. Labs: INR, aPTT, CBC, fibrinogen.

C. Tenecteplase (TNKase):

<60 kg 30 mg IVP

60-69 kg 35 mg IVP

70-79 kg 40 mg IVP

80-89 kg 45 mg IVP

$90 kg 50 mg IVP

C. Streptokinase (Streptase):

1. 1.5 million IU in 100 mL NS IV over 60 min. Pretreat

with diphenhydramine (Benadryl) 50 mg IV push

AND

Methylprednisolone (Soln-Medrol) 250 mg IV push.

2. Check baseline fibrinogen level and q6h for 24h until

level >100 mg/dL.

3. No IM or arterial punctures, watch IV for bleeding.

Beta-Blockers (within the first 12 hours of onset of

chest pain): Contraindicated in cardiogenic shock.

-Metoprolol (Lopressor) 5 mg IV q2-5min x 3 doses;

then 25 mg PO q6h for 48h, then 100 mg PO q12h;

hold if heart rate <60/min or systolic BP <100 mm

Hg OR

-Atenolol (Tenormin), 5 mg IV, repeated in 5 minutes,

followed by 50-100 mg PO qd OR

-Esmolol (Brevibloc) 500 mcg/kg IV over 1 min, then 50

mcg/kg/min IV infusion, titrated to heart rate >60

bpm (max 300 mcg/kg/min).

Angiotensin Converting Enzyme Inhibitor (within the

first 24 hours of onset of chest pain):

-Lisinopril (Zestril, Prinivil) 2.5-5 mg PO qd; titrate to 10-

20 mg qd.

Long-Acting Nitrates:

-Nitroglycerin patch 0.2 mg/hr qd. Allow for nitrate-free

period to prevent tachyphylaxis.

-Isosorbide dinitrate (Isordil) 10-60 mg PO tid [5,10,20,

30,40 mg] OR

-Isosorbide mononitrate (Imdur) 30-60 mg PO qd.

pFOX (partial fatty acid oxidation) inhibitors

-Ranolazine (Ranexa) 500 mg twice daily, which can be

increased to a maximum of 1000 mg twice daily as

needed; contraindicated in hepatic impairment or

pre-existing QT prolongation.

Aldosterone Receptor Blocker if EF <40%:

-Eplerenone (Inspra) 24 mg PO qd

-Spironolactone (Aldactone) 25 mg PO qd

Statins:

-Rosuvastatin (Crestor) 10 mg PO qhs OR

-Atorvastatin (Lipitor) 10 mg PO qhs OR

-Pravastatin (Pravachol) 40 mg PO qhs OR

-Simvastatin (Zocor) 40 mg PO qhs OR

-Lovastatin (Mevacor) 20 mg PO qhs OR

-Fluvastatin (Lescol)10-20 mg PO qhs.

11. Symptomatic Medications:

-Morphine sulfate 2-4 mg IV push prn chest pain.

-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn

headache.

-Lorazepam (Ativan) 1-2 mg PO tid-qid prn anxiety

-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.

-Docusate (Colace) 100 mg PO bid.

-Ondansetron (Zofran) 2-4 mg IV q4h prn nausea or

vomiting.

-Famotidine (Pepcid) 20 mg IV/PO bid OR

-Lansoprazole (Prevacid) 30 mg qd.

12. Extras: ECG stat and in 12h and in AM, portable

CXR, impedance cardiography, echocardiogram.

Cardiology consult.

13. Labs: SMA7 and 12, magnesium. Cardiac enzymes:

CPK, CPK-MB, troponin T, myoglobin STAT and q8h

x 3. CBC, INR/PTT, UA.

Non-ST Segment Elevation

Myocardial Infarction (NSTEMI)

and Unstable Angina

1. Admit to: Coronary care unit

2. Diagnosis: Acute coronary syndrome

3 Condition:

4. Vital Signs: q1h. Call physician if pulse >90,<60; BP

>150/90, <90/60; R>25, <12; T >38.5°C.

5. Activity: Bed rest with bedside commode.

7. Nursing: Guaiac stools. If patient has chest pain,

obtain 12-lead ECG and call physician.

8. Diet: Cardiac diet, 1-2 gm sodium, low fat, low

cholesterol. No caffeine or temperature extremes.

9. IV Fluids: D5W at TKO

10. Special Medications:

-Oxygen 2-4 L/min by NC.

-Aspirin 325 mg PO, chew and swallow immediately,

then aspirin EC 162 mg PO qd OR

-Clopidogrel (Plavix) 75 mg PO qd (if allergic to aspirin)

OR

-Aspirin 325 mg to chew and swallow, then 81-162 mg

PO qd PLUS clopidogrel 300 mg PO x 1, then 75

mg PO qd.

-Nitroglycerin infusion 10 mcg/min infusion (50 mg in

250-500 mL D5W, 100-200 mcg/mL). Titrate to

control symptoms in 5-10 mcg/min steps, up to 1-3

mcg/kg/min; maintain systolic BP >90 OR

-Nitroglycerin SL, 0.4 mg mg SL q5min until pain-free

(up to 3 tabs) OR

-Nitroglycerin spray (0.4 mg/aerosol spray) 1-2 sprays

under the tongue q 5min; may repeat 2 times.

-Heparin 60 U/kg IV push, then 15 U/kg/hr by

continuous IV infusion for 48 hours to maintain aPTT

of 50-70 seconds. Check aPTTq6h x 4, then qd.

Repeat aPTT 6 hours after each dosage change.

Glycoprotein IIb/IIIa Blockers in High-Risk Patients and

Those with Planned Percutaneous Coronary

Intervention (PCI):

-Eptifibatide (Integrilin) 180 mcg/kg IVP, then 2

mcg/kg/min for 48-72 hours OR

-Tirofiban (Aggrastat) 0.4 mcg/kg/min for 30 min, then

0.1 mcg/kg/min for 48-108 hours.

Glycoprotein IIb/IIIa Blockers for Use During PCI:

-Abciximab (ReoPro) 0.25 mg/kg IVP, then 0.125

mcg/kg/min IV infusion for 12 hours OR

-Eptifibatide (Integrilin) 180 mcg/kg IVP, then 2

mcg/kg/min for 18-24 hours.

Beta-Blockers: Contraindicated in cardiogenic shock.

-Metoprolol (Lopressor) 5 mg IV q2-5min x 3 doses;

then 25 mg PO q6h for 48h, then 100 mg PO q12h;

keep HR <60/min, hold if systolic BP <100 mm Hg

OR

-Atenolol (Tenormin), 5 mg IV, repeated in 5 minutes,

followed by 50-100 mg PO qd OR

-Esmolol (Brevibloc) 500 mcg/kg IV over 1 min, then 50

mcg/kg/min IV infusion, titrated to heart rate >60

bpm (max 300 mcg/kg/min).

Angiotensin Converting Enzyme Inhibitors:

-Lisinopril (Zestril, Prinivil) 2.5-5 mg PO qd; titrate to

10-20 mg qd.

-Benazepril (Lotensin) 10 mg qd OR

-Rampril (Altace) 5-10 mg qd OR

-Perindopril (Aceon) 4-8 mg qd.

Long-Acting Nitrates:

-Nitroglycerin patch 0.2 mg/hr qd. Allow for nitrate-free

period to prevent tachyphylaxis.

-Isosorbide dinitrate (Isordil) 10-60 mg PO tid [5,10,20,

30,40 mg] OR

-Isosorbide mononitrate (Imdur) 30-60 mg PO qd.

Statins:

-Rosuvastatin (Crestor) 10 mg PO qd OR

-Atorvastatin (Lipitor) 10 mg PO qhs OR

-Pravastatin (Pravachol) 40 mg PO qhs OR

-Simvastatin (Zocor) 40 mg PO qhs OR

-Lovastatin (Mevacor) 20 mg PO qhs OR

-Fluvastatin (Lescol)10-20 mg PO qhs.

11. Symptomatic Medications:

-Morphine sulfate 2-4 mg IV push prn chest pain.

-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn

headache.

-Lorazepam (Ativan) 1-2 mg PO tid-qid prn anxiety.

-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.

-Docusate (Colace) 100 mg PO bid.

-Ondansetron (Zofran) 2-4 mg IV q4h prn N/V.

-Famotidine (Pepcid) 20 mg IV/PO bid OR

-Lansoprazole (Prevacid) 30 mg qd.

12. Extras: ECG stat and in 12h and in AM, portable

CXR, impedance cardiography, echocardiogram.

Cardiology consult.

13. Labs: SMA7 and 12, magnesium. Cardiac enzymes:

CPK, CPK-MB, troponin T, myoglobin STAT and q6h

for 24h. CBC, INR/PTT, UA.

Congestive Heart Failure

1. Admit to:

2. Diagnosis: Congestive Heart Failure

3. Condition:

4. Vital Signs: q1h. Call physician if P >120; BP >150/100

<80/60; T >38.5EC; R >25, <10.

5. Activity: Bed rest with bedside commode.

6. Nursing: Daily weights, measure inputs and outputs.

Head-of-bed at 45 degrees, legs elevated.

7. Diet: 1-2 gm salt, cardiac diet.

8. IV Fluids: Heparin lock with flush q shift.

9. Special Medications:

-Oxygen 2-4 L/min by NC.

Diuretics:

-Furosemide (Lasix) 10-160 mg IV qd-bid or 20-80 mg

PO qAM-bid [20, 40, 80 mg] or 10-40 mg/hr IV

infusion OR

-Torsemide (Demadex) 10-40 mg IV or PO qd; max 200

mg/day [5, 10, 20, 100 mg] OR

-Bumetanide (Bumex) 0.5-1 mg IV q2-3h until response;

then 0.5-1.0 mg IV q8-24h (max 10 mg/d); or 0.5-2.0

mg PO qAM.

-Metolazone (Zaroxolyn) 2.5-10 mg PO qd, max 20

mg/d; 30 min before loop diuretic [2.5, 5, 10 mg].

ACE Inhibitors:

-Quinapril (Accupril) 5-10 mg PO qd x 1 dose, then 20-

80 mg PO qd in 1 to 2 divided doses [5, 10, 20, 40

mg] OR

-Lisinopril (Zestril, Prinivil) 5-40 mg PO qd [5, 10, 20, 40

mg] OR

-Benazepril (Lotensin) 10-20 mg PO qd-bid, max 80

mg/d [5, 10, 20, 40 mg] OR

-Fosinopril (Monopril) 10-40 mg PO qd, max 80 mg/d

[10, 20 mg] OR

-Ramipril (Altace) 2.5-10 mg PO qd, max 20 mg/d [1.25,

2.5, 5, 10 mg].

-Captopril (Capoten) 6.25-50 mg PO q8h [12.5,

25,50,100 mg] OR

-Enalapril (Vasotec) 1.25-5 mg slow IV push q6h or 2.5-

20 mg PO bid [5,10,20 mg] OR

-Moexipril (Univasc) 7.5 mg PO qd x 1 dose, then 7.5-

15 mg PO qd-bid [7.5, 15 mg tabs] OR

-Trandolapril (Mavik) 1 mg qd x 1 dose, then 2-4 mg qd

[1, 2, 4 mg tabs].

Angiotensin-II Receptor Blockers:

-Irbesartan (Avapro) 150 mg qd, max 300 mg qd [75,

150, 300 mg].

-Losartan (Cozaar) 25-50 mg bid [25, 50 mg].

-Valsartan (Diovan) 80 mg qd; max 320 mg qd [80, 160

mg].

-Candesartan (Atacand) 8-16 mg qd-bid [4, 8, 16, 32

mg].

-Telmisartan (Micardis) 40-80 mg qd [40, 80 mg].

Adosterone Receptor Blockers:

-Spironolactose (Aldactone) 25 mg PO qd

-Eplerenone (Inspra) 25 mg PO qd.

Beta-Blockers:

-Carvedilol (Coreg) 1.625-3.125 mg PO bid, then slowly

increase the dose every 2 weeks to target dose of 25-

50 mg bid [tab 3.125, 6.25, 12.5, 25 mg] OR

-Metoprolol (Lopressor) start at 12.5 mg bid, then slowly

increase to target dose of 100 mg bid [50, 100 mg]

OR

-Bisoprolol (Zebeta) start at 1.25 mg qd, then slowly

increase to target of 10 mg qd [5,10 mg] OR

-Metoprolol XL (Toprol XL) 50-100 mg PO qd.

Digoxin (Lanoxin) 0.125-0.25 mg PO or IV qd [0.125,

0.25, 0.5 mg].

Inotropic Agents:

-Dobutamine (Dobutrex) 2.5-10 mcg/kg/min IV, max of

14 mcg/kg/min (500 mg in 250 mL D5W, 2 mcg/mL)

OR

-Dopamine (Intropin) 3-15 mcg/kg/min IV (400 mg in

250 cc D5W, 1600 mcg/mL), titrate to CO >4, CI >2;

systolic >90 OR

-Milrinone (Primacor) 0.375 mcg/kg/min IV infusion (40

mg in 200 mL NS, 0.2 mg/mL); titrate to 0.75

mgc/kg/min; arrhythmogenic; may cause hypotension.

Vasodilators:

-Nitroglycerin 5 mcg/min IV infusion (50 mg in 250 mL

D5W). Titrate in increments of 5 mcg/min to control

symptoms and maintain systolic BP >90 mmHg.

-Nesiritide (Natrecor) 2 mcg/kg IV load over 1 min, then

0.010 mcg/kg/min IV infusion. Titrate in increments of

0.005 mcg/kg/min q3h to max 0.03 mcg/kg/min IV

infusion.

-Isosorbide dinitrate/hydralazine (BiDil), 20 mg/37.5

mg tabs, 1-2 tabs tid; shown to decrease mortality

in black patients with heart failure when added to

standard treatment.

Potassium:

-KCL (Micro-K) 20-60 mEq PO qd if the patient is

taking loop diuretics.

Pacing:

-Synchronized biventricular pacing if ejection fraction

<40% and QRS duration >135 msec.

10. Symptomatic Medications:

-Morphine sulfate 2-4 mg IV push prn dyspnea or

anxiety.

-Heparin 5000 U SQ q12h or enoxaparin (Lovenox) 1

mg/kg SC q12h.

-Docusate (Colace) 100-200 mg PO qhs.

-Famotidine (Pepcid) 20 mg IV/PO q12h OR

-Lansoprazole (Prevacid) 30 mg qd.

11. Extras: CXR PA and LAT, ECG now and repeat if

chest pain or palpitations, impedance cardiography,

echocardiogram.

12. Labs: SMA 7&12, CBC; B-type natriuretic peptide

(BNP), cardiac enzymes: CPK, CPK-MB, troponin T,

myoglobin STAT and q6h for 24h. Repeat SMA 7 in

AM. UA.

Supraventricular Tachycardia

1. Admit to:

2. Diagnosis: PSVT

3. Condition:

4. Vital Signs: q1h. Call physician if BP >160/90, <90-

/60; apical pulse >130, <50; R >25, <10; T >38.5EC

5. Activity: Bedrest with bedside commode.

6. Nursing:

7. Diet: Low fat, low cholesterol, no caffeine.

8. IV Fluids: D5W at TKO.

9. Special Medications:

Attempt vagal maneuvers (Valsalva maneuver) before

drug therapy.

Cardioversion (if unstable or refractory to drug therapy):

1. NPO for 6h, digoxin level must be less than 2.4

and potassium and magnesium must be normal.

2. Midazolam (Versed) 2-5 mg IV push.

3. If stable, cardiovert with synchronized 10-50 J,

and increase by 50 J increments if necessary. If

unstable, start with 100 J, then increase to 200 J

and 360 J.

Pharmacologic Therapy of Supraventricular

Tachycardia:

-Adenosine (Adenocard) 6 mg rapid IV over 1-2 sec,

followed by saline flush, may repeat 12 mg IV after

2-3 min, up to max of 30 mg total OR

-Verapamil (Isoptin) 2.5-5 mg IV over 2-3 min (may

give calcium gluconate 1 gm IV over 3-6 min prior

to verapamil); then 40-120 mg PO q8h [40, 80,

120 mg] or verapamil SR 120-240 mg PO qd [120,

180, 240 mg] OR

-Esmolol(Brevibloc) 500 mcg/kg IV over 1 min, then

50 mcg/kg/min IV infusion, titrated to HR of <80

(max of 300 mcg/kg/min) OR

-Diltiazem (Cardizem) 0.25 mg/kg IV over 2-5

minutes, followed by 5 mg/h IV infusion. Titrate to

max 15 mg/h; then diltiazem-CD (Cardizem-CD)

120-240 mg PO qd OR

-Metoprolol (Lopressor) 5 mg IVP q4-6h; then 50-100

mg PO bid, or metoprolol XL (Toprol-XL) 50-100

mg PO qd OR

-Digoxin (Lanoxin) 0.25 mg q4h as needed; up to 1.0-

1.5 mg; then 0.125-0.25 mg PO qd.

10.Symptomatic Medications:

-Lorazepam (Ativan) 1-2 mg PO tid prn anxiety.

11.Extras: Portable CXR, ECG; repeat if chest pain.

Cardiology consult.

12.Labs: CBC, SMA 7 & 12, Mg, thyroid panel. UA.

Ventricular Arrhythmias

1. Ventricular Fibrillation and Tachycardia:

-If unstable (see ACLS protocol): Defibrillate with

unsynchronized 200 J, then 300 J.

-Oxygen 100% by mask.

-Lidocaine (Xylocaine) loading dose 75-100 mg IV,

then 2-4 mg/min IV OR

-Amiodarone (Cordarone) 300 mg in 100 mL of D5W,

IV infusion over 10 min, then 900 mg in 500 mL of

D5W, at 1 mg/min for 6 hrs, then at 0.5 mg/min

thereafter; or 400 mg PO q8h x 14 days, then 200-

400 mg qd.

-Also see "other antiarrhythmics" below.

2. Torsades de Pointes Ventricular Tachycardia:

-Correct underlying causes, including

hypomagnesemia, and hypokalemia, and consider

discontinuing quinidine, procainamide, disopyramide,

moricizine, amiodarone, sotalol, ibutilide,

phenothiazine, haloperidol, tricyclic and tetracyclic

antidepressants, ketoconazole, itraconazole,

bepridil.

-Magnesium sulfate 1-4 gm in IV bolus over 5-15 min,

or infuse 3-20 mg/min for 7-48h until QTc interval

<440 msec.

-Isoproterenol (Isuprel), 2-20 mcg/min (2 mg in 500

mL D5W, 4 mcg/mL).

-Consider ventricular pacing and/or cardioversion.

3. Other Antiarrhythmics:

Class I:

-Moricizine (Ethmozine) 200-300 mg PO q8h, max

900 mg/d [200, 250, 300 mg].

Class Ia:

-Quinidine gluconate (Quinaglute) 324-648 mg PO

q8-12h [324 mg].

-Procainamide (Procan, Procanbid)

IV: 15 mg/kg IV loading dose at 20 mg/min,

followed by 2-4 mg/min continuous IV infusion.

PO: 500 mg (nonsustained release) PO q2h x 2

doses, then Procanbid 1-2 gm PO q12h [500,

1000 mg].

-Disopyramide (Norpace, Norpace CR) 100-300 mg

PO q6-8h [100, 150, mg] or disopyramide CR 100-

150 mg PO bid [100, 150 mg].

Class Ib:

-Lidocaine (Xylocaine) 75-100 mg IV, then 2-4 mg/min

IV

-Mexiletine (Mexitil) 100-200 mg PO q8h, max 1200

mg/d [150, 200, 250 mg].

-Tocainide (Tonocard) loading 400-600 mg PO, then

400-600 mg PO q8-12h (1200-1800 mg/d) PO in

divided doses q8-12h [400, 600 mg].

-Phenytoin (Dilantin), loading dose 100-300 mg IV

given as 50 mg in NS over 10 min IV q5min, then

100 mg IV q5min prn.

Class Ic:

-Flecainide (Tambocor) 50-100 mg PO q12h, max

400 mg/d [50, 100, 150 mg].

-Propafenone (Rythmol) 150-300 mg PO q8h, max

1200 mg/d [150, 225, 300 mg].

Class II:

-Propranolol (Inderal) 1-3 mg IV in NS (max 0.15

mg/kg) or 20-80 mg PO tid-qid [10, 20, 40, 60, 80

mg]; propranolol-LA (Inderal-LA), 80-120 mg PO

qd [60, 80, 120, 160 mg]

-Esmolol (Brevibloc) loading dose 500 mcg/kg over 1

min, then 50-200 mcg/kg/min IV infusion

-Atenolol (Tenormin) 50-100 mg/d PO [25, 50, 100

mg].

-Nadolol (Corgard) 40-100 mg PO qd-bid [20, 40, 80,

120, 160 mg].

-Metoprolol (Lopressor) 50-100 mg PO bid-tid [50,

100 mg], or metoprolol XL (Toprol-XL) 50-200 mg

PO qd [50, 100, 200 mg].

Class III:

-Amiodarone (Cordarone), PO loading 400-1200 mg/d

in divided doses for 2-4 weeks, then 200-400 mg

PO qd (5-10 mg/kg) [200 mg] or amiodarone

(Cordarone) 300 mg in 100 mL of D5W, IV

infusion over 10-20 min, then 900 mg in 500 mL of

D5W, at 1 mg/min for 6 hrs, then at 0.5 mg/min

thereafter.

-Sotalol (Betapace) 40-80 mg PO bid, max 320 mg/d

in 2-3 divided doses [80, 160 mg].

4. Extras: CXR, ECG, Holter monitor, signal averaged

ECG, cardiology consult.

5. Labs: SMA 7&12, Mg, calcium, CBC, drug levels. UA.

Hypertensive Emergencies

1. Admit to:

2. Diagnosis: Hypertensive emergencies

3. Condition:

4. Vital Signs: q30min until BP controlled, then q4h.

5. Activity: Bed rest

6. Nursing: Intra-arterial BP monitoring, daily weights,

inputs and outputs.

7. Diet: Clear liquids.

8. IV Fluids: D5W at TKO.

9. Special Medications:

-Nitroprusside sodium 0.25-10 mcg/kg/min IV (50 mg

in 250 mL of D5W), titrate to desired BP

-Labetalol (Trandate, Normodyne) 20 mg IV bolus

(0.25 mg/kg), then 20-80 mg boluses IV q10-

15min, titrate to desired BP or continuous IV infusion

of 1.0-2.0 mg/min, titrate to desired BP. Ideal

in patients with thoracic or aortic abdominal

aneurysm.

-Fenoldopam (Corlopam) 0.01mcg/kg/min IV infusion.

Adjust dose by 0.025-0.05 mcg/kg/min q15min to

max 0.3 mcg/kg/min. [10 mg in 250 mL D5W].

-Nicardipine (Cardene IV) 5 mg/hr IV infusion,

increase rate by 2.5 mg/hr every 15 min up to 15

mg/hr (25 mg in D5W 250 mL).

-Enalaprilat (Vasotec IV) 1.25- 5.0 mg IV q6h. Do not

use in presence of acute myocardial infarction or

bilateral renal stenosis.

-Esmolol (Brevibloc) 500 mcg/kg/min IV infusion for 1

minute, then 50 mcg/kg/min; titrate by 50

mcg/kg/min increments to 300 mcg/kg/min (2.5 gm

in D5W 250 mL).

-Clonidine (Catapres), initial 0.1-0.2 mg PO followed

by 0.1 mg per hour until DBP <115 (max total

dose of 0.8 mg).

-Phentolamine (pheochromocytoma), 5-10 mg IV,

repeated as needed up to 20 mg.

-Trimethaphan (Arfonad [dissecting aneurysm]) 2-4

mg/min IV infusion (500 mg in 500 mL of D5W).

10. Symptomatic Medications:

-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn

headache.

-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.

-Docusate sodium (Colace) 100-200 mg PO qhs.

11. Extras: Portable CXR, ECG, impedance

cardiography, echocardiogram.

12. Labs: CBC, SMA 7, UA with micro. TSH, free T4,

24h urine for metanephrine. Plasma catecholamines,

urine drug screen.

Hypertension

I. Initial Diagnostic Evaluation of Hypertension

A. 15-Lead electrocardiography may document

evidence of ischemic heart disease, rhythm and

conduction disturbances, or left ventricular

hypertrophy.

B. Screening labs. Complete blood count, glucose,

potassium, calcium, creatinine, BUN, uric acid,

and fasting lipid panel.

C. Urinalysis. Glucose, protein, and hemoglobin.

D. Selected patients may require plasma renin

activity, 24 hour urine catecholamines.

II. Antihypertensive Drugs

A. Thiazide Diuretics

1. Hydrochlorothiazide (HCTZ, HydroDiuril),

12.5-25 mg qd [25 mg].

2. Chlorothiazide (Diuril) 250 mg qd [250, 500

mg].

3. Thiazide/Potassium Sparing Diuretic

Combinations

a. Maxzide (hydrochlorothiazide 50/triamterene

75 mg) 1 tab qd.

b. Moduretic (hydrochlorothiazide 50

mg/amiloride 5 mg) 1 tab qd.

c. Dyazide (hydrochlorothiazide 25

mg/triamterene 37.5) 1 cap qd.

B. Beta-Adrenergic Blockers

1. Cardioselective Beta-Blockers

a. Atenolol (Tenormin) initial dose 50 mg qd,

then 50-100 mg qd, max 200 mg/d [25, 50,

100 mg].

b. Metoprolol XL (Toprol XL) 100-200 mg qd

[50, 100, 200 mg tab ER].

c. Bisoprolol (Zebeta) 2.5-10 mg qd; max 20

mg qd [5,10 mg].

2. Non-Cardioselective Beta-Blockers

a. Propranolol LA (Inderal LA), 80-160 mg qd

[60, 80, 120, 160 mg].

b. Nadolol (Corgard) 40-80 mg qd, max 320

mg/d [20, 40, 80, 120, 160 mg].

c. Pindolol (Visken) 5-20 mg qd, max 60 mg/d

[5, 10 mg].

d. Carteolol (Cartrol) 2.5-10 mg qd [2.5, 5

mg].

C. Angiotensin-Converting Enzyme (ACE)

Inhibitors

1. Ramipril (Altace) 2.5-10 mg qd, max 20

mg/day [1.25, 2.5, 5, 10 mg].

2. Quinapril (Accupril) 20-80 mg qd [5, 10, 20,

40 mg].

3. Lisinopril (Zestril, Prinivil) 10-40 mg qd [2.5,

5, 10, 20, 40 mg].

4. Benazepril (Lotensin) 10-40 mg qd, max 80

mg/day [5, 10, 20, 40 mg].

5. Fosinopril (Monopril) 10-40 mg qd [10, 20

mg].

6. Enalapril (Vasotec) 5-40 mg qd, max 40

mg/day [2.5, 5, 10, 20 mg].

7. Moexipril (Univasc) 7.5-15 mg qd [7.5 mg].

D. Angiotensin Receptor Blockers

1. Losartan (Cozaar) 25-50 mg bid [25, 50 mg].

2. Valsartan (Diovan) 80-160 mg qd; max 320

mg qd [80, 160 mg].

3. Irbesartan (Avapro) 150 mg qd; max 300 mg

qd [75, 150, 300 mg].

4. Candesartan (Atacand) 8-16 mg qd-bid [4, 8,

16, 32 mg].

5. Telmisartan (Micardis) 40-80 mg qd [40, 80

mg].

E. Calcium Entry Blockers

1. Diltiazem SR (Cardizem SR) 60-120 mg bid

[60, 90, 120 mg] or Cardizem CD 180-360 mg

qd [120, 180, 240, 300 mg].

2. Nifedipine XL (Procardia-XL, Adalat-CC) 30-

90 mg qd [30, 60, 90 mg].

3. Verapamil SR (Calan SR, Covera-HS) 120-

240 mg qd [120, 180, 240 mg].

4. Amlodipine (Norvasc) 2.5-10 mg qd [2.5, 5,

10 mg].

5. Felodipine (Plendil) 5-10 mg qd [2.5, 5, 10

mg].

Syncope

1. Admit to: Monitored ward

2. Diagnosis: Syncope

3. Condition:

4. Vital Signs: q1h, postural BP and pulse q12h. Call

physician if BP >160/90, <90/60; P >120, <50; R>25,

<10

5. Activity: Bed rest.

6. Nursing: Fingerstick glucose.

7. Diet: Regular

8. IV Fluids: Normal saline at TKO.

9. Special medications:

High-Grade AV Block with Syncope:

-Atropine 1 mg IV x 2.

-Isoproterenol 0.5-1 mcg/min initially, then slowly

titrate to 10 mcg/min IV infusion (1 mg in 250 mL

NS).

-Transthoracic pacing.

Drug-Induced Syncope:

-Discontinue vasodilators, centrally acting hypotensive

agents, tranquilizers, antidepressants, and alcohol

use.

Vasovagal Syncope:

-Scopolamine 1.5 mg transdermal patch q3 days.

Postural Syncope:

-Midodrine (ProAmatine) 2.5 mg PO tid, then increase

to 5-10 mg PO tid [2.5, 5 mg]; contraindicated in

coronary artery disease.

-Fludrocortisone 0.1-1.0 mg PO qd.

10. Symptomatic Medications:

-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn

headache.

-Docusate sodium (Colace) 100-200 mg PO qhs.

11. Extras: CXR, ECG, 24h Holter monitor,

electrophysiologic study, tilt test, CT/MRI, EEG,

impedance cardiography, echocardiogram.

12. Labs: CBC, SMA 7&12, CPK, CK-MB, troponin T,

myoglobin, Mg, calcium, drug levels. UA, urine drug

screen.

Pulmonary Disorders

Asthma

1. Admit to:

2. Diagnosis: Exacerbation of asthma

3. Condition:

4. Vital Signs: q6h. Call physician if P >140; R >30,

<10; T >38.5EC; pulse oximeter <90%

5. Activity: Up as tolerated.

6. Nursing: Pulse oximeter, bedside peak flow rate

before and after bronchodilator treatments.

7. Diet: Regular, no caffeine.

8. IV Fluids: D5 ½ NS at 125 cc/h.

9. Special Medications:

-Oxygen 2 L/min by NC. Keep O2 sat >90%.

Beta-Agonists, Acute Treatment:

-Albuterol (Ventolin) 0.5 mg and ipratropium

(Atrovent) 0.5 mg in 2.5 mL NS q1-2h until peak

flow meter $200-250 L/min and sat $90%, then q4h

OR

-Levalbuterol (Xopenex) 0.63-1.25 mg by nebulization

q6-8h prn.

-Albuterol (Ventolin) MDI 3-8 puffs, then 2 puffs q3-6h

prn, or powder 200 mcg/capsule inhaled qid.

-Albuterol/Ipratropium (Combivent) 2-4 puffs qid.

Systemic Corticosteroids:

-Methylprednisolone (Solu-Medrol) 60-125 mg IV q6h;

then 30-60 mg PO qd. OR

-Prednisone 20-60 mg PO qAM.

Aminophylline and Theophylline (second-line

therapy):

-Aminophylline load dose: 5.6 mg/kg total body

weight in 100 mL D5W IV over 20 min. Maintenance

of 0.5-0.6 mg/kg ideal body weight/h (500

mg in 250 mL D5W); reduce if elderly, heart/liver

failure (0.2-0.4 mg/kg/hr). Reduce load 50-75% if

taking theophylline (1 mg/kg of aminophylline will

raise levels 2 mcg/mL) OR

-Theophylline IV solution loading dose 4.5 mg/kg total

body weight, then 0.4-0.5 mg/kg ideal body

weight/hr.

-Theophylline (Theo-Dur) 100-400 mg PO bid (3

mg/kg q8h); 80% of total daily IV aminophylline in 2-

3 doses.

Maintenance Inhaled Corticosteroids (adjunct

therapy):

-Advair Diskus (fluticasone/salmeterol) one puff bid

[doses of 100/50 mcg, 250/50 mcg, and 500/50

mcg]. Not appropriate for acute attacks.

-Beclomethasone (Beclovent) MDI 4-8 puffs bid, with

spacer 5 min after bronchodilator, followed by

gargling with water.

-Triamcinolone (Azmacort) MDI 2 puffs tid-qid or 4

puffs bid.

-Flunisolide (AeroBid) MDI 2-4 puffs bid.

-Fluticasone (Flovent) 2-4 puffs bid (44 or 110

mcg/puff).

Maintenance Treatment:

-Salmeterol (Serevent) 2 puffs bid; not effective for

acute asthma because of delayed onset of action.

-Pirbuterol (Maxair) MDI 2 puffs q4-6h prn.

-Bitolterol (Tornalate) MDI 2-3 puffs q1-3min, then 2-3

puffs q4-8h prn.

-Fenoterol (Berotec) MDI 3 puffs, then 2 bid-qid.

-Ipratropium (Atrovent) MDI 2-3 puffs tid-qid.

Prevention and Prophylaxis:

-Cromolyn (Intal) 2-4 puffs tid-qid.

-Nedocromil (Tilade) 2-4 puffs bid-qid.

-Montelukast (Singulair) 10 mg PO qd.

-Zafirlukast (Accolate) 20 mg PO bid.

-Zileuton (Zyflo) 600 mg PO qid.

Acute Bronchitis

-Ampicillin/sulbactam (Unasyn) 1.5 gm IV q6h OR

-Cefuroxime (Zinacef) 750 mg IV q8h OR

-Cefuroxime axetil (Ceftin) 250-500 mg PO bid OR

-Trimethoprim/sulfamethoxazole (Bactrim DS), 1 tab

PO bid OR

-Levofloxacin (Levaquin) 500 mg PO/IV PO qd [250,

500 mg].

-Amoxicillin 875 mg/clavulanate 125 mg (Augmentin

875) 1 tab PO bid.

10. Symptomatic Medications:

-Docusate sodium (Colace) 100 mg PO qhs.

-Famotidine (Pepcid) 20 mg IV/PO q12h OR

-Lansoprazole (Prevacid) 30 mg qd.

-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn

headache.

-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.

11. Extras: Portable CXR, ECG, pulmonary function

tests before and after bronchodilators; pulmonary

rehabilitation; impedance cardiography,

echocardiogram.

12. Labs: ABG, CBC with eosinophil count, SMA7, Btype

natriuretic peptide (BNP). Theophylline level stat

and after 24h of infusion. Sputum Gram stain, C&S.

Chronic Obstructive Pulmonary

Disease

1. Admit to:

2. Diagnosis: Exacerbation of COPD

3. Condition:

4. Vital Signs: q4h. Call physician if P >130; R >30,

<10; T >38.5EC; O2 saturation <90%.

5. Activity: Up as tolerated; bedside commode.

6. Nursing: Pulse oximeter. Measure peak flow with

portable peak flow meter bid and chart with vital signs.

No sedatives.

7. Diet: No added salt, no caffeine. Push fluids.

8. IV Fluids: D5 1/2 NS with 20 mEq KCL/L at 125 cc/h.

9. Special Medications:

-Oxygen 1-2 L/min by NC or 24-35% by Venturi mask,

keep O2 saturation 90-91%.

Beta-Agonists, Acute Treatment:

-Albuterol (Ventolin) 0.5 mg and ipratropium

(Atrovent) 0.5 mg in 2.5 mL NS q1-2h until peak

flow meter $200-250 L/min, then q4h prn OR

-Levalbuterol (Xopenex) 0.63-1.25 mg by

nebulization q6-8h prn.

-Albuterol (Ventolin) MDI 2-4 puffs q4-6h.

-Albuterol/Ipratropium (Combivent) 2-4 puffs qid.

Maintenance Corticosteroids and Anticholinergics:

-Methylprednisolone (Solu-Medrol) 60-125 mg IV q6h

or 30-60 mg PO qd. Followed by:

-Prednisone 20-60 mg PO qd.

-Triamcinolone (Azmacort) MDI 2 puffs qid or 4 puffs

bid.

-Beclomethasone (Beclovent) MDI 4-8 puffs bid with

spacer, followed by gargling with water OR

-Flunisolide (AeroBid) MDI 2-4 puffs bid OR

-Ipratropium (Atrovent) MDI 2 puffs tid-qid OR

-Fluticasone (Flovent) 2-4 puffs bid (44 or 110

mcg/puff).

Aminophylline and Theophylline (second line

therapy):

-Aminophylline loading dose, 5.6 mg/kg total body

weight over 20 min (if not already on theophylline);

then 0.5-0.6 mg/kg ideal body weight/hr (500 mg in

250 mL of D5W); reduce if elderly, or heart or liver

disease (0.2-0.4 mg/kg/hr). Reduce loading to 50-

75% if already taking theophylline (1 mg/kg of

aminophylline will raise levels by 2 mcg/mL) OR

-Theophylline IV solution loading dose, 4.5 mg/kg

total body weight, then 0.4-0.5 mg/kg ideal body

weight/hr.

-Theophylline long acting (Theo-Dur) 100-400 mg PO

bid-tid (3 mg/kg q8h); 80% of daily IV aminophylline

in 2-3 doses.

Acute Bronchitis

-Trimethoprim/sulfamethoxazole (Septra DS) 160/800

mg PO bid or 160/800 mg IV q12h (10-15 mL in 100

cc D5W tid) OR

-Cefuroxime (Zinacef) 750 mg IV q8h OR

-Ampicillin/sulbactam (Unasyn) 1.5 gm IV q6h OR

-Doxycycline (Vibra-tabs) 100 mg PO/IV bid OR

-Azithromycin (Zithromax) 500 mg x 1, then 250 mg

PO qd x 4 or 500 mg IV q24h OR

-Clarithromycin (Biaxin) 250-500 mg PO bid OR

-Levofloxacin (Levaquin) 500 mg PO/IV qd [250, 500

mg].

10. Symptomatic Medications:

-Docusate sodium (Colace) 100 mg PO qhs.

-Famotidine (Pepcid) 20 mg IV/PO bid OR

-Lansoprazole (Prevacid) 30 mg qd.

-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn

headache.

-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.

11. Extras: Portable CXR, PFTs with bronchodilators,

ECG, impedance cardiography, echocardiogram.

12. Labs: ABG, CBC, SMA7, UA. Theophylline level stat

and after 12-24h of infusion. Sputum Gram stain and

C&S, alpha 1 antitrypsin level.

Hemoptysis

1. Admit to: Intensive care unit

2. Diagnosis: Hemoptysis

3. Condition:

4. Vital Signs: q1-6h. Orthostatic BP and pulse bid. Call

physician if BP >160/90, <90/60; P >130, <50; R>25,

<10; T >38.5EC; O2 sat <90%.

5. Activity: Bed rest with bedside commode. Keep patient

in lateral decubitus, Trendelenburg's position,

bleeding side down.

6. Nursing: Quantify all sputum and expectorated blood,

suction prn. O2 at 100% by mask, pulse oximeter. Discontinue

narcotics and sedatives. Have double lumen

endotracheal tube available for use. Foley to closed

drainage.

7. Diet: NPO

8. IV Fluids: 1 L of NS wide open ($6 gauge), then

transfuse PRBC. Then infuse D5 1/2 NS at 125 cc/h.

9. Special Medications:

-Transfuse 2-4 U PRBC wide open.

-Promethazine/codeine (Phenergan with codeine) 5

cc PO q4-6h prn cough. Contraindicated in massive

hemoptysis.

-Initiate empiric antibiotics if bronchitis or infection is

present.

10. Extras: CXR PA, LAT, ECG, VQ scan, contrast CT,

bronchoscopy. PPD, pulmonary and thoracic surgery

consults.

11. Labs: Type and cross 2-4 U PRBC. ABG, CBC,

platelets, SMA7 and 12, ESR. Anti-glomerular

basement antibody, rheumatoid factor, complement,

anti-nuclear cytoplasmic antibody. Sputum Gram

stain, C&S, AFB, fungal culture, and cytology qAM for

3 days. UA, INR/PTT, von Willebrand Factor. Repeat

CBC q6h.

Anaphylaxis

1. Admit to:

2. Diagnosis: Anaphylaxis

3. Condition:

4. Vital Signs: q1-4h; call physician if BP systolic >160,

<90; diastolic >90, <60; P >120, <50; R>25, <10; T

>38.5EC

5. Activity: Bedrest

6. Nursing: O2 at 6 L/min by NC or mask. Keep patient

in Trendelenburg's position, No. 4 or 5 endotracheal

tube at bedside. Foley to closed drainage.

7. Diet: NPO

8. IV Fluids: 2 IV lines. Normal saline or LR 1 L over 1-

2h, then D5 ½ NS at 125 cc/h.

9. Special Medications:

Gastrointestinal Decontamination:

-Gastric lavage with normal saline until clear fluid if

indicated for recent oral ingestion.

-Activated charcoal 50-100 gm, followed by

magnesium citrate 6% solution 150-300 mL PO.

Bronchodilators:

-Epinephrine (1:1000) 0.3-0.5 mL SQ or IM q10min or

1-4 mcg/min IV OR in severe life-threatening

reactions, give 0.5 mg (5.0 mL of 1: 10,000

solution) IV q5-10min prn. Epinephrine, 0.3 mg of

1:1000 solution, may be injected SQ at site of

allergen injection OR

-Albuterol (Ventolin) 0.5%, 0.5 mL in 2.5 mL NS

q30min by nebulizer prn OR

-Aerosolized 2% racemic epinephrine, 0.5-0.75 mL in

2-3 mL saline nebulized q1-6h.

Corticosteroids:

-Methylprednisolone (Solu-Medrol) 250 mg IV x 1,

then 125 mg IV q6h OR

-Hydrocortisone sodium succinate 200 mg IV x 1,

then 100 mg q6h, followed by oral prednisone 60

mg PO qd, tapered over 5 days.

Antihistamines:

-Diphenhydramine (Benadryl) 25-50 mg PO/IV q4-6h

OR

-Hydroxyzine (Vistaril) 25-50 mg IM or PO q2-4h.

-Cetrizine (Zyrtec) 5-10 mg PO qd.

-Cimetadine (Tagamet) 300 mg PO/IV q6-8h.

Pressors and Other Agents:

-Norepinephrine (Levophed) 8-12 mcg/min IV, titrate

to systolic 100 mm Hg (8 mg in 500 mL D5W) OR

-Dopamine (Intropin) 5-20 mcg/kg/min IV.

10. Extras: Portable CXR, ECG, allergy consult.

11. Labs: CBC, SMA 7&12.

Pleural Effusion

1. Admit to:

2. Diagnosis: Pleural effusion

3. Condition:

4. Vital Signs: q shift. Call physician if BP >160/90,

<90/60; P>120, <50; R>25, <10; T >38.5EC

5. Activity:

6. Diet: Regular.

7. IV Fluids: D5W at TKO

8. Extras: CXR PA and LAT, repeat after thoracentesis;

left and right lateral decubitus x-rays, ECG, ultrasound,

PPD; pulmonary consult.

9. Labs: CBC, SMA 7&12, protein, albumin, amylase,

ANA, ESR, INR/PTT, UA. Cryptococcal antigen,

histoplasma antigen, fungal culture.

Thoracentesis:

Tube 1: LDH, protein, amylase, triglyceride, glucose

(10 mL).

Tube 2: Gram stain, C&S, AFB, fungal C&S (20-60

mL, heparinized).

Tube 3: Cell count and differential (5-10 mL, EDTA).

Syringe: pH (2 mL collected anaerobically,

heparinized on ice).

Bag or Bottle: Cytology.

Hematologic Disorders

Anticoagulant Overdose

Unfractionated Heparin Overdose:

1. Discontinue heparin infusion.

2. Protamine sulfate, 1 mg IV for every 100 units of

heparin infused in preceding hour, dilute in 25 mL

fluid, and give IV over 10 min (max 50 mg in 10

min period).

Low-Molecular-Weight Heparin (Enoxaparin)

Overdose:

-Protamine sulfate 1 mg IV for each 1 mg of

enoxaparin given. Repeat protamine 0.5 mg IV for

each 1 mg of enoxaparin, if bleeding continues

after 2-4 hours. Measure factor Xa.

Warfarin (Coumadin) Overdose:

-Gastric lavage with normal saline until clear fluid

and activated charcoal if recent oral ingestion.

Discontinue coumadin and heparin, and

monitor hematocrit q2h.

Partial Reversal:

-Vitamin K (Phytonadione), 0.5-1.0 mg IV/SQ.

Check INR in 24 hours, and repeat vitamin K

dose if INR remains elevated.

Minor Bleeds:

-Vitamin K (Phytonadione), 5-10 mg IV/SQ q12h,

titrated to desired INR.

Serious Bleeds:

-Vitamin K (Phytonadione), 10-20 mg in 50-100 mL

fluid IV over 30-60 min (check INR q6h until

corrected) AND

-Fresh frozen plasma 2-4 units x 1.

-Type and cross match for 2 units of PRBC, and

transfuse wide open.

-Cryoprecipitate 10 U x 1 if fibrinogen is less than

100 mg/dL.

Labs: CBC, platelets, PTT, INR.

Deep Venous Thrombosis

1. Admit to:

2. Diagnosis: Deep vein thrombosis

3. Condition:

4. Vital Signs: q shift. Call physician if BP systolic >160,

<90 diastolic, >90, <60; P >120, <50; R>25, <10; T

>38.5EC.

5. Activity: Bed rest with legs elevated; bedside

commode.

6. Nursing: Guaiac stools, warm packs to leg prn;

measure calf and thigh circumference qd; no

intramuscular injections.

7. Diet: Regular

8. IV Fluids: D5W at TKO

9. Special Medications:

Anticoagulation:

-Heparin (unfractionated) 80 U/kg IVP, then 18

U/kg/hr IV infusion. Check PTT 6 hours after initial

bolus; adjust q6h until PTT 1.5-2.0 times control

(50-80 sec). Overlap heparin and warfarin

(Coumadin) for at least 4 days and discontinue

heparin when INR has been 2.0-3.0 for two

consecutive days OR

-Enoxaparin (Lovenox) outpatient: 1 mg/kg SQ q12h

for DVT without pulmonary embolism. Overlap

enoxaparin and warfarin for 4-5 days until INR is 2-

3.

-Enoxaparin (Lovenox) inpatient: 1 mg/kg SQ q12h or

1.5 mg/kg SQ q24 h for DVT with or without

pulmonary embolism. Overlap enoxaparin and

warfarin (Coumadin) for at least 4 days and

discontinue heparin when INR has been 2.0-3.0 for

two consecutive days.

-Warfarin (Coumadin) 5-10 mg PO qd x 2-3 d;

maintain INR 2.0-3.0. Coumadin is initiated on the

first or second day only if the PTT is 1.5-2.0 times

control [tab 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 mg].

10. Symptomatic Medications:

-Propoxyphene/acetaminophen (Darvocet N100) 1-2

tab PO q3-4h prn pain OR

-Hydrocodone/acetaminophen (Vicodin), 1-2 tab q4-

6h PO prn pain.

-Docusate sodium (Colace) 100 mg PO qhs.

-Famotidine (Pepcid) 20 mg IV/PO q12h OR

-Lansoprazole (Prevacid) 30 mg qd.

-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.

11. Extras: CXR PA and LAT, ECG; Doppler scan of

legs. V/Q scan, chest CT scan.

12. Labs: CBC, INR/PTT, SMA 7. Protein C, protein S,

antithrombin III, anticardiolipin antibody. UA with

dipstick for blood. PTT 6h after bolus and q4-6h until

PTT 1.5-2.0 x control then qd. INR at initiation of

warfarin and qd.

Pulmonary Embolism

1. Admit to:

2. Diagnosis: Pulmonary embolism

3. Condition:

4. Vital Signs: q1-4h. Call physician if BP >160/90,

<90/60; P >120, <50; R >30, <10; T >38.5EC; O2 sat <

90%

5. Activity: Bedrest with bedside commode

6. Nursing: Pulse oximeter, guaiac stools, O2 at 2 L by

NC. Antiembolism stockings. No intramuscular

injections. Foley to closed drainage.

7. Diet: Regular

8. IV Fluids: D5W at TKO.

9. Special Medications:

Anticoagulation:

-Heparin IV bolus 5000-10,000 Units (100 U/kg) IVP,

then 1000-1500 U/h IV infusion (20 U/kg/h) [25,000

U in 500 mL D5W (50 U/mL)]. Check PTT 6 hours

after initial bolus; adjust q6h until PTT 1.5-2 times

control (60-80 sec). Overlap heparin and

Coumadin for at least 4 days and discontinue

heparin when INR has been 2.0-3.0 for two

consecutive days.

-Enoxaparin (Lovenox) 1 mg/kg SQ q12h for 5 days

for uncomplicated pulmonary embolism. Overlap

warfarin as outlined above.

-Warfarin (Coumadin) 5-10 mg PO qd for 2-3 d, then

2-5 mg PO qd. Maintain INR of 2.0-3.0. Coumadin

is initiated on second day if the PTT is 1.5-2.0

times control. Check INR at initiation of warfarin

and qd [tab 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 mg].

Thrombolytics (indicated for hemodynamic

compromise):

Baseline Labs: CBC, INR/PTT, fibrinogen q6h.

Alteplase (recombinant tissue plasminogen

activator, Activase): 100 mg IV infusion over 2

hours, followed by heparin infusion at 15 U/kg/h to

maintain PTT 1.5-2.5 x control OR

Streptokinase (Streptase): Pretreat with

methylprednisolone 250 mg IV push and

diphenhydramine (Benadryl) 50 mg IV push. Then

give streptokinase, 250,000 units IV over 30 min,

then 100,000 units/h for 24-72 hours. Initiate

heparin infusion at 10 U/kg/hour; maintain PTT

1.5-2.5 x control.

10. Symptomatic Medications:

-Meperidine (Demerol) 25-100 mg IV prn pain.

-Docusate sodium (Colace) 100 mg PO qhs.

-Famotidine (Pepcid) 20 mg IV/PO q12h OR

-Lansoprazole (Prevacid) 30 mg qd.

11. Extras: CXR PA and LAT, ECG, VQ scan; chest CT

scan, pulmonary angiography; Doppler scan of lower

extremities, impedance cardiography.

12. Labs: CBC, INR/PTT, SMA7, ABG, cardiac enzymes.

Protein C, protein S, antithrombin III,

anticardiolipin antibody. UA . PTT 6 hours after bolus

and q4-6h. INR now and qd.

Sickle Cell Crisis

1. Admit to:

2. Diagnosis: Sickle Cell Crisis

3. Condition:

4. Vital Signs: q shift.

5. Activity: Bedrest with bathroom privileges.

6. Nursing:

7. Diet: Regular diet, push oral fluids.

8. IV Fluids: D5 ½ NS at 100-125 mL/h.

9. Special Medications:

-Oxygen 2 L/min by NC or 30-100% by mask.

-Meperidine (Demerol) 50-150 mg IM/IV q4-6h prn

pain.

-Hydroxyzine (Vistaril) 25-100 mg IM/IV/PO q3-4h prn

pain.

-Morphine sulfate 10 mg IV/IM/SC q2-4h prn pain OR

-Ketorolac (Toradol) 30-60 mg IV/IM, then 15-30 mg

IV/IM q6h prn pain (maximum of 3 days).

-Acetaminophen/codeine (Tylenol 3) 1-2 tabs PO q4-

6h prn.

-Folic acid 1 mg PO qd.

-Penicillin V (prophylaxis), 250 mg PO qid [tabs

125,250,500 mg].

-Ondansetron (Zofran) 4 mg PO/IV q4-6h prn nausea

or vomiting.

10. Symptomatic Medications:

-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.

-Docusate sodium (Colace) 100-200 mg PO qhs.

Vaccination:

-Pneumovax before discharge 0.5 cc IM x 1 dose.

-Influenza vaccine (Fluogen) 0.5 cc IM once a year in

the Fall.

11. Extras: CXR.

12. Labs: CBC, SMA 7, blood C&S, reticulocyte count,

blood type and screen, parvovirus titers. UA.

Infectious Diseases

Meningitis

1. Admit to:

2. Diagnosis: Meningitis.

3. Condition:

4. Vital Signs: q1h. Call physician if BP systolic

>160/90, <90/60; P >120, <50; R>25, <10; T >39EC

or less than 36EC

5. Activity: Bed rest with bedside commode.

6. Nursing: Respiratory isolation, inputs and outputs,

lumbar puncture tray at bedside.

7. Diet: NPO

8. IV Fluids: D5 ½ NS at 125 cc/h with KCL 20 mEq/L.

9. Special Medications:

Empiric Therapy 15-50 years old:

-Vancomycin 1 gm IV q12h AND EITHER

-Ceftriaxone (Rocephin) 2 gm IV q12h (max 4 gm/d)

OR

Cefotaxime (Claforan) 2 gm IV q4h.

Empiric Therapy >50 years old, Alcoholic, Corticosteroids

or Hematologic Malignancy or other

Debilitating Condition:

-Ampicillin 2 gm IV q4h AND EITHER

-Cefotaxime (Claforan) 2 gm IV q6h OR

Ceftriaxone (Rocephin) 2 gm IV q12h.

-Use Vancomycin 1 gm IV q12h in place of ampicillin

if drug-resistant pneumococcus is suspected.

10. Symptomatic Medications:

-Dexamethasone (Decadron) 0.4 mg/kg IV q12h x 2

days to commence with first dose of antibiotic.

-Heparin 5000 U SC q12h or pneumatic compression

stockings.

-Famotidine (Pepcid) 20 mg IV/PO q12h.

-Acetaminophen (Tylenol) 650 mg PO/PR q4-6h prn

temp >39°C.

-Docusate sodium 100-200 mg PO qhs.

11. Extras: CXR, ECG, PPD, CT scan.

12. Labs: CBC, SMA 7&12. Blood C&S x 2. UA with

micro, urine C&S. Antibiotic levels peak and trough

after 3rd dose, VDRL.

Lumbar Puncture:

CSF Tube 1: Gram stain, C&S for bacteria (1-4 mL).

CSF Tube 2: Glucose, protein (1-2 mL).

CSF Tube 3: Cell count and differential (1-2 mL).

CSF Tube 4: Latex agglutination or counterimmunoelectrophoresis

antigen tests for S. pneumoniae, H.

influenzae (type B), N. meningitides, E. coli, group

B strep, VDRL, cryptococcal antigen, toxoplasma

titers. India ink, fungal cultures, AFB (8-10 mL).

Infective Endocarditis

1. Admit to:

2. Diagnosis: Infective endocarditis

3. Condition:

4. Vital Signs: q4h. Call physician if BP systolic

>160/90, <90/60; P >120, <50; R>25, <10; T >38.5EC

5. Activity: Up ad lib, bathroom privileges.

6. Diet: Regular

7. IV Fluids: Heparin lock with flush q shift.

8. Special Medications:

Subacute Bacterial Endocarditis Empiric Therapy:

-Penicillin G 3-5 million U IV q4h or ampicillin 2 gm IV

q4h AND

Gentamicin 1-1.5/mg/kg IV q8h.

Acute Bacterial Endocarditis Empiric Therapy

-Gentamicin 2 mg/kg IV; then 1-1.5 mg/kg IV q8h

AND

Nafcillin or oxacillin 2 gm IV q4h OR

Vancomycin 1 gm IV q12h (1 gm in 250 mL of D5W

over 1h).

Streptococci viridans/bovis:

-Penicillin G 3-5 million U IV q4h for 4 weeks OR

Vancomycin 1 gm IV q12h for 4 weeks AND

Gentamicin 1 mg/kg q8h for first 2 weeks.

Enterococcus:

-Gentamicin 1 mg/kg IV q8h for 4-6 weeks AND

Ampicillin 2 gm IV q4h for 4-6 weeks OR

Vancomycin 1 gm IV q12h for 4-6 weeks.

Staphylococcus aureus (methicillin sensitive, native

valve):

-Nafcillin or Oxacillin 2 gm IV q4h for 4-6 weeks OR

Vancomycin 1 gm IV q12h for 4-6 weeks AND

Gentamicin 1 mg/kg IV q8h for first 3-5 days.

Methicillin-resistant Staphylococcus aureus (native

valve):

-Vancomycin 1 gm IV q12h (1 gm in 250 mL D5W

over 1h) for 4-6 weeks AND

Gentamicin 1 mg/kg IV q8h for 3-5 days.

Methicillin-resistant Staph aureus or epidermidis

(prosthetic valve):

-Vancomycin 1 gm IV q12h for 6 weeks AND

Rifampin 600 mg PO q8h for 6 weeks AND

Gentamicin 1 mg/kg IV q8h for 2 weeks.

Culture Negative Endocarditis:

-Penicillin G 3-5 million U IV q4h for 4-6 weeks OR

Ampicillin 2 gm IV q4h for 4-6 weeks AND

Gentamicin 1.5 mg/kg q8h for 2 weeks (or nafcillin, 2

gm IV q4h, and gentamicin if Staph aureus

suspected in drug abuser or prosthetic valve).

Fungal Endocarditis:

-Amphotericin B 0.5 mg/kg/d IV plus flucytosine (5-

FC) 150 mg/kg/d PO.

9. Symptomatic Medications:

-Famotidine (Pepcid) 20 mg IV/PO q12h.

-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn

temp >39N C.

-Docusate sodium 100-200 mg PO qhs.

10. Extras: CXR PA and LAT, echocardiogram, ECG.

11. Labs: CBC with differential, SMA 7&12. Blood C&S x

3-4 over 24h, serum cidal titers, minimum inhibitory

concentration, minimum bactericidal concentration.

Repeat C&S in 48h, then once a week. Antibiotic

levels peak and trough at 3rd dose. UA, urine C&S.

Pneumonia

1. Admit to:

2. Diagnosis: Pneumonia

3. Condition:

4. Vital Signs: q4-8h. Call physician if BP >160/90,

<90/60; P >120, <50; R>25, <10; T >38.5EC or O2 saturation <90%.

5. Activity: Up ad lib, bathroom privileges.

6. Nursing: Pulse oximeter, inputs and outputs,

nasotracheal suctioning prn, incentive spirometry.

7. Diet: Regular.

8. IV Fluids: IV D5 ½ NS at 125 cc/hr.

9. Special Medications:

-Oxygen by NC at 2-4 L/min, or 24-50% by Ventimask,

or 100% by non-rebreather (reservoir) to

maintain O2 saturation >90%.

Moderately Ill Patients Without Underlying Lung

Disease From the Community:

-Cefuroxime (Zinacef) 0.75-1.5 gm IV q8h OR

Ampicillin/sulbactam (Unasyn) 1.5 gm IV q6h AND

EITHER

-Erythromycin 500 mg IV/PO q6h OR

Clarithromycin (Biaxin) 500 mg PO bid OR

Azithromycin (Zithromax) 500 mg PO x 1, then 250

mg PO qd x 4 OR

Doxycycline (Vibramycin) 100 mg IV/PO q12h.

Moderately Ill Patients With Recent Hospitalization

or Debilitated Nursing Home Patient:

-Ceftazidime (Fortaz) 1-2 gm IV q8h OR

Cefepime (Maxipime) 1-2 gm IV q12h AND EITHER

Gentamicin 1.5-2 mg/kg IV, then 1.0-1.5 mg/kg IV

q8h or 7 mg/kg in 50 mL of D5W over 60 min IV

q24h OR

-Ciprofloxacin (Cipro) 400 mg IV q12h or 500 mg PO

q12h.

Critically Ill Patients:

-Initial treatment should consist of a macrolide with 2

antipseudomonal agents for synergistic activity:

-Erythromycin 0.5-1.0 gm IV q6h AND EITHER

-Cefepime (Maxipime) 20 mg IV q12h OR

Piperacillin/tazobactam (Zosyn) 3.75-4.50 gm IV q6h

OR

Ticarcillin/clavulanate (Timentin) 3.1 gm IV q6h OR

Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6h

AND EITHER

-Levofloxacin (Levaquin) 500 mg IV q24h OR

Ciprofloxacin (Cipro) 400 mg IV q12h OR

Tobramycin 2.0 mg/kg IV, then 1.5 mg/kg IV q8h or 7

mg/kg IV q24h.

Aspiration Pneumonia (community acquired):

-Clindamycin (Cleocin) 600-900 mg IV q8h (with

gentamicin or 3rd gen cephalosporin) OR

-Ampicillin/sulbactam (Unasyn) 1.5-3 gm IV q6h (with

gentamicin or 3rd gen cephalosporin)

Aspiration Pneumonia (nosocomial):

-Tobramycin 2 mg/kg IV then 1.5 mg/kg IV q8h or 7

mg/kg in 50 mL of D5W over 60 min IV q24h OR

Ceftazidime (Fortaz) 1-2 gm IV q8h AND EITHER

-Clindamycin (Cleocin) 600-900 mg IV q8h OR

Ampicillin/sulbactam or ticarcillin/clavulanate, or

piperacillin/tazobactam or imipenem/cilastatin (see

above) OR

Metronidazole (Flagyl) 500 mg IV q8h.

10. Symptomatic Medications:

-Acetaminophen (Tylenol) 650 mg 2 tab PO q4-6h prn

temp >38°C or pain.

-Docusate sodium (Colace) 100 mg PO qhs.

-Famotidine (Pepcid) 20 mg IV/PO q12h.

-Heparin 5000 U SQ q12h or pneumatic compression

stockings.

11. Extras: CXR PA and LAT, ECG, PPD.

12. Labs: CBC with differential, SMA 7&12, ABG. Blood

C&S x 2. Sputum Gram stain, C&S. Methenamine

silver sputum stain (PCP); AFB smear/culture.

Aminoglycoside levels peak and trough 3rd dose.

UA, urine culture.

Specific Therapy for Pneumonia

Pneumococcus:

-Ceftriaxone (Rocephin) 2 gm IV q12h OR

-Cefotaxime (Claforan) 2 gm IV q6h OR

-Erythromycin 500 mg IV q6h OR

-Levofloxacin (Levaquin) 500 mg IV q24h OR

-Vancomycin 1 gm IV q12h if drug resistance.

Staphylococcus aureus:

-Nafcillin 2 gm IV q4h OR

-Oxacillin 2 gm IV q4h.

Klebsiella pneumoniae:

-Gentamicin 1.5-2 mg/kg IV, then 1.0-1.5 mg/kg IV

q8h or 7 mg/kg in 50 mL of D5W over 60 min IV

q24h OR

Ceftizoxime (Cefizox) 1-2 gm IV q8h OR

Cefotaxime (Claforan) 1-2 gm IV q6h.

Methicillin-resistant staphylococcus aureus (MRSA):

-Vancomycin 1 gm IV q12h.

Vancomycin-Resistant Enterococcus:

-Linezolid (Zyvox) 600 mg IV/PO q12h; active against

MRSA as well OR

-Quinupristin/dalfopristin (Synercid) 7.5 mg/kg IV q8h

(does not cover E faecalis).

Haemophilus influenzae:

-Ampicillin 1-2 gm IV q6h (beta-lactamase negative)

OR

-Ampicillin/sulbactam (Unasyn) 1.5-3.0 gm IV q6h OR

-Cefuroxime (Zinacef) 1.5 gm IV q8h (beta-lactamase

pos) OR

-Ceftizoxime (Cefizox) 1-2 gm IV q8h OR

-Ciprofloxacin (Cipro) 400 mg IV q12h OR

-Ofloxacin (Floxin) 400 mg IV q12h.

-Levofloxacin (Levaquin) 500 mg IV q24h.

Pseudomonas aeruginosa:

-Tobramycin 1.5-2.0 mg/kg IV, then 1.5-2.0 mg/kg IV

q8h or 7 mg/kg in 50 mL of D5W over 60 min IV

q24h AND EITHER

-Piperacillin, ticarcillin, mezlocillin or azlocillin 3 gm IV

q4h OR

-Cefepime (Maxipime) 2 gm IV q12h.

Enterobacter Aerogenes or Cloacae:

-Gentamicin 2.0 mg/kg IV, then 1.5 mg/kg IV q8h

AND EITHER

Meropenem (Merrem) 1 gm IV q8h OR

Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6h.

Serratia Marcescens:

-Ceftizoxime (Cefizox) 1-2 gm IV q8h OR

-Aztreonam (Azactam) 1-2 gm IV q6h OR

-Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6h OR

-Meropenem (Merrem) 1 gm IV q8h.

Mycoplasma pneumoniae:

-Clarithromycin (Biaxin) 500 mg PO bid OR

-Azithromycin (Zithromax) 500 mg PO x 1, then 250

mg PO qd for 4 days OR

-Erythromycin 500 mg PO or IV q6h OR

-Doxycycline (Vibramycin) 100 mg PO/IV q12h OR

-Levofloxacin (Levaquin) 500 mg PO/IV q24h.

Legionella pneumoniae:

-Erythromycin 1.0 gm IV q6h OR

-Levofloxacin (Levaquin) 500 mg PO/IV q24h.

-Rifampin 600 mg PO qd may be added to

erythromycin or levofloxacin.

Moraxella catarrhalis:

-Trimethoprim/sulfamethoxazole (Bactrim, Septra)

one DS tab PO bid or 10 mL IV q12h OR

-Ampicillin/sulbactam (Unasyn) 1.5-3 gm IV q6h OR

-Cefuroxime (Zinacef) 0.75-1.5 gm IV q8h OR

-Erythromycin 500 mg IV q6h OR

-Levofloxacin (Levaquin) 500 mg PO/IV q24h.

Anaerobic Pneumonia:

-Penicillin G 2 MU IV q4h OR

-Clindamycin (Cleocin) 900 mg IV q8h OR

-Metronidazole (Flagyl) 500 mg IV q8h.

Pneumocystis Carinii Pneumonia

and HIV

1. Admit to:

2. Diagnosis: PCP pneumonia

3. Condition:

4. Vital Signs: q2-6h. Call physician if BP >160/90,

<90/60; P >120, <50; R>25, <10; T >38.5EC; O2 sat

<90%

5. Activity: Bedrest, bedside commode.

6. Nursing: Pulse oximeter.

7. Diet: Regular, encourage fluids.

8. IV Fluids: D5 ½ NS at 125 cc/h.

9. Special Medications:

Pneumocystis Carinii Pneumonia:

-Oxygen at 2-4 L/min by NC or by mask.

-Trimethoprim/sulfamethoxazole (Bactrim, Septra) 15

mg of TMP/kg/day (20 mL in 250 mL of D5W IVPB

q8h) for 21 days [inj: 80/400 mg per 5 mL].

-If severe PCP (PaO2 <70 mm Hg): add prednisone

40 mg PO bid for 5 days, then 40 mg qd for 5 days,

then 20 mg qd for 11 days OR Methylprednisolone

(Solu-Medrol) 30 mg IV q12h for 5 days, then 30

mg IV qd for 5 days, then 15 mg IV qd for 11 days.

-Pentamidine (Pentam) 4 mg/kg IV qd for 21 days,

with prednisone as above. Pentamidine is an

alternative if inadequate response or intolerant to

TMP-SMX.

Pneumocystis Carinii Prophylaxis (previous PCP or

CD4 <200, or constitutional symptoms):

-Trimethoprim/SMX DS (160/800 mg) PO qd OR

-Pentamidine, 300 mg in 6 mL sterile water via

Respirgard II nebulizer over 20-30 min q4 weeks

OR

-Dapsone (DDS) 50 mg PO bid or 100 mg twice a

week; contraindicated in G-6-PD deficiency.

Antiretroviral Therapy:

A. Combination therapy with 3 agents (two nucleoside

analogs and a protease inhibitor) is recommended

as initial therapy. Nucleotide analogs are similar to

nucleosides and may be used interchangeably.

Combination of atazanavir plus tenofovir or

lamivudine plus abacavir plus tenofovir should be

avoided because of the risk of treatment failure.

B. Nucleoside Analogs

1. Abacavir (Ziagen) 300 mg PO bid [300 mg, 20

mg/mL].

2. Didanosine (Videx, ddI) 200 mg bid for patients

>60 kg; or 125 mg bid for patients <60 kg.

[chewable tabs: 25, 50, 100, 150 mg; pwd 100,

167, 250 mg packets].

3. Emtricitabine (Emtriva) 200 mg PO qd.

4. Lamivudine (Epivir, 3TC) 150 mg twice daily

[150 mg].

5. Stavudine (Zerit, D4T) 40 mg bid [15 mg, 20

mg, 30 mg and 40 mg capsules].

6. Zalcitabine (Hivid, ddC) 0.75 mg tid [0.375,

0.75].

7. Zidovudine (Retrovir, AZT) 200 mg tid (100,

200 mg caps, 50 mg/5 mL syrup).

C. Protease Inhibitors

1. Amprenavir (Agenerase) 1200 mg bid [50, 150

mg].

2. Atazanavir (Reyataz) 400 mg PO qd.

3. Indinavir (Crixivan) 800 mg tid [200, 400 mg].

4. Lopinavir/ritonavir (Kaletra) 400 mg/100 mg PO

bid.

5. Nelfinavir (Viracept) 750 mg PO tid [250 mg].

6. Ritonavir (Norvir) 600 mg bid [100 mg, 80

mg/dL].

7. Saquinavir (Invirase) 600 mg tid with a meal

[cap 200 mg].

D. Non-Nucleoside Reverse Transcriptase

Inhibitors

1. Delavirdine (U-90) 400 mg tid.

2. Efavirenz (Sustiva) 600 mg PO qd [50, 100, 200

mg].

3. Nevirapine (Viramune) 200 mg qd for 2 weeks,

then bid [200 mg].

E. Nucleotide Analogs

1. Tenofovir (Viread) 300 mg PO qd with food.

Postexposure HIV Prophylaxis

A. The injury should be immediately washed and

scrubbed with soap and water.

B. Zidovudine 200 mg PO tid and lamivudine (3TC)

150 mg PO bid, plus indinavir (Crixivan) 800 mg

PO tid for highest risk exposures. Treatment is

continued for one month.

Zidovudine-Induced Neutropenia/Ganciclovir-

Induced Leucopenia

-Recombinant human granulocyte colony-stimulating

factor (G-CSF, Filgrastim, Neupogen) 1-2 mcg/kg

SQ qd until absolute neutrophil count 500-1000;

indicated only if endogenous erythropoietin level is

low.

10. Symptomatic Medications:

-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn

headache or fever.

-Docusate sodium 100-200 mg PO qhs.

10. Extras: CXR PA and LAT.

11. Labs: ABG, CBC, SMA 7&12. Blood C&S x 2.

Sputum for Gram stain, C&S, AFB. Giemsa

immunofluorescence for Pneumocystis. CD4 count,

HIV RNA, VDRL, serum cryptococcal antigen, UA.

Opportunistic Infections in HIVInfected

Patients

Oral Candidiasis:

-Fluconazole (Diflucan) 100-200 mg PO qd OR

-Ketoconazole (Nizoral) 400 mg PO qd OR

-Itraconazole (Sporanox) 200 mg PO qd OR

-Clotrimazole (Mycelex) troches 10 mg dissolved

slowly in mouth 5 times/d.

Candida Esophagitis:

-Fluconazole (Diflucan) 200-400 mg PO qd for 14-21

days OR

-Ketoconazole (Nizoral) 200 mg PO bid OR

-Itraconazole (Sporanox) 200 mg PO qd for 2 weeks.

-Caspofungin (Cancidas) 50 mg IV qd x 2 weeks.

Primary or Recurrent Mucocutaneous HSV

-Acyclovir (Zovirax), 200-400 mg PO 5 times a day for

10 days, or 5 mg/kg IV q8h OR in cases of

acyclovir resistance, foscarnet, 40 mg/kg IV q8h for

21 days.

Herpes Simplex Encephalitis (or visceral disease):

-Acyclovir (Zovirax) 10 mg/kg IV q8h for 10-21 days.

Herpes Varicella Zoster

-Acyclovir (Zovirax) 10 mg/kg IV over 60 min q8h for

7-14 days OR 800 mg PO 5 times/d for 7-10 days

OR

-Famciclovir (Famvir) 500 mg PO q8h for 7 days [500

mg] OR

-Valacyclovir (Valtrex) 1000 mg PO q8h for 7 days

[500 mg] OR

-Foscarnet (Foscavir) 40 mg/kg IV q8h.

Cytomegalovirus Retinitis:

-Ganciclovir (Cytovene) 5 mg/kg IV (dilute in 100 mL

D5W over 60 min) q12h for 14-21 days OR

-Foscarnet (Foscavir) 60 mg/kg IV q8h for 2-3 weeks

OR

-Cidofovir (Vistide) 5 mg/kg IV over 60 min q week for

2 weeks. Administer probenecid, 2 g PO 3 hours

prior to cidofovir, 1 g PO 2 hours after, and 1 g PO

8 hours after.

Suppressive Treatment for Cytomegalovirus

Retinitis:

-Ganciclovir (Cytovene) 5 mg/kg qd.

-Foscarnet (Foscavir) 90-120 mg IV qd OR

-Cidofovir (Vistide) 5 mg/kg IV over 60 min every 2

weeks with probenecid.

Acute Toxoplasmosis:

-Pyrimethamine 200 mg, then 50-75 mg qd, plus

sulfadiazine 1.0-1.5 gm PO q6h, plus folinic acid

10 mg PO qd OR

-Atovaquone (Mepron) 750 mg PO tid.

Suppressive Treatment for Toxoplasmosis:

-Pyrimethamine 25-50 mg PO qd plus sulfadiazine

0.5-1.0 gm PO q6h plus folinic acid 5 mg PO qd

OR

-Pyrimethamine 50 mg PO qd, plus clindamycin 300

mg PO qid, plus folinic acid 5 mg PO qd.

Cryptococcus Neoformans Meningitis:

-Amphotericin B 0.7-1.0 mg/kg/d IV; total dosage of 2

g, with or without 5-flucytosine 100 mg/kg PO qd in

divided doses, followed by fluconazole (Diflucan)

400 mg PO qd or itraconazole (Sporanox) 200 mg

PO bid 6-8 weeks OR

-Amphotericin B liposomal (Abelcet) 5 mg/kg IV q24h

OR

-Fluconazole (Diflucan) 400-800 mg PO qd for 8-12

weeks

Suppressive Treatment of Cryptococcus:

-Fluconazole (Diflucan) 200 mg PO qd indefinitely.

Active Tuberculosis:

-Isoniazid (INH) 300 mg PO qd; and rifampin 600 mg

PO qd; and pyrazinamide 15-25 mg/kg PO qd (500

mg bid-tid); and ethambutol 15-25 mg/kg PO qd

(400 mg bid-tid).

-All four drugs are continued for 2 months; isoniazid

and rifampin are continued for a period of at least 9

months and at least 6 months after the last

negative cultures.

-Pyridoxine (Vitamin B6) 50 mg PO qd concurrent with

INH.

Prophylaxis for Inactive Tuberculosis:

-Isoniazid 300 mg PO qd; and pyridoxine 50 mg PO

qd for 12 months.

Disseminated Mycobacterium Avium Complex

(MAC):

-Clarithromycin (Biaxin) 500 mg PO bid AND

Ethambutol 800-1000 mg qd; with or without rifabutin

450 mg qd.

Prophylaxis against Mycobacterium Avium Complex:

-Azithromycin (Zithromax) 1200 mg once a week.

Disseminated Coccidioidomycosis:

-Amphotericin (Fungizone) B 0.5-0.8 mg/kg IV qd, to a

total dose 2.0 gm OR

-Amphotericin B liposomal (Abelcet) 5 mg/kg IV q24h

OR

-Fluconazole (Diflucan) 400-800 mg PO or IV qd.

Disseminated Histoplasmosis:

-Amphotericin B (Fungizone) 0.5-0.8 mg/kg IV qd, to a

total dose 15 mg/kg OR

-Amphotericin B liposomal (Abelcet) 5 mg/kg IV q24h

OR

-Fluconazole (Diflucan) 400 mg PO qd OR

-Itraconazole (Sporanox) 300 mg PO bid for 3 days,

then 200 mg PO bid.

Suppressive Treatment for Histoplasmosis:

-Fluconazole (Diflucan) 400 mg PO qd OR

-Itraconazole (Sporanox) 200 mg PO bid.

Septic Arthritis

1. Admit to:

2. Diagnosis: Septic arthritis

3. Condition:

4. Vital Signs: q shift

5. Activity: Up in chair as tolerated. Bedside commode

with assistance.

6. Nursing: Warm compresses prn, keep joint

immobilized. Passive range of motion exercises of the

affected joint bid.

7. Diet: Regular diet.

8. IV Fluids: Heparin lock

9. Special Medications:

Empiric Therapy for Adults without Gonorrhea

Contact:

-Nafcillin or oxacillin 2 gm IV q4h AND

Ceftizoxime (Cefizox) 1 gm IV q8h or ceftazidime 1

gm IV q8h or ciprofloxacin 400 mg IV q12h if Gram

stain indicates presence of Gram negative

organisms.

Empiric Therapy for Adults with Gonorrhea:

-Ceftriaxone (Rocephin) 1 gm IV q12h OR

-Ceftizoxime (Cefizox) 1 gm IV q8h OR

-Ciprofloxacin (Cipro) 400 mg IV q12h.

-Complete course of therapy with cefuroxime axetil

(Ceftin) 400 mg PO bid.

10. Symptomatic Medications:

-Acetaminophen and codeine (Tylenol 3) 1-2 PO q4-

6h prn pain.

-Heparin 5000 U SQ bid.

-Famotidine (Pepcid) 20 mg IV/PO q12h.

-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.

-Docusate sodium 100-200 mg PO qhs.

11. Extras: X-ray views of joint (AP and lateral), CXR.

Synovial fluid culture. Physical therapy consult for

exercise program.

12. Labs: CBC, SMA 7&12, blood C&S x 2, VDRL, UA.

Gonorrhea cultures of urethra, cervix. Antibiotic levels.

Blood cultures x 2 for gonorrhea.

Synovial fluid:

Tube 1 - Glucose, protein, lactate, pH.

Tube 2 - Gram stain, C&S.

Tube 3 - Cell count.

Septic Shock

1. Admit to:

2. Diagnosis: Sepsis

3. Condition:

4. Vital Signs: q1h; Call physician if BP >160/90,

<90/60; P >120, <50; R>25, <10; T >38.5EC; urine

output < 25 cc/hr for 4h, O2 saturation <90%.

5. Activity: Bed rest.

6. Nursing: Inputs and outputs, pulse oximeter. Foley

catheter to closed drainage.

7. Diet: NPO

8. IV Fluids: 1 liter of normal saline wide open, then D5

½ NS at 125 cc/h

9. Special Medications:

-Oxygen at 2-5 L/min by NC or mask.

Antibiotic Therapy

A. Initial treatment of life-threatening sepsis should

include a third-generation cephalosporin

(cefepime, ceftazidime, cefotaxime, ceftizoxime or

ceftriaxone), or piperacillin/tazobactam, or

ticarcillin/clavulanic acid or imipenem, each with an

aminoglycoside (gentamicin, tobramycin or

amikacin). If Enterobacter aerogenes or cloacae is

suspected, treatment should begin with

meropenem or imipenem with an aminoglycoside.

B. Intra-abdominal or pelvic infections, likely to

involve anaerobes, should be treated with

ampicillin, gentamicin and metronidazole; or either

ticarcillin/clavulanic acid, ampicillin/sulbactam,

piperacillin/tazobactam, imipenem, cefoxitin or

cefotetan, each with an aminoglycoside.

C. Febrile neutropenic patients with neutrophil

counts <500/mm3 should be treated with

vancomycin and ceftazidime, or

piperacillin/tazobactam and tobramycin or

imipenem and tobramycin.

D. Dosages for Antibiotics Used in Sepsis

-Ampicillin 1-2 gm IV q4h.

-Cefepime (Maxipime) 2 gm IV q12h.

-Cefotaxime (Claforan) 2 gm q4-6h.

-Ceftizoxime (Cefizox) 1-2 gm IV q8h.

-Ceftriaxone (Rocephin) 1-2 gm IV q12h (max 4

gm/d).

-Cefoxitin (Mefoxin) 1-2 gm q6h.

-Cefotetan (Cefotan) 1-2 gm IV q12h.

-Ceftazidime (Fortaz) 1-2 g IV q8h.

-Ticarcillin/clavulanate (Timentin) 3.1 gm IV q4-6h

(200-300 mg/kg/d).

-Ampicillin/sulbactam (Unasyn) 1.5-3.0 gm IV q6h.

-Piperacillin/tazobactam (Zosyn) 3.375-4.5 gm IV

q6h.

-Piperacillin or ticarcillin 3 gm IV q4-6h.

-Imipenem/cilastatin (Primaxin) 1.0 gm IV q6h.

-Meropenem (Merrem) 0.5-1.0 gm IV q8h.

-Gentamicin, tobramycin 100-120 mg (1.5 mg/kg)

IV, then 80 mg IV q8h (1 mg/kg) or 7 mg/kg in 50

mL of D5W over 60 min IV q24h.

-Amikacin (Amikin) 7.5 mg/kg IV loading dose;

then 5 mg/kg IV q8h.

-Vancomycin 1 gm IV q12h.

-Metronidazole (Flagyl) 500 mg (7.5 mg/kg) IV q6-

8h.

-Clindamycin (Cleocin) 900 mg IV q8h.

-Aztreonam (Azactam) 1-2 gm IV q6-8h; max 8

g/day.

Nosocomial sepsis with IV catheter or IV drug abuse

-Nafcillin or oxacillin 2 gm IV q4h OR

-Vancomycin 1 gm q12h (1 gm in 250 cc D5W over 60

min) AND

Gentamicin or tobramycin as above AND EITHER

Ceftazidime (Fortaz) or ceftizoxime (Cefizox)1-2 gm

IV q8h OR

Piperacillin, ticarcillin or mezlocillin 3 gm IV q4-6h.

Recombinant human activated protein C

-Drotrecogin alfa, (Xigris), 24 mg/kg/h IV infusion for

96 hours.

Blood Pressure Support

-Dopamine 4-20 mcg/kg/min (400 mg in 250 cc D5W,

1600 mcg/mL).

-Norepinephrine 2-8 mcg/min IV infusion (8 mg in 250

mL D5W).

-Albumin 25 gm IV (100 mL of 25% solution) OR

-Hetastarch (Hespan) 500-1000 cc over 30-60 min

(max 1500 cc/d).

-Dobutamine 5 mcg/kg/min, and titrate blood pressure

to keep systolic BP >90 mm Hg; max 10

mcg/kg/min.

10. Symptomatic Medications:

-Acetaminophen (Tylenol) 650 mg PR q4-6h prn temp

>39EC.

-Famotidine (Pepcid) 20 mg IV/PO q12h.

-Heparin 5000 U SQ q12h or pneumatic compression

stockings.

-Docusate sodium 100-200 mg PO qhs.

11. Extras: CXR, KUB, ECG. Ultrasound, lumbar puncture.

12. Labs: CBC with differential, SMA 7&12, blood C&S x

3, T&C for 3-6 units PRBC, INR/PTT, drug levels peak

and trough at 3rd dose. UA. Cultures of urine, sputum,

wound, IV catheters, decubitus ulcers, pleural fluid.

Peritonitis

1. Admit to:

2. Diagnosis: Peritonitis

3. Condition:

4. Vital Signs: q1-6h. Call physician if BP >160/90, <90-

/60; P >120, <50; R>25, <10; T >38.5EC.

5. Activity: Bed rest.

6. Nursing: Guaiac stools.

7. Diet: NPO

8. IV Fluids: D5 ½ NS at 125 cc/h.

9. Special Medications:

Primary Bacterial Peritonitis - Spontaneous:

Option 1:

-Ampicillin 1-2 gm IV q 4-6h (vancomycin 1 gm IV

q12h if penicillin allergic) AND EITHER

Cefotaxime (Claforan) 1-2 gm IV q6h OR

Ceftizoxime (Cefizox) 1-2 gm IV q8h OR

Gentamicin or tobramycin 1.5 mg/kg IV, then 1 mg/kg

q8h or 7 mg/kg in 50 mL of D5W over 60 min IV

q24h.

Option 2:

-Ticarcillin/clavulanate (Timentin) 3.1 gm IV q6h OR

-Piperacillin/tazobactam (Zosyn) 3.375 gm IV q6h OR

-Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6h OR

-Meropenem (Merrem) 500-1000 mg IV q8h.

Secondary Bacterial Peritonitis - Abdominal

Perforation or Rupture:

Option 1:

-Ampicillin 1-2 gm IV q4-6h AND

Gentamicin or tobramycin as above AND

Metronidazole (Flagyl) 500 mg IV q8h OR

Cefoxitin (Mefoxin) 1-2 gm IV q6h OR

Cefotetan (Cefotan) 1-2 gm IV q12h.

Option 2:

-Ticarcillin/clavulanate (Timentin) 3.1 gm IV q4-6h

(200-300 mg/kg/d) with an aminoglycoside as

above OR

-Piperacillin/tazobactam (Zosyn) 3.375 gm IV q6h with

an aminoglycoside as above OR

-Ampicillin/sulbactam (Unasyn) 1.5-3.0 gm IV q6h with

aminoglycoside as above OR

-Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6-8h

OR

-Meropenem (Merrem) 500-1000 mg IV q8h.

Fungal Peritonitis:

-Amphotericin B peritoneal dialysis, 2 mg/L of dialysis

fluid over the first 24 hours, then 1.5 mg in each

liter OR

-Fluconazole (Diflucan) 200 mg IV x 1, then 100 mg

IV qd.

-Caspofungin (Candidas) 70 mg IV x1, then 50 mg IV

qd.

10. Symptomatic Medications:

-Famotidine (Pepcid) 20 mg IV/PO q12h.

-Acetaminophen (Tylenol) 325 mg PO/PR q4-6h prn

temp >38.5EC.

-Heparin 5000 U SQ q12h.

11. Extras: Plain film, upright abdomen, lateral decubitus,

CXR PA and LAT; surgery consult; ECG,

abdominal ultrasound, CT scan.

12. Labs: CBC with differential, SMA 7&12, amylase,

lactate, INR/PTT, UA with micro, C&S; drug levels

peak and trough 3rd dose.

Paracentesis Tube 1: Cell count and differential (1-2

mL, EDTA purple top tube).

Tube 2: Gram stain of sediment; inject 10-20 mL into anaerobic

and aerobic culture bottle; AFB, fungal C&S

(3-4 mL).

Tube 3: Glucose, protein, albumin, LDH, triglycerides,

specific gravity, bilirubin, amylase (2-3 mL, red top

tube).

Syringe: pH, lactate (3 mL).

Diverticulitis

1. Admit to:

2. Diagnosis: Diverticulitis

3. Condition:

4. Vital Signs: qid. Call physician if BP systolic >160/90,

<90/60; P >120, <50; R>25, <10; T >38.5EC.

5. Activity: Up ad lib.

6. Nursing: Inputs and outputs.

7. Diet: NPO. Advance to clear liquids as tolerated.

8. IV Fluids: 0.5-2 L NS over 1-2 hr then, D5 ½ NS at

125 cc/hr. NG tube at low intermittent suction (if

obstructed).

9. Special Medications:

Regimen 1:

-Gentamicin or tobramycin 100-120 mg IV (1.5-2

mg/kg), then 80 mg IV q8h (5 mg/kg/d) or 7 mg/kg

in 50 mL of D5W over 60 min IV q24h AND

EITHER

Cefoxitin (Mefoxin) 2 gm IV q6-8h OR

Clindamycin (Cleocin) 600-900 mg IV q8h.

Regimen 2:

-Metronidazole (Flagyl) 500 mg q8h AND

Ciprofloxacin (Cipro) 250-500 mg PO bid or 200-300

mg IV q12h.

Outpatient Regimen:

-Metronidazole (Flagyl) 500 mg PO q6h AND EITHER

Ciprofloxacin (Cipro) 500 mg PO bid OR

Trimethoprim/SMX (Bactrim) 1 DS tab PO bid.

10. Symptomatic Medications:

-Meperidine (Demerol) 50-100 mg IM or IV q3-4h prn

pain.

-Zolpidem (Ambien) 5-10 mg qhs PO prn insomnia.

11. Extras: Acute abdomen series, CXR PA and LAT,

ECG, CT scan of abdomen, ultrasound, surgery and

GI consults.

12. Labs: CBC with differential, SMA 7&12, amylase,

lipase, blood cultures x 2, drug levels peak and trough

3rd dose. UA, C&S.

Lower Urinary Tract Infection

1. Admit to:

2. Diagnosis: UTI.

3. Condition:

4. Vital Signs: q shift. Call physician if BP <90/60; >160-

/90; R >30, <10; P >120, <50; T >38.5EC.

5. Activity: Up ad lib

6. Nursing:

7. Diet: Regular

8. IV Fluids:

9. Special Medications:

Lower Urinary Tract Infection (treat for 3-7 days):

-Trimethoprim-sulfamethoxazole (Septra) 1 double

strength tab (160/800 mg) PO bid.

-Norfloxacin (Noroxin) 400 mg PO bid.

-Ciprofloxacin (Cipro) 250 mg PO bid.

-Levofloxacin (Levaquin) 500 mg IV/PO q24h.

-Lomefloxacin (Maxaquin) 400 mg PO qd.

-Enoxacin (Penetrex) 200-400 mg PO q12h; 1h

before or 2h after meals.

-Cefpodoxime (Vantin) 100 mg PO bid.

-Cephalexin (Keflex) 500 mg PO q6h.

-Cefixime (Suprax) 200 mg PO q12h or 400 mg PO

qd.

-Cefazolin (Ancef) 1-2 gm IV q8h.

Complicated or Catheter-Associated Urinary Tract

Infection:

-Ceftizoxime (Cefizox) 1 gm IV q8h.

-Gentamicin 2 mg/kg, then 1.5/kg q8h or 7 mg/kg in

50 mL of D5W over 60 min IV q24h.

-Ticarcillin/clavulanate (Timentin) 3.1 gm IV q4-6h

-Ciprofloxacin (Cipro) 500 mg PO bid.

-Levofloxacin (Levaquin) 500 mg IV/PO q24h.

Prophylaxis ($3 episodes/yr):

-Trimethoprim/SMX single strength tab PO qhs.

Candida Cystitis

-Fluconazole (Diflucan) 100 mg PO or IV x 1 dose,

then 50 mg PO or IV qd for 5 days OR

-Amphotericin B continuous bladder irrigation, 50

mg/1000 mL sterile water via 3-way Foley catheter

at 1 L/d for 5 days.

10. Symptomatic Medications:

-Phenazopyridine (Pyridium) 100 mg PO tid.

-Docusate sodium (Colace) 100 mg PO qhs.

-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn

temp >39N C.

-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.

11. Extras: Renal ultrasound.

12. Labs: CBC, SMA 7. UA with micro, urine Gram stain,

C&S.

Pyelonephritis

1. Admit to:

2. Diagnosis: Pyelonephritis

3. Condition:

4. Vital Signs: tid. Call physician if BP <90/60; >160/90;

R >30, <10; P >120, <50; T >38.5EC.

5. Activity:

6. Nursing: Inputs and outputs.

7. Diet: Regular

8. IV Fluids: D5 ½ NS at 125 cc/h.

9. Special Medications:

-Trimethoprim-sulfamethoxazole (Septra) 160/800 mg

(10 mL in 100 mL D5W IV over 2 hours) q12h or 1

double strength tab PO bid.

-Ciprofloxacin (Cipro) 500 mg PO bid or 400 mg IV

q12h.

-Norfloxacin (Noroxin) 400 mg PO bid.

-Ofloxacin (Floxin) 400 mg PO or IV bid.

-Levofloxacin (Levaquin) 500 mg PO/IV q24h.

-In more severely ill patients, treatment with an IV

third-generation cephalosporin, or

ticarcillin/clavulanic acid, or piperacillin/tazobactam

or imipenem is recommended with an

aminoglycoside.

-Ceftizoxime (Cefizox) 1 gm IV q8h.

-Ceftazidime (Fortaz) 1 gm IV q8h.

-Ticarcillin/clavulanate (Timentin) 3.1 gm IV q6h.

-Piperacillin/tazobactam (Zosyn) 3.375 gm IV/PB q6h.

-Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6-8h.

-Gentamicin or tobramycin, 2 mg/kg IV, then 1.5

mg/kg q8h or 7 mg/kg in 50 mL of D5W over 60

min IV q24h.

10. Symptomatic Medications:

-Phenazopyridine (Pyridium) 100 mg PO tid.

-Meperidine (Demerol) 50-100 mg IM q4-6h prn pain.

-Docusate sodium (Colace) 100 mg PO qhs.

-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn

temp >39N C.

-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.

11. Extras: Renal ultrasound, KUB.

12. Labs: CBC with differential, SMA 7. UA with micro,

urine Gram stain, C&S; blood C&S x 2. Drug levels

peak and trough third dose.

Osteomyelitis

1. Admit to:

2. Diagnosis: Osteomyelitis

3. Condition:

4. Vital Signs: qid. Call physician if BP <90/60; T

>38.5EC.

5. Activity: Bed rest with bathroom privileges.

6. Nursing: Keep involved extremity elevated. Range of

motion exercises tid.

7. Diet: Regular, high fiber.

8. IV Fluids: Heparin lock with flush q shift.

9. Special Medications:

Adult Empiric Therapy:

-Nafcillin or oxacillin 2 gm IV q4h OR

-Cefazolin (Ancef) 1-2 gm IV q8h OR

-Vancomycin 1 gm IV q12h (1 gm in 250 cc D5W over

1h).

-Add 3rd generation cephalosporin if gram negative

bacilli on Gram stain. Treat for 4-6 weeks.

Post-Operative or Post-Trauma:

-Vancomycin 1 gm IV q12h AND ceftazidime (Fortaz)

1-2 gm IV q8h.

-Imipenem/cilastatin (Primaxin)(single-drug

treatment) 0.5-1.0 gm IV q6-8h.

-Ticarcillin/clavulanate (Timentin)(single-drug

treatment) 3.1 gm IV q4-6h.

-Ciprofloxacin (Cipro) 500-750 mg PO bid or 400 mg

IV q12h AND

Rifampin 600 mg PO qd.

Osteomyelitis with Decubitus Ulcer:

-Cefoxitin (Mefoxin), 2 gm IV q6-8h.

-Ciprofloxacin (Cipro) and metronidazole 500 mg IV

q8h.

-Imipenem/cilastatin (Primaxin), 0.5-1.0 gm IV q6-8h.

-Nafcillin, gentamicin and clindamycin; see dosage

above.

10. Symptomatic Medications:

-Meperidine (Demerol) 50-100 mg IM q3-4h prn pain.

-Docusate (Colace) 100 mg PO qhs.

-Heparin 5000 U SQ bid.

11. Extras: Technetium/gallium bone scans, multiple Xray

views, CT/MRI.

12. Labs: CBC with differential, SMA 7, blood C&S x 3,

MIC, MBC, UA with micro, C&S. Needle biopsy of

bone for C&S. Trough antibiotic levels.

Active Pulmonary Tuberculosis

1. Admit to:

2. Diagnosis: Active Pulmonary Tuberculosis

3. Condition:

4. Vital Signs: q shift

5. Activity: Up ad lib in room.

6. Nursing: Respiratory isolation.

7. Diet: Regular

8. Special Medications:

-Isoniazid 300 mg PO qd (5 mg/kg/d, max 300 mg/d)

AND

Rifampin 600 mg PO qd (10 mg/kg/d, 600 mg/d max)

AND

Pyrazinamide 500 mg PO bid-tid (15-30 mg/kg/d,

max 2.5 gm) AND

Ethambutol 400 mg PO bid-tid (15-25 mg/kg/d, 2.5

gm/d max).

-Empiric treatment consists of a 4-drug combination of

isoniazid (INH), rifampin, pyrazinamide (PZA), and

either ethambutol or streptomycin. A modified

regimen is recommended for patients known to

have INH-resistant TB. Treat for 8 weeks with the

four-drug regimen, followed by 18 weeks of INH

and rifampin.

-Pyridoxine 50 mg PO qd with INH.

Prophylaxis

-Isoniazid 300 mg PO qd (5 mg/kg/d) x 6-9 months.

9. Extras: CXR PA, LAT, ECG.

10. Labs: CBC with differential, SMA7 and 12, LFTs,

HIV serology. First AM sputum for AFB x 3 samples.

Cellulitis

1. Admit to:

2. Diagnosis: Cellulitis

3. Condition:

4. Vital Signs: tid. Call physician if BP <90/60; T

>38.5EC

5. Activity: Up ad lib.

6. Nursing: Keep affected extremity elevated; warm

compresses prn.

7. Diet: Regular, encourage fluids.

8. IV Fluids: Heparin lock with flush q shift.

9. Special Medications:

Empiric Therapy Cellulitis

-Nafcillin or oxacillin 1-2 gm IV q4-6h OR

-Cefazolin (Ancef) 1-2 gm IV q8h OR

-Vancomycin 1 gm q12h (1 gm in 250 cc D5W over

1h) OR

-Erythromycin 500 IV/PO q6h OR

-Dicloxacillin 500 mg PO qid; may add penicillin VK,

500 mg PO qid, to increase coverage for

streptococcus OR

-Cephalexin (Keflex) 500 mg PO qid.

Immunosuppressed, Diabetic Patients, or Ulcerated

Lesions:

-Nafcillin or cefazolin and gentamicin or aztreonam.

Add clindamycin or metronidazole if septic.

-Cefazolin (Ancef) 1-2 gm IV q8h.

-Cefoxitin (Mefoxin) 1-2 gm IV q6-8h.

-Gentamicin 2 mg/kg, then 1.5 mg/kg IV q8h or 7

mg/kg in 50 mL of D5W over 60 min IV q24h OR

aztreonam (Azactam) 1-2 gm IV q6h PLUS

-Metronidazole (Flagyl) 500 mg IV q8h or clindamycin

900 mg IV q8h.

-Ticarcillin/clavulanate (Timentin) (single-drug

treatment) 3.1 gm IV q4-6h.

-Ampicillin/Sulbactam (Unasyn) (single-drug

therapy) 1.5-3.0 gm IV q6h.

-Imipenem/cilastatin (Primaxin) (single-drug therapy)

0.5-1 mg IV q6-8h.

10. Symptomatic Medications:

-Acetaminophen/codeine (Tylenol #3) 1-2 PO q4-6h

prn pain.

-Docusate (Colace) 100 mg PO qhs.

-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn

temp >39N C.

-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.

11. Extras: Technetium/Gallium scans.

12. Labs: CBC, SMA 7, blood C&S x 2. Leading edge

aspirate for Gram stain, C&S; UA, antibiotic levels.

Pelvic Inflammatory Disease

1. Admit to:

2. Diagnosis: Pelvic Inflammatory Disease

3. Condition:

4. Vital Signs: q8h. Call physician if BP >160/90,

<90/60; P >120, <50; R>25, <10; T >38.5EC

5. Activity: Up ad lib.

6. Nursing: Inputs and outputs.

7. Diet: Regular

8. IV Fluids: D5 ½ NS at 100-125 cc/hr.

9. Special Medications:

-Cefotetan (Cefotan), 2 g IV q12h, or cefoxitin

(Mefoxin, 2 g IV q6h) plus doxycycline (100 mg IV

or PO q12h) OR

-Clindamycin (Cleocin), 900 mg IV q8h, plus

gentamicin (1-1.5 mg/kg IV q8h)

-Ampicillin-sulbactam (Unasyn), 3 g IV Q6h plus

doxycycline (100 mg IV or PO Q12h)

-Parenteral administration of antibiotics should be

continued for 24 hours after clinical response,

followed by doxycycline (100 mg PO BID) or

clindamycin (Cleocin, 450 mg PO QID) for a total

of 14 days.

-Levofloxacin (Levaquin), 500 mg IV q24h, plus

metronidazole (Flagyl, 500 mg IV q8h). With this

regimen, azithromycin (Zithromax, 1 g PO once)

should be given as soon as the patient is tolerating

oral intake.

10. Symptomatic Medications:

-Acetaminophen (Tylenol) 1-2 tabs PO q4-6h prn pain

or temperature >38.5EC.

-Meperidine (Demerol) 25-100 mg IM q4-6h prn pain.

-Zolpidem (Ambien) 10 mg PO qhs prn insomnia.

11. Labs: beta-HCG pregnancy test, CBC, SMA 7&12,

ESR. GC culture, chlamydia direct fluorescent

antibody stain. UA with micro, C&S, VDRL, HIV, blood

cultures x 2. Pelvic ultrasound.

Gastrointestinal Disorders

Gastroesophageal Reflux Disease

1. Admit to:

2. Diagnosis: Gastroesophageal reflux disease.

3. Condition:

4. Vital Signs: q4h. Call physician if BP >160/90,

<90/60; P >120, <50; T >38.5EC.

5. Activity: Up ad lib. Elevate the head of the bed by 6

to 8 inches.

6. Nursing: Guaiac stools.

7. Diet: Low-fat diet; no cola, citrus juices, or tomato

products; avoid the supine position after meals; no

eating within 3 hours of bedtime.

8. IV Fluids: D5 ½ NS with 20 mEq KCL at TKO.

9. Special Medications:

-Pantoprazole (Protonix) 40 mg PO/IV q24h OR

-Nizatidine (Axid) 300 mg PO qhs OR

-Omeprazole (Prilosec) 20 mg PO bid (30 minutes

prior to meals) OR

-Lansoprazole (Prevacid) 15-30 mg PO qd [15, 30 mg

caps] OR

-Esomeprazole (Nexium) 20 or 40 mg PO qd OR

-Rabeprazole (Aciphex) 20 mg delayed-release tablet

PO qd OR

-Ranitidine (Zantac) 50 mg IV bolus, then continuous

infusion at 12.5 mg/h (300 mg in 250 mL D5W at

11 mL/h over 24h) or 50 mg IV q8h OR

-Cimetidine (Tagamet) 300 mg IV bolus, then

continuous infusion at 50 mg/h (1200 mg in 250

mL D5W over 24h) or 300 mg IV q6-8h OR

-Famotidine (Pepcid) 20 mg IV q12h.

10. Symptomatic Medications:

-Mylanta Plus or Maalox Plus 30 mg PO q2h prn.

-Trimethobenzamide (Tigan) 100-250 mg PO or 100-

200 mg IM/PR q6h prn nausea OR

-Prochlorperazine (Compazine) 5-10 mg IM/IV/PO q4-

6h or 25 mg PR q4-6h prn nausea.

11. Extras: Upright abdomen, KUB, CXR, ECG,

endoscopy. GI consult, surgery consult.

12. Labs: CBC, SMA 7&12, amylase, lipase, LDH. UA.

Peptic Ulcer Disease

1. Admit to:

2. Diagnosis: Peptic ulcer disease.

3. Condition:

4. Vital Signs: q4h. Call physician if BP >160/90,

<90/60; P >120, <50; T >38.5EC.

5. Activity: Up ad lib

6. Nursing: Guaiac stools.

7. Diet: NPO 48h, then regular diet, no caffeine.

8. IV Fluids: D5 ½ NS with 20 mEq KCL at 125 cc/h. NG

tube at low intermittent suction (if obstructed).

9. Special Medications:

-Ranitidine (Zantac) 50 mg IV bolus, then continuous

infusion at 12.5 mg/h (300 mg in 250 mL D5W at

11 mL/h over 24h) or 50 mg IV q8h OR

-Cimetidine (Tagamet) 300 mg IV bolus, then

continuous infusion at 50 mg/h (1200 mg in 250

mL D5W over 24h) or 300 mg IV q6-8h OR

-Famotidine (Pepcid) 20 mg IV q12h OR

-Pantoprazole (Protonix) 40 mg PO/IV q24h OR

-Nizatidine (Axid) 300 mg PO qhs OR

-Omeprazole (Prilosec) 20 mg PO bid (30 minutes

prior to meals) OR

-Lansoprazole (Prevacid) 15-30 mg PO qd prior to

breakfast [15, 30 mg caps].

Eradication of Helicobacter pylori

A. Bismuth, Metronidazole, Tetracycline,

Ranitidine

1. 14 day therapy.

2. Bismuth (Pepto Bismol) 2 tablets PO qid.

3. Metronidazole (Flagyl) 250 mg PO qid (tid if

cannot tolerate the qid dosing).

4. Tetracycline 500 mg PO qid.

5. Ranitidine (Zantac) 150 mg PO bid.

6. Efficacy is greater than 90%.

B. Amoxicillin, Omeprazole, Clarithromycin (AOC)

1. 10 days of therapy.

2. Amoxicillin 1 gm PO bid.

3. Omeprazole (Prilosec) 20 mg PO bid.

4. Clarithromycin (Biaxin) 500 mg PO bid.

C. Metronidazole, Omeprazole, Clarithromycin

(MOC)

1. 10 days of therapy

2. Metronidazole 500 mg PO bid.

3. Omeprazole (Prilosec) 20 mg PO bid.

4. Clarithromycin (Biaxin) 500 mg PO bid.

5. Efficacy is >80%

6. Expensive, usually well tolerated.

D. Omeprazole, Clarithromycin (OC)

1. 14 days of therapy.

2. Omeprazole (Prilosec) 40 mg PO qd for 14

days, then 20 mg qd for an additional 14 days of

therapy.

3. Clarithromycin (Biaxin) 500 mg PO tid.

E. Ranitidine-Bismuth-Citrate, Clarithromycin

(RBC-C)

1. 28 days of therapy.

2. Ranitidine-bismuth-citrate (Tritec) 400 mg PO

bid for 28 days.

3. Clarithromycin (Biaxin) 500 mg PO tid for 14

days.

4. Efficacy is 70-80%; expensive

10. Symptomatic Medications:

-Mylanta Plus or Maalox Plus 30 mg PO q2h prn.

-Trimethobenzamide (Tigan) 100-250 mg PO or 100-

200 mg IM/PR q6h prn nausea OR

-Prochlorperazine (Compazine) 5-10 mg IM/IV/PO q4-

6h or 25 mg PR q4-6h prn nausea.

11. Extras: Upright abdomen, KUB, CXR, ECG,

endoscopy. GI consult, surgery consult.

12. Labs: CBC, SMA 7&12, amylase, lipase, LDH. UA,

Helicobacter pylori serology. Fasting serum gastrin

qAM for 3 days. Urea breath test for H pylori.

Gastrointestinal Bleeding

1. Admit to:

2. Diagnosis: Upper/lower GI bleed

3. Condition:

4. Vital Signs: q30min. Call physician if BP >160/90,

<90/60; P >120, <50; R>25, <10; T >38.5EC; urine

output <15 mL/hr for 4h.

5. Activity: Bed rest

6. Nursing: Place nasogastric tube, then lavage with 2 L

of room temperature normal saline, then connect to

low intermittent suction. Repeat lavage q1h. Record

volume and character of lavage. Foley to closed

drainage; inputs and outputs.

7. Diet: NPO

8. IV Fluids: Two 16 gauge IV lines. 1-2 L NS wide

open; transfuse 2-6 units PRBC to run as fast as

possible, then repeat CBC.

9. Special Medications:

-Oxygen 2 L by NC.

-Pantoprazole (Protonix) 80 mg IV over 15min, then 8

mg/hr IV infusion OR

80 mg IV q12h.

-Ranitidine (Zantac) 50 mg IV bolus, then continuous

infusion at 12.5 mg/h [300 mg in 250 mL D5W

over 24h (11 cc/h)], or 50 mg IV q6-8h OR

-Famotidine (Pepcid) 20 mg IV q12h.

-Vitamin K (Phytonadione) 10 mg IV/SQ qd for 3 days

(if INR is elevated).

Esophageal Variceal Bleeds:

-Somatostatin (Octreotide) 50 mcg IV bolus, followed

by 50 mcg/h IV infusion (1200 mcg in 250 mL of

D5W at 11 mL/h).

Vasopressin/Nitroglycerine Paste Therapy:

-Vasopressin (Pitressin) 20 U IV over 20-30

minutes, then 0.2-0.3 U/min [100 U in 250 mL of

D5W (0.4 U/mL)] for 30 min, followed by

increases of 0.2 U/min until bleeding stops or

max of 0.9 U/min. If bleeding stops, taper over

24-48h AND

-Nitroglycerine paste 1 inch q6h OR nitroglycerin

IV at 10-30 mcg/min continuous infusion (50 mg

in 250 mL of D5W).

10. Extras: Portable CXR, upright abdomen, ECG.

Surgery and GI consults.

Upper GI Bleeds: Esophagogastroduodenoscopy with

coagulation or sclerotherapy; Linton-Nachlas tube for

tamponade of esophageal varices.

Lower GI Bleeds: Sigmoidoscopy/colonoscopy (after a

GoLytely purge 6-8 L over 4-6h), technetium 99m

RBC scan, angiography with embolization.

11. Labs: Repeat hematocrit q2h; CBC with platelets

q12-24h. Repeat INR in 6 hours. SMA 7&12, ALT,

AST, alkaline phosphatase, INR/PTT, type and cross

for 3-6 U PRBC and 2-4 U FFP.

Cirrhotic Ascites and Edema

1. Admit to:

2. Diagnosis: Cirrhotic ascites and edema

3. Condition:

4. Vital Signs: Vitals q4-6 hours. Call physician if BP

>160/90, <90/60; P >120, <50; T >38.5EC; urine

output <25 cc/hr for 4h.

5. Activity: Bed rest with legs elevated.

6. Nursing: Inputs and outputs, daily weights, measure

abdominal girth qd, guaiac all stools.

7. Diet: 2500 calories, 100 gm protein; 500 mg sodium

restriction; fluid restriction to 1-1.5 L/d (if

hyponatremia, Na <130).

8. IV Fluids: Heparin lock with flush q shift.

9. Special Medications:

-Diurese to reduce weight by 0.5-1 kg/d (if edema) or

0.25 kg/d (if no edema).

-Spironolactone (Aldactone) 25-50 mg PO qid or 200

mg PO qAM, increase by 100 mg/d to max of 400

mg/d.

-Furosemide (Lasix [refractory ascites]) 40-120 mg

PO or IV qd-bid. Add KCL 20-40 mEq PO qAM if

renal function is normal OR

-Torsemide (Demadex) 20-40 mg PO/IV qd-bid.

-Metolazone (Zaroxolyn) 5-10 mg PO qd (max 20

mg/d).

-Captopril (Capoten) 6.75 mg PO q8h; increase to

max 50 mg PO q8h for refractory ascites caused

by hyperaldosteronism.

-Famotidine (Pepcid) 20 mg IV/PO q12h.

-Vitamin K 10 mg SQ qd for 3 days.

-Folic acid 1 mg PO qd.

-Thiamine 100 mg PO qd.

-Multivitamin PO qd.

Paracentesis: Remove up to 5 L of ascites if

peripheral edema, tense ascites, or decreased diaphragmatic

excursion. If large volume paracentesis

without peripheral edema or with renal

insufficiency, give salt-poor albumin, 12.5 gm for

each 2 liters of fluid removed (50 mL of 25%

solution); infuse 25 mL before paracentesis and 25

mL 6h after.

10. Symptomatic Medications:

-Docusate (Colace) 100 mg PO qhs.

-Lactulose 30 mL PO bid-qid prn constipation.

-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn

headache.

11. Extras: KUB, CXR, abdominal ultrasound, liverspleen

scan, GI consult.

12. Labs: Ammonia, CBC, SMA 7&12, LFTs, albumin,

amylase, lipase, INR/PTT. Urine creatinine, Na, K.

HBsAg, anti-HBs, hepatitis C virus antibody, alpha-1-

antitrypsin.

Paracentesis Ascitic Fluid

Tube 1: Protein, albumin, specific gravity, glucose,

bilirubin, amylase, lipase, triglyceride, LDH (3-5

mL, red top tube).

Tube 2: Cell count and differential (3-5 mL, purple top

tube).

Tube 3: C&S, Gram stain, AFB, fungal (5-20 mL);

inject 20 mL into bottle of blood culture at bedside.

Tube 4: Cytology (>20 mL).

Syringe: pH (2 mL).

Viral Hepatitis

1. Admit to:

2. Diagnosis: Hepatitis

3. Condition:

4. Vital Signs: qid. Call physician if BP <90/60; T

>38.5EC.

5. Activity:

6. Nursing: Stool isolation.

7. Diet: Clear liquid (if nausea), low fat (if diarrhea).

8. Special Medications:

-Famotidine (Pepcid) 20 mg IV/PO q12h.

-Vitamin K 10 mg SQ qd for 3d.

-Multivitamin PO qd.

9. Symptomatic Medications:

-Meperidine (Demerol) 50-100 mg IM q4-6h prn pain.

-Trimethobenzamide (Tigan) 250 mg PO q6-8h prn

pruritus or nausea q6-8h prn.

-Hydroxyzine (Vistaril) 25 mg IM/PO q4-6h prn pruritus

or nausea.

-Diphenhydramine (Benadryl) 25-50 mg PO/IV q4-6h

prn pruritus.

10. Extras: Ultrasound, GI consult.

11. Labs: CBC, SMA 7&12, GGT, LDH, amylase, lipase,

INR/PTT, IgM anti-HAV, IgM anti-HBc, HBsAg, anti-

HCV; alpha-1-antitrypsin, ANA, ferritin, ceruloplasmin,

urine copper.

Cholecystitis and Cholangitis

1. Admit to:

2. Diagnosis: Bacterial cholangitis

3. Condition:

4. Vital Signs: q4h. Call physician if BP systolic >160,

<90; diastolic. >90, <60; P >120, <50; R>25, <10; T

>38.5EC.

5. Activity: Bed rest

6. Nursing: Inputs and outputs

7. Diet: NPO

8. IV Fluids: 0.5-1 L LR over 1h, then D5 ½ NS with 20

mEq KCL/L at 125 cc/h. NG tube at low constant

suction. Foley to closed drainage.

9. Special Medications:

-Ticarcillin or piperacillin 3 gm IV q4-6h (single agent).

-Ampicillin 1-2 gm IV q4-6h and gentamicin 100 mg

(1.5-2 mg/kg), then 80 mg IV q8h (3-5 mg/kg/d)

and metronidazole 500 mg IV q8h.

-Imipenem/cilastatin (Primaxin) 1.0 gm IV q6h (single

agent).

-Ampicillin/sulbactam (Unasyn) 1.5-3.0 gm IV q6h

(single agent).

10. Symptomatic Medications:

-Meperidine (Demerol) 50-100 mg IV/IM q4-6h prn

pain.

-Hydroxyzine (Vistaril) 25-50 mg IV/IM q4-6h prn with

meperidine.

-Omeprazole (Prilosec) 20 mg PO bid.

-Heparin 5000 U SQ q12h.

-Enoxaparin (Lovenox) 30 mg SQ q12h.

11. Extras: CXR, ECG, RUQ ultrasound, HIDA scan,

acute abdomen series. GI consult, surgical consult.

12. Labs: CBC, SMA 7&12, GGT, amylase, lipase, blood

C&S x 2. UA, INR/PTT.

Acute Pancreatitis

1. Admit to:

2. Diagnosis: Acute pancreatitis

3. Condition:

4. Vital Signs: q1-4h, call physician if BP >160/90,

<90/60; P >120, <50; R>25, <10; T >38.5EC; urine

output < 25 cc/hr for more than 4 hours.

5. Activity: Bed rest with bedside commode.

6. Nursing: Inputs and outputs, fingerstick glucose qid,

guaiac stools. Foley to closed drainage.

7. Diet: NPO

8. IV Fluids: 1-4 L NS over 1-3h, then D5 ½ NS with 20

mEq KCL/L at 125 cc/hr. NG tube at low constant

suction (if obstruction).

9. Special Medications:

-Ranitidine (Zantac) 6.25 mg/h (150 mg in 250 mL

D5W at 11 mL/h) IV or 50 mg IV q6-8h OR

Famotidine (Pepcid) 20 mg IV q12h.

-Antibiotics are indicated for infected pancreatic

pseudocysts or for abscess. Uncomplicated

pancreatitis does not require antibiotics.

-Ticarcillin/clavulanate (Timentin) 3.1 gm IV, or

ampicillin/sulbactam (Unasyn) 3.0 gm IV q6h or

imipenem (Primaxin) 0.5-1.0 gm IV q6h.

-Heparin 5000 U SQ q12h.

-Total parenteral nutrition should be provided until the

amylase and lipase are normal and symptoms

have resolved.

10. Symptomatic Medications:

-Meperidine 50-100 mg IM/IV q3-4h prn pain.

11. Extras: Upright abdomen, portable CXR, ECG, ultrasound,

CT with contrast. Surgery and GI consults.

12. Labs: CBC, platelets, SMA 7&12, calcium,

triglycerides, amylase, lipase, LDH, AST, ALT; blood

C&S x 2, hepatitis B surface antigen, INR/PTT, type

and hold 4-6 U PRBC and 2-4 U FFP. UA.

Acute Diarrhea

1. Admit to:

2. Diagnosis: Acute Diarrhea

3. Condition:

4. Vital Signs: q6h; call physician if BP >160/90,

<80/60; P >120; R>25; T >38.5EC.

5. Activity: Up ad lib

6. Nursing: Daily weights, inputs and outputs.

7. Diet: NPO except ice chips for 24h, then low residual

elemental diet; no milk products.

8. IV Fluids: 1-2 L NS over 1-2 hours; then D5 ½ NS

with 40 mEq KCL/L at 125 cc/h.

9. Special Medications:

Febrile or gross blood in stool or neutrophils on

microscopic exam or prior travel:

-Ciprofloxacin (Cipro) 500 mg PO bid OR

-Levofloxacin (Levaquin) 500 mg PO qd OR

-Trimethoprim/SMX (Bactrim DS) (160/800 mg) one

DS tab PO bid.

11. Extras: Upright abdomen. GI consult.

12. Labs: SMA7 and 12, CBC with differential, UA, blood

culture x 2.

Stool studies: Wright's stain for fecal leukocytes, ova

and parasites x 3, clostridium difficile toxin, culture for

enteric pathogens, E coli 0157:H7 culture.

Specific Treatment of Acute

Diarrhea

Shigella:

-Trimethoprim/SMX, (Bactrim) one DS tab PO bid for

5 days OR

-Ciprofloxacin (Cipro) 500 mg PO bid for 5 days OR

-Azithromycin (Zithromax) 500 mg PO x 1, then 250

mg PO qd x 4.

Salmonella (bacteremia):

-Ofloxacin (Floxin) 400 mg IV/PO q12h for 14 days

OR

-Ciprofloxacin (Cipro) 400 mg IV q12h or 750 mg PO

q12h for 14 days OR

-Trimethoprim/SMX (Bactrim) one DS tab PO bid for

14 days OR

-Ceftriaxone (Rocephin) 2 gm IV q12h for 14 days.

Campylobacter jejuni:

-Erythromycin 250 mg PO qid for 5-10 days OR

-Azithromycin (Zithromax) 500 mg PO x 1, then 250

mg PO qd x 4 OR

-Ciprofloxacin (Cipro) 500 mg PO bid for 5 days.

Enterotoxic/Enteroinvasive E coli (Travelers

Diarrhea):

-Ciprofloxacin (Cipro) 500 mg PO bid for 5-7 days OR

-Trimethoprim/SMX (Bactrim), one DS tab PO bid for

5-7 days.

Antibiotic-Associated and Pseudomembranous

Colitis (Clostridium difficile):

-Metronidazole (Flagyl) 250 mg PO or IV qid for 10-14

days OR

-Vancomycin 125 mg PO qid for 10 days (500 PO qid

for 10-14 days, if recurrent).

Yersinia Enterocolitica (sepsis):

-Trimethoprim/SMX (Bactrim), one DS tab PO bid for

5-7 days OR

-Ciprofloxacin (Cipro) 500 mg PO bid for 5-7 days OR

-Ofloxacin (Floxin) 400 mg PO bid OR

-Ceftriaxone (Rocephin) 1 gm IV q12h.

Entamoeba Histolytica (Amebiasis):

Mild to Moderate Intestinal Disease:

-Metronidazole (Flagyl) 750 mg PO tid for 10 days OR

-Tinidazole 2 gm per day PO for 3 days Followed By:

-Iodoquinol 650 mg PO tid for 20 days OR

-Paromomycin 25-30 mg/kg/d PO tid for 7 days.

Severe Intestinal Disease:

-Metronidazole (Flagyl)750 mg PO tid for 10 days OR

-Tinidazole 600 mg PO bid for 5 days Followed By:

-Iodoquinol 650 mg PO tid for 20 days OR

-Paromomycin 25-30 mg/kg/d PO tid for 7 days.

Giardia Lamblia:

-Quinacrine 100 mg PO tid for 5d OR

-Metronidazole 250 mg PO tid for 7 days OR

-Nitazoxanide (Alinia) 200 mg PO q12h x 3 days.

Cryptosporidium:

-Paromomycin 500 mg PO qid for 7-10 days [250 mg]

OR

-Nitazoxanide (Alinia) 200 mg PO q12h x 3 days.

Crohn's Disease

1. Admit to:

2. Diagnosis: Crohn's disease.

3. Condition:

4. Vital Signs: q8h. Call physician if BP >160/90,

<90/60; P >120, <50; R>25, <10; T >38.5EC

5. Activity: Up ad lib.

6. Nursing: Inputs and outputs. NG at low intermittent

suction (if obstruction).

7. Diet: NPO except for ice chips and medications for

48h, then low residue or elemental diet, no milk products.

8. IV Fluids: 1-2 L NS over 1-3h, then D5 ½ NS with 40

mEq KCL/L at 125 cc/hr.

9. Special Medications:

-Mesalamine (Asacol) 400-800 mg PO tid or

mesalamine (Pentasa) 1000 mg (four 250 mg tabs)

PO qid OR

-Sulfasalazine (Azulfidine) 0.5-1 gm PO bid; increase

over 10 days to 0.5-1 gm PO qid OR

-Olsalazine (Dipentum) 500 mg PO bid.

-Infliximab (Remicade) 5 mg/kg IV over 2 hours; may

repeat at 2 and 6 weeks

-Prednisone 40-60 mg PO qd OR

-Hydrocortisone 50-100 mg IV q6h OR

-Methylprednisolone (Solu-Medrol) 10-20 mg IV q6h.

-Metronidazole (Flagyl) 250-500 mg PO q6h.

-Vitamin B12, 100 mcg IM for 5d, then 100-200 mcg IM

q month.

-Multivitamin PO qAM or 1 ampule IV qAM.

-Folic acid 1 mg PO qd.

10. Extras: Abdominal x-ray series, CXR, colonoscopy.

GI consult.

11. Labs: CBC, SMA 7&12, Mg, ionized calcium, blood

C&S x 2; stool Wright's stain, stool culture, C difficile

antigen assay, stool ova and parasites x 3.

Ulcerative Colitis

1. Admit to:

2. Diagnosis: Ulcerative colitis

3. Condition:

4. Vital Signs: q4-6h. Call physician if BP >160/90,

<90/60; P >120, <50; R>25, <10; T >38.5EC.

5. Activity: Up ad lib in room.

6. Nursing: Inputs and outputs.

7. Diet: NPO except for ice chips for 48h, then low

residue or elemental diet, no milk products.

8. IV Fluids: 1-2 L NS over 1-2h, then D5 ½ NS with 40

mEq KCL/L at 125 cc/hr.

9. Special Medications:

-Mesalamine (Asacol) 400-800 mg PO tid OR

-5-aminosalicylate (Mesalamine) 400-800 mg PO tid

or 1 gm PO qid or enema 4 gm/60 mL PR qhs OR

-Sulfasalazine (Azulfidine) 0.5-1 gm PO bid, increase

over 10 days as tolerated to 0.5-1.0 gm PO qid OR

-Olsalazine (Dipentum) 500 mg PO bid OR

-Hydrocortisone retention enema, 100 mg in 120 mL

saline bid.

-Methylprednisolone (Solu-Medrol) 10-20 mg IV q6h

OR

-Hydrocortisone 100 mg IV q6h OR

-Prednisone 40-60 mg PO qd.

-B12, 100 mcg IM for 5d then 100-200 mcg IM q

month.

-Multivitamin PO qAM or 1 ampule IV qAM.

-Folate 1 mg PO qd.

10. Symptomatic Medications:

-Loperamide (Imodium) 2-4 mg PO tid-qid prn, max

16 mg/d OR

-Kaopectate 60-90 mL PO qid prn.

11. Extras: Upright abdomen. CXR, colonoscopy, GI

consult.

12. Labs: CBC, SMA 7&12, Mg, ionized calcium, liver

panel, blood C&S x 2; stool Wright's stain, stool for

ova and parasites x 3, culture for enteric pathogens;

Clostridium difficile antigen assay, UA.

Parenteral Nutrition

General Considerations: Daily weights, inputs and

outputs. Finger stick glucose q6h.

Central Parenteral Nutrition:

-Infuse 40-50 mL/h of amino acid-dextrose solution in

the first 24h; increase daily by 40 mL/hr increments

until providing 1.3-2 x basal energy requirement

and 1.2-1.7 gm protein/kg/d (see formula page 97).

Standard solution:

Amino acid solution (Aminosyn) 7-10% .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500 mL

Dextrose 40-70% . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500 mL

Sodium . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 mEq

Potassium . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 mEq

Chloride . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 mEq

Calcium . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5 mEq

Phosphate . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 mmol

Magnesium . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.0 mEq

Acetate . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82-104 mEq

Multi-trace element formula . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 mL/d

(zinc, copper, manganese, chromium)

Regular insulin (if indicated) . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10-60 U/L

Multivitamin(12)(2 amp) . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 mL/d

Vitamin K (in solution, SQ, IM) . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 mg/week

Vitamin B12 . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1000

mcg/week

Selenium (after 20 days of continuous TPN)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 mcg/d

Intralipid 20%, 500 mL/d IVPB; infuse in parallel with

standard solution at 1 mL/min for 15 min; if no

adverse reactions, increase to 100 mL/hr once daily

or 20 mg/hr continuously. Obtain serum triglyceride

6h after end of infusion (maintain <250 mg/dL).

Cyclic Total Parenteral Nutrition:

-12h night schedule; taper continuous infusion in

morning by reducing rate to half of original rate

for 1 hour. Further reduce rate by half for an

additional hour, then discontinue. Finger stick

glucose q4-6h; restart TPN in afternoon. Taper

at beginning and end of cycle. Final rate of 185

mL/hr for 9-10 h and 2 hours of taper at each

end for total of 2000 mL.

Peripheral Parenteral Supplementation:

-3% amino acid solution (ProCalamine) up to 3 L/d at

125 cc/h OR

-Combine 500 mL amino acid solution 7% or 10%

(Aminosyn) and 500 mL 20% dextrose and

electrolyte additive. Infuse at up to 100 cc/hr in

parallel with:

-Intralipid 10% or 20% at 1 mL/min for 15 min (test

dose); if no adverse reactions, infuse 500 mL/d

at 21 mL/h over 24h, or up to 100 mL/h over 5

hours daily.

-Draw triglyceride level 6h after end of Intralipid

infusion.

7. Special Medications:

-Famotidine (Pepcid) 20 mg IV q12h or 40 mg/day in

TPN OR

-Ranitidine (Zantac) 50 mg IV q8h or 150 mg/day in

TPN.

8. Extras: Nutrition consult.

9. Labs:

Daily labs: SMA7, osmolality, CBC, cholesterol,

triglyceride, urine glucose and specific gravity.

Twice weekly Labs: Calcium, phosphate, SMA-12,

magnesium

Weekly Labs: Serum albumin and protein, prealbumin,

ferritin, INR/PTT, zinc, copper, B12, folate,

24h urine nitrogen and creatinine.

Enteral Nutrition

General Considerations: Daily weights, inputs and

outputs, nasoduodenal feeding tube. Head-of-bed at

30E while enteral feeding and 2 hours after

completion.

Enteral Bolus Feeding: Give 50-100 mL of enteral

solution (Pulmocare, Jevity, Vivonex, Osmolite, Vital

HN) q3h. Increase amount in 50 mL steps to max of

250-300 mL q3-4h; 30 kcal of nonprotein calories/

kg/d and 1.5 gm protein/kg/d. Before each

feeding, measure residual volume, and delay feeding

by 1h if >100 mL. Flush tube with 100 cc of water

after each bolus.

Continuous enteral infusion: Initial enteral solution

(Pulmocare, Jevity, Vivonex, Osmolite) 30 mL/hr.

Measure residual volume q1h for 12h then tid; hold

feeding for 1h if >100 mL. Increase rate by 25-50

mL/hr at 24 hr intervals as tolerated until final rate of

50-100 mL/hr. Three tablespoonfuls of protein powder

(Promix) may be added to each 500 cc of solution.

Flush tube with 100 cc water q8h.

Special Medications:

-Metoclopramide (Reglan) 10-20 mg IV/NG OR

-Erythromycin 125 mg IV or via nasogastric tube q8h.

-Famotidine (Pepcid) 20 mg IV/PO q12h OR

-Ranitidine (Zantac) 150 mg NG bid.

Symptomatic Medications:

-Loperamide (Imodium) 2-4 mg NG/J-tube q6h prn,

max 16 mg/d OR

-Diphenoxylate/atropine (Lomotil) 1-2 tabs or 5-10 mL

(2.5 mg/5 mL) PO/J-tube q4-6h prn, max 12

tabs/d OR

-Kaopectate 30 cc NG or in J-tube q8h.

Extras: CXR, plain abdominal x-ray for tube placement,

nutrition consult.

Labs:

Daily labs: SMA7, osmolality, CBC, cholesterol,

triglyceride. SMA-12

Weekly labs when indicated: Protein, Mg, INR/PTT,

24h urine nitrogen and creatinine. Pre-albumin,

retinol-binding protein.

Hepatic Encephalopathy

1. Admit to:

2. Diagnosis: Hepatic encephalopathy

3. Condition:

4. Vital Signs: q1-4h, neurochecks q4h. Call physician if

BP >160/90,<90/60; P >120,<50; R>25,<10; T

>38.5EC.

5. Allergies: Avoid sedatives, NSAIDS or hepatotoxic

drugs.

6. Activity: Bed rest.

7. Nursing: Keep head-of-bed at 40 degrees, guaiac

stools; turn patient q2h while awake, chart stools.

Seizure precautions, egg crate mattress, soft

restraints prn. Record inputs and outputs. Foley to

closed drainage.

8. Diet: NPO for 8 hours, then low-protein nasogastric

enteral feedings (Hepatic-Aid II) at 30 mL/hr. Increase

rate by 25-50 mL/hr at 24 hr intervals as tolerated until

final rate of 50-100 mL/hr as tolerated.

9. IV Fluids: D5W at TKO.

10.Special Medications:

-Sorbitol 70% solution, 30-60 gm PO now.

-Lactulose 30-45 mL PO q1h for 3 doses, then 15-45

mL PO bid-qid, titrate to produce 3 soft stools/d OR

-Lactulose enema 300 mL added to 700 mL of tap water;

instill 200-250 mL per rectal tube bid-qid AND

-Neomycin 1 gm PO q6h (4-12 g/d) OR

-Metronidazole (Flagyl) 250 mg PO q6h.

-Ranitidine (Zantac) 50 mg IV q8h or 150 mg PO bid

OR

-Famotidine (Pepcid) 20 mg IV/PO q12h.

-Flumazenil (Romazicon) 0.2 mg (2 mL) IV over 30

seconds q1min until a total dose of 3 mg; if a partial

response occurs, continue 0.5 mg doses until a

total of 5 mg. Flumazenil may help reverse hepatic

encephalopathy, irrespective of benzodiazepine

use.

-Multivitamin PO qAM or 1 ampule IV qAM.

-Folic acid 1 mg PO/IV qd.

-Thiamine 100 mg PO/IV qd.

-Vitamin K 10 mg SQ qd for 3 days if elevated INR.

11. Extras: CXR, ECG; GI and dietetics consults.

12. Labs: Ammonia, CBC, platelets, SMA 7&12, AST,

ALT, GGT, LDH, alkaline phosphatase, protein, albumin,

bilirubin, INR/PTT, ABG, blood C&S x 2,

hepatitis B surface antibody. UA.

Alcohol Withdrawal

1. Admit to:

2. Diagnosis: Alcohol withdrawals/delirium tremens.

3. Condition:

4. Vital Signs: q4-6h. Call physician if BP >160/90, <90-

/60; P >130, <50; R>25, <10; T >38.5EC; or increase

in agitation.

5. Activity:

6. Nursing: Seizure precautions. Soft restraints prn.

7. Diet: Regular, push fluids.

8. IV Fluids: Heparin lock or D5 ½ NS at 100-125 cc/h.

9. Special Medications:

Withdrawal syndrome:

-Chlordiazepoxide (Librium) 50-100 mg PO/IV q6h for

3 days OR

-Lorazepam (Ativan) 1 mg PO tid-qid.

Delirium tremens:

-Chlordiazepoxide (Librium) 100 mg slow IV push or

PO, repeat q4-6h prn agitation or tremor for 24h;

max 500 mg/d. Then give 50-100 mg PO q6h prn

agitation or tremor OR

-Diazepam (Valium) 5 mg slow IV push, repeat q6h

until calm, then 5-10 mg PO q4-6h.

Seizures:

-Thiamine 100 mg IV push AND

-Dextrose water 50%, 50 mL IV push.

-Lorazepam (Ativan) 0.1 mg/kg IV at 2 mg/min; may

repeat x 1 if seizures continue.

Wernicke-Korsakoff Syndrome:

-Thiamine 100 mg IV stat, then 100 mg IV qd.

10. Symptomatic Medications:

-Multivitamin 1 amp IV, then 1 tab PO qd.

-Folate 1 mg PO qd.

-Thiamine 100 mg PO qd.

-Acetaminophen (Tylenol) 1-2 PO q4-6h prn headache.

11. Extras: CXR, ECG. Alcohol rehabilitation and social

work consult.

12. Labs: CBC, SMA 7&12, Mg, amylase, lipase, liver

panel, urine drug screen. UA, INR/PTT.

Toxicology

Poisoning and Drug Overdose

Decontamination:

-Gastric Lavage: Place patient left side down, place

nasogastric tube, and check position by injecting air

and auscultating. Lavage with normal saline until

clear fluid, then leave activated charcoal or other

antidote. Gastric lavage is contraindicated for

corrosives.

-Cathartics:

-Magnesium citrate 6% solution 150-300 mL PO

-Magnesium sulfate 10% solution 150-300 mL PO.

-Activated Charcoal: 50 gm PO (first dose should be

given using product containing sorbitol). Repeat

q2-6h for large ingestions.

-Hemodialysis should be for isopropanol, methanol,

ethylene glycol, severe salicylate intoxication (>100

mg/dL), lithium, or theophylline (if neurotoxicity,

seizures, or coma).

Antidotes:

Narcotic Overdose:

-Naloxone (Narcan) 0.4 mg IV/ET/IM/SC, may

repeat q2min.

Methanol Ingestion:

-Ethanol (10% in D5W) 7.5 mL/kg load, then 1.4

mL/kg/hr IV infusion until methanol level <20

mg/dL. Maintain ethanol level of 100-150 mg/100

mL.

Ethylene Glycol Ingestion:

-Fomepizole (Antizol) 15 mg/kg IV over 30 min,

then 10 mg/kg IV q12h x 4 doses, then 15 mg/kg

IV q12h until ethylene glycol level is less than 20

mg/dL AND

-Pyridoxine 100 mg IV q6h for 2 days and thiamine

100 mg IV q6h for 2 days.

Carbon Monoxide Intoxication:

-Hyperbaric oxygen therapy or 100% oxygen by

mask if hyperbaric oxygen is not available.

Tricyclic Antidepressants Overdose:

-Gastric lavage

-Magnesium citrate 300 mg PO/NG x1.

-Activated charcoal premixed with sorbitol 50 gm

NG round-the-clock until level is less than the

toxic range.

Benzodiazepine Overdose:

-Flumazenil (Romazicon) 0.2 mg (2 mL) IV over 30

seconds q1min until a total dose of 3 mg; if a

partial response occurs, repeat 0.5 mg doses

until a total of 5 mg. If sedation persists, repeat

the above regimen or start a continuous IV

infusion of 0.1-0.5 mg/h.

Labs: Drug screen (serum, gastric, urine); blood levels,

SMA 7, fingerstick glucose, CBC, LFTs, ECG.

Acetaminophen Overdose

1. Admit to: Medical intensive care unit.

2. Diagnosis: Acetaminophen overdose

3. Condition:

4. Vital Signs: q1h with neurochecks. Call physician if

BP >160/90, <90/60; P >130, <50 <50; R>25, <10;

urine output <20 cc/h for 3 hours.

5. Activity: Bed rest with bedside commode.

6. Nursing: Inputs and outputs, aspiration and seizure

precautions. Place large bore (Ewald) NG tube, then

lavage with 2 L of NS.

7. Diet: NPO

8. IV Fluids:

9. Special Medications:

-Activated charcoal 30-100 gm doses, remove via

nasogastric suction prior to acetylcysteine.

-Acetylcysteine (Mucomyst, NAC) 5% solution loading

dose 140 mg/kg via nasogastric tube, then 70

mg/kg via NG tube q4h x 17 doses OR acetylcysteine

150 mg/kg IV in 200 mL D5W over 15 min,

followed by 50 mg/kg in 500 mL D5W, infused over

4h, followed by 100 mg/kg in 1000 mL of D5W over

next 16h. Complete all NAC doses even if

acetaminophen levels fall below toxic range.

-Phytonadione (Aquamephyton) 5 mg IV/IM/SQ (if INR

increased).

-Fresh frozen plasma 2-4 U (if INR is unresponsive to

Aquamephyton).

-Trimethobenzamide (Tigan) 100-200 mg IM/PR q6h

prn nausea.

10. Extras: ECG.

11. Labs: CBC, SMA 7&12, LFTs, INR/PTT, acetaminophen

level now and in 4h. UA.

Theophylline Overdose

1. Admit to: Medical intensive care unit.

2. Diagnosis: Theophylline overdose

3. Condition:

4. Vital Signs: Neurochecks q2h. Call physician if BP

>160/90, <90/60; P >130; <50; R >25, <10.

5. Activity: Bed rest

6. Nursing: ECG monitoring until level <20 mcg/mL,

aspiration and seizure precautions. Insert single

lumen NG tube and lavage with normal saline if recent

ingestion.

7. Diet: NPO

8. IV Fluids: D5 ½ NS at 125 cc/h

9. Special Medications:

-Activated charcoal 50 gm PO round-the-clock, with

sorbitol cathartic, until theophylline level <20 mcg/

mL. Maintain head-of-bed at 30-45 degrees to

prevent aspiration of charcoal.

-Charcoal hemoperfusion should be considered if the

serum level is >60 mcg/mL or if signs of neurotoxicity,

seizure, coma are present.

-Seizure: Lorazepam (Ativan) 0.1 mg/kg IV at 2

mg/min; may repeat x 1 if seizures continue.

10. Extras: ECG.

11. Labs: CBC, SMA 7&12, theophylline level now and

in q6-8h; INR/PTT, liver panel. UA.

Tricyclic Antidepressant Overdose

1. Admit to: Medical intensive care unit.

2. Diagnosis: TCA Overdose

3. Condition:

4. Vital Signs: Neurochecks q1h.

5. Activity: Bedrest.

6. Nursing: Continuous suicide observation. ECG

monitoring, measure QRS width hourly, inputs and

outputs, aspiration and seizure precautions. Place

single-lumen nasogastric tube and lavage with 2 liters

of normal saline if recent ingestion.

7. Diet: NPO

8. IV Fluids: NS at 100-150 cc/hr.

9. Special Medications:

-Activated charcoal premixed with sorbitol, 50 gm via

NG tube q4-6h round-the-clock until the TCA level

decreases to therapeutic range. Maintain head-ofbed

at 30-45 degree angle to prevent charcoal

aspiration.

-Magnesium citrate 300 mL via nasogastric tube x 1

dose.

10. Protection Against Cardiac Toxicity:

-If mechanical ventilation is necessary, hyperventilate

to maintain pH 7.50-7.55.

-Administer sodium bicarbonate 50-100 mEq (1-2

amps or 1-2 mEq/kg) IV over 5-10 min, followed by

infusion of sodium bicarbonate (2 amps in D5W 1 L)

at 100-150 cc/h. Adjust rate to maintain pH 7.50-

7.55.

11. Extras: ECG.

12. Labs: Urine toxicology screen, serum TCA levels,

liver panel, CBC, SMA-7 and 12, UA.

Neurologic Disorders

Ischemic Stroke

1. Admit to:

2. Diagnosis: Ischemic stroke

3. Condition:

4. Vital Signs: Vital signs and neurochecks q30minutes

for 6 hours, then q60 minutes for 12 hours. Call

physician if BP >185/105, <110/60; P >120, <50;

R>24, <10; T >38.5EC; or change in neurologic status.

5. Activity: Bedrest.

6. Nursing: Head-of-bed at 30 degrees, turn q2h when

awake, range of motion exercises qid. Foley catheter,

eggcrate mattress. Guaiac stools, inputs and outputs.

Bleeding precautions: check puncture sites for

bleeding or hematomas. Apply digital pressure or

pressure dressing to active compressible bleeding

sites.

7. Diet: NPO except medications for 24 hours, then

dysphagia ground diet with thickened liquids.

8. IV Fluids and Oxygen: 0.45% normal saline at 100

cc/h. Oxygen at 2 L per minute by nasal cannula.

9. Special Medications:

Ischemic Stroke <3 hours:

a. Tissue plasminogen activator (t-PA, Alteplase) is

indicated if the patient presents within 3 hours of

onset of symptoms and the stroke is nonhemorrhagic;

0.9 mg/kg (max 90 mg) over 60 min.

Give 10% of the total dose as an initial bolus over 1

minute.

b. Repeat CT scan or MRI 24 hours after completion

of tPA. Begin heparin if scan results are negative

for hemorrhage.

c. Heparin 12 U/kg/h continuous IV infusion, without a

bolus. Check aPTT q6h to maintain 1.2-1.5 x

control.

Completed Ischemic Stroke >3 hours:

-Aspirin enteric coated 325 mg PO qd OR

-Clopidogrel (Plavix) 75 mg PO qd OR

-Aspirin 25 mg/dipyridamole 200 mg (Aggrenox) 1 tab

PO bid OR

-Aspirin 325 mg PO qd PLUS Clopidogrel (Plavix) 75

mg PO qd

10. Symptomatic Medications:

-Famotidine (Pepcid) 20 mg IV/PO q12h.

-Omeprazole (Prilosec) 20 mg PO bid or qhs.

-Docusate sodium (Colace) 100 mg PO qhs

-Bisacodyl (Dulcolax) 10-15 mg PO qhs or 10 mg PR

prn.

-Acetaminophen (Tylenol) 650 mg PO/PR q4-6h prn

temp >38°C or headache.

11. Extras: CXR, ECG, CT without contrast or MRI with

gadolinium contrast; carotid duplex scan; echocardiogram,

24-hour Holter monitor; swallowing studies.

Physical therapy consult for range of motion

exercises; neurology and rehabilitation medicine

consults.

12. Labs: CBC, glucose, SMA 7&12, fasting lipid profile,

VDRL, ESR; drug levels, INR/PTT, UA. Lupus

anticoagulant, anticardiolipin antibody.

Transient Ischemic Attack

1. Admit to:

2. Diagnosis: Transient ischemic attack

3. Condition:

4. Vital Signs: q1-4h with neurochecks. Call physician if

BP >160/90, <90/60; P >120, <50; R>25, <10; T

>38.5EC; or change in neurologic status.

5. Activity: Up as tolerated.

6. Nursing: Guaiac stools.

7. Diet: Dysphagia ground with thickened liquids or

regular diet.

8. IV Fluids: Heparin lock with flush q shift.

9. Special Medications:

-Aspirin 325 mg PO qd OR

-Clopidogrel (Plavix) 75 mg PO qd OR

-Aspirin 25 mg/dipyridamole 200 mg (Aggrenox) 1 tab

PO bid.

-Heparin (only if recurrent TIAs or cardiogenic or

vertebrobasilar source for emboli) 700-800 U/h (12

U/kg/h) IV infusion without a bolus (25,000 U in

500 mL D5W); adjust q6-12h until PTT 1.2-1.5 x

control.

-Warfarin (Coumadin) 5.0-7.5 mg PO qd for 3d, then

2-4 mg PO qd. Titrate to INR of 2.0-2.5.

10. Symptomatic Medications:

-Famotidine (Pepcid) 20 mg IV/PO q12h.

-Docusate sodium (Colace) 100 mg PO qhs.

-Milk of magnesia 30 mL PO qd prn constipation.

11. Extras: CXR, ECG, CT without contrast; carotid

duplex scan, echocardiogram, 24-hour Holter monitor.

Physical therapy, neurology consults.

12. Labs: CBC, glucose, SMA 7&12, fasting lipid profile,

VDRL, drug levels, INR/PTT, UA.

Subarachnoid Hemorrhage

1. Admit to:

2. Diagnosis: Subarachnoid hemorrhage

3. Condition:

4. Vital Signs: Vital signs and neurochecks q1-4h. Call

physician if BP >185/105, <110/60; P >120, <50;

R>24, <10; T >38.5EC; or change in neurologic status.

5. Activity: Bedrest.

6. Nursing: Head-of-bed at 30 degrees, turn q2h when

awake. Foley catheter to closed drainage, eggcrate

mattress. Guaiac stools, inputs and outputs.

7. Diet: NPO except medications.

8. IV Fluids and Oxygen: 0.45% normal saline at 100

cc/h. Oxygen at 2 L per minute by nasal cannula.

-Keep room dark and quiet; strict bedrest. Neurologic

checks q1h for 12 hours, then q2h for 12 hours,

then q4h. Call physician if abrupt change in

neurologic status.

-Restrict total fluids to 1000 mL/day; diet as tolerated.

9. Special Medications:

-Nimodipine (Nimotop) 60 mg PO or via NG tube q4h

for 21d, must start within 96 hours.

-Phenytoin (seizures) load 15 mg/kg IV in NS (infuse

at max 50 mg/min), then 300 mg PO/IV qAM (4-6

mg/kg/d) OR

-Valproic acid (Depakene) 500-1000 mg IV q6h.

Hypertension:

-Nitroprusside sodium, 0.1-0.5 mcg/kg/min (50 mg in

250 mL NS), titrate to control blood pressure OR

-Labetalol (Trandate) 10-20 mg IV q15min prn or 1-2

mg/min IV infusion.

10. Extras: CXR, ECG, CT without contrast; MRI angiogram;

cerebral angiogram. Neurology,

neurosurgery consults.

11. Labs: CBC, SMA 7&12, VDRL, UA.

Seizure and Status Epilepticus

1. Admit to:

2. Diagnosis: Seizure

3. Condition:

4. Vital Signs: q6h with neurochecks. Call physician if

BP >160/90, <90/60; P >120, <50; R>25, <10; T

>38.5EC; or any change in neurological status.

5. Activity: Bed rest

6. Nursing: Finger stick glucose. Seizure precautions

with bed rails up; padded tongue blade at bedside.

EEG monitoring.

7. Diet: NPO for 24h, then regular diet if alert.

8. IV Fluids: D5 ½ NS at 100 cc/hr; change to heparin

lock when taking PO.

9. Special Medications:

Status Epilepticus:

1. Maintain airway.

2. Position the patient laterally with the head down.

The head and extremities should be cushioned to

prevent injury.

3. A bite block or other soft object may be inserted

into the mouth to prevent injury to the tongue.

4. Give 100% O2 by mask. Obtain brief history and a

fingerstick glucose.

5. Secure IV access and draw blood for glucose

analysis. Give thiamine 100 mg IV push, then

dextrose 50% 50 mL IV push.

6. Initial Control:

Lorazepam (Ativan) 6-8 mg (0.1 mg/kg; not to

exceed 2 mg/min) IV at 1-2 mg/min. May repeat

6-8 mg q5-10min (max 80 mg/24h) OR

Diazepam (Valium), 5-10 mg slow IV at 1-2

mg/min. Repeat 5-10 mg q5-10 min prn (max

100 mg/24h).

Phenytoin (Dilantin) 15-20 mg/kg load in NS at 50

mg/min. Repeat 100-150 mg IV q30min, max 1.5

gm; monitor BP.

Fosphenytoin (Cerebyx) 20 mg/kg IV/IM (at 150

mg/min), then 4-6 mg/kg/day in 2 or 3 doses

(150 mg IV/IM q8h). Fosphenytoin is metabolized

to phenytoin; fosphenytoin may be given IM.

If seizures persist, administer phenobarbital 20

mg/kg IV at 50 mg/min, repeat 2 mg/kg q15min;

additional phenobarbital may be given, up to max

of 30-60 mg/kg.

7. If seizures persist, intubate the patient and give:

- Midazolam (Versed) 0.2 mg/kg IV push, then 0.045

mg/kg/hr; titrate up to 0.6 mg/kg/hr OR

-Propofol (Diprivan) 2 mg/kg IV push over 2-5 min,

then 50 mcg/kg/min; titrate up to 165 mcg/kg/min

OR

-Phenobarbital as above.

-Induce coma with pentobarbital 10-15 mg/kg IV over

1-2h, then 1-1.5 mg/kg/h continuous infusion.

Initiate continuous EEG monitoring.

8. Consider Intubation and General Anesthesia

Maintenance Therapy for Epilepsy:

Primary Generalized Seizures - First-Line Therapy:

-Carbamazepine (Tegretol) 200-400 mg PO tid [100,

200 mg]. Monitor CBC.

-Phenytoin (Dilantin) loading dose of 400 mg PO,

followed by 300 mg PO q4h for 2 doses (total of 1

g), then 300 mg PO qd or 100 mg tid or 200 mg bid

[30, 50, 100 mg].

-Divalproex (Depakote) 250-500 mg PO tid-qid with

meals [125, 250, 500 mg].

-Valproic acid (Depakene) 250-500 mg PO tid-qid with

meals [250 mg].

Primary Generalized Seizures -- Second Line

Therapy:

-Phenobarbital 30-120 mg PO bid [8, 16, 32, 65, 100

mg].

-Primidone (Mysoline) 250-500 mg PO tid [50, 250

mg]; metabolized to phenobarbital.

-Felbamate (Felbatol) 1200-2400 mg PO qd in 3-4

divided doses, max 3600 mg/d [400, 600 mg; 600

mg/5 mL susp]; adjunct therapy; aplastic anemia,

hepatotoxicity.

-Gabapentin (Neurontin), 300-400 mg PO bid-tid; max

1800 mg/day [100, 300, 400 mg]; adjunct therapy.

-Lamotrigine (Lamictal) 50 mg PO qd, then increase

to 50-250 mg PO bid [25, 100, 150, 200 mg];

adjunct therapy .

Partial Seizure:

-Carbamazepine (Tegretol) 200-400 mg PO tid [100,

200 mg].

-Divalproex (Depakote) 250-500 mg PO tid with meals

[125, 250, 500 mg].

-Valproic acid (Depakene) 250-500 mg PO tid-qid with

meals [250 mg].

-Phenytoin (Dilantin) 300 mg PO qd or 200 mg PO bid

[30, 50, 100].

-Phenobarbital 30-120 mg PO tid or qd [8, 16, 32, 65,

100 mg].

-Primidone (Mysoline) 250-500 mg PO tid [50, 250

mg]; metabolized to phenobarbital.

-Gabapentin (Neurontin), 300-400 mg PO bid-tid; max

1800 mg/day [100, 300, 400 mg]; adjunct therapy.

-Lamotrigine (Lamictal) 50 mg PO qd, then increase

to 50-250 mg PO bid [25, 100, 150, 200 mg];

adjunct therapy.

-Topiramate (Topamax) 25 mg PO bid; titrate to max

200 mg PO bid [tab 25, 100, 200 mg]; adjunctive

therapy.

Absence Seizure:

-Divalproex (Depakote) 250-500 mg PO tid-qid [125,

250, 500 mg].

-Clonazepam (Klonopin) 0.5-5 mg PO bid-qid [0.5, 1,

2 mg].

-Lamotrigine (Lamictal) 50 mg PO qd, then increase

to 50-250 mg PO bid [25, 100, 150, 200 mg];

adjunct therapy.

10. Extras: MRI with and without gadolinium or CT with

contrast; EEG (with photic stimulation,

hyperventilation, sleep deprivation, awake and asleep

tracings); portable CXR, ECG.

11. Labs: CBC, SMA 7, glucose, Mg, calcium, phosphate,

liver panel, VDRL, anticonvulsant levels. UA,

drug screen.

Endocrinologic Disorders

Diabetic Ketoacidosis

1. Admit to:

2. Diagnosis: Diabetic ketoacidosis

3. Condition:

4. Vital Signs: q1-4h, postural BP and pulse. Call

physician if BP >160/90, <90/60; P >140, <50; R >30,

<10; T >38.5EC; or urine output <20 mL/hr for more

than 2 hours.

5. Activity: Bed rest with bedside commode.

6. Nursing: Inputs and outputs. Foley to closed

drainage. Record labs on flow sheet.

7. Diet: NPO for 12 hours, then clear liquids as

tolerated.

8. IV Fluids:

1-2 L NS over 1-3h ($16 gauge), infuse at 400-1000

mL/h until hemodynamically stable, then change to

0.45% saline at 125-150 cc/hr; keep urine output >30-

60 mL/h.

Add KCL when serum potassium is <5.0 mEq/L.

Concentration.......20-40 mEq KCL/L

Use K phosphate, 20-40 mEq/L, in place of KCL if

hypophosphatemic.

Change to 5% dextrose in 0.45% saline with 20-40 mEq

KCL/liter when blood glucose is 250-300 mg/dL.

9. Special Medications:

-Oxygen at 2 L/min by NC.

-Insulin regular (Humulin) 7-10 units (0.1 U/kg) IV

bolus, then 7-10 U/h IV infusion (0.1 U/kg/h); 50 U

in 250 mL of 0.9% saline; flush IV tubing with 20

mL of insulin solution before starting infusion.

Adjust insulin infusion to decrease serum glucose

by 100 mg/dL or less per hour. When bicarbonate

level is >16 mEq/L and the anion gap is <16

mEq/L, decrease insulin infusion rate by half.

-When the glucose level reaches 250 mg/dL, 5%

dextrose should be added to the replacement fluids

with KCL 20-40 mEq/L.

-Use 10% glucose at 50-100 mL/h if anion gap

persists and serum glucose has decreased to less

than 100 mg/dL while on insulin infusion.

-Change to subcutaneous insulin when the anion gap

has cleared; discontinue insulin infusion 1-2h after

subcutaneous dose.

10. Symptomatic Medications:

-Famotidine (Pepcid) 20 mg IV q12h.

-Docusate sodium (Colace) 100 mg PO qhs.

-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn

headache.

11. Extras: Portable CXR, ECG.

12. Labs: Fingerstick glucose q1-2h. SMA 7 q4-6h. SMA

12, pH, bicarbonate, phosphate, amylase, lipase,

hemoglobin A1c; CBC. UA, serum pregnancy test.

Nonketotic Hyperosmolar

Syndrome

1. Admit to:

2. Diagnosis: Nonketotic hyperosmolar syndrome

3. Condition:

4. Vital Signs: q1h. Call physician if BP >160/90,

<90/60; P >140, <50; R>25, <10; T >38.5E C; or urine

output <20 cc/hr for more than 4 hours.

5. Activity: Bed rest with bedside commode.

6. Nursing: Input and output measurement. Foley to

closed drainage. Record labs on flow sheet.

7. Diet: NPO.

8. IV Fluids: 1-2 L NS over 1h ($16 gauge IV catheter),

then give 0.45% saline at 125 cc/hr. Maintain urine

output $50 mL/h.

-Add 20-40 mEq/L KCL when urine output adequate.

9. Special Medications:

-Insulin regular 2-3 U/h IV infusion (50 U in 250 mL of

0.9% saline).

-Famotidine (Pepcid) 20 mg IV/PO q12h OR

-Lansoprazole (Prevacid) 30 mg PO qd.

-Heparin 5000 U SQ q12h.

10. Extras: Portable CXR, ECG.

11. Labs: Fingerstick glucose q1-2h x 6h, then q6h.

SMA 7, osmolality. SMA 12, phosphate, ketones,

hemoglobin A1C, CBC. UA.

Thyroid Storm and

Hyperthyroidism

1. Admit to:

2. Diagnosis: Thyroid Storm

3. Condition:

4. Vital Signs: q1-4h. Call physician if BP >160/90,

<90/60; P >130, <50; R>25, <10; T >38.5EC.

5. Activity: Bed rest

6. Nursing: Cooling blanket prn temp >39EC, inputs and

outputs. Oxygen 2 L/min by nasal canula.

7. Diet: Regular

8. IV Fluids: D5 ½ NS at 125 mL/h.

9. Special Medications:

Thyroid Storm and Hyperthyroidism

Subtotal Thyroidectomy: Indicated in patients with

large goiter that extends retrosternally, in pregnant

patients, and children who have major adverse

reaction to medications.

-Methimazole (Tapazole) 30-60 mg PO, then

maintenance of 15 mg PO qd-bid OR

-Propylthiouracil (PTU) 1000 mg PO, then 50-250 mg

PO q4-8h, up to 1200 mg/d; usual maintenance

dose 50 mg PO tid AND

-Iodide solution (Lugol's solution), 3-6 drops tid; one

hour after propylthiouracil AND

-Dexamethasone (Decadron) 2 mg IV q6h AND

-Propranolol 40-160 mg PO q6h or 5-10 mg/h, max 2-

5 mg IV q4h or propranolol-LA (Inderal-LA), 80-120

mg PO qd [60, 80, 120, 160 mg].

-Acetaminophen (Tylenol) 1-2 tabs PO q4-6h prn

temp >38EC.

-Zolpidem (Ambien) 10 mg PO qhs prn insomnia OR

-Lorazepam (Ativan) 1-2 mg IV/IM/PO q4-8h prn

anxiety.

10. Extras: CXR PA and LAT, ECG, endocrine consult.

11. Labs: CBC, SMA 7&12; sensitive TSH, free T4. UA.

Myxedema Coma and

Hypothyroidism

1. Admit to:

2. Diagnosis: Myxedema Coma

3. Condition:

4. Vital Signs: q1h. Call physician if BP systolic

>160/90, <90/60; P >130, <50; R>25, <10; T

>38.5EC.

5. Activity: Bed rest

6. Nursing: Triple blankets prn temp <36EC, inputs and

outputs, aspiration precautions.

7. Diet: NPO

8. IV Fluids: IV D5 NS TKO.

9. Special Medications:

Myxedema Coma and Hypothyroidism:

-Volume replacement with NS 1 L rapid IV over 1 hour,

then 125 mL/h.

-Levothyroxine (Synthroid, Levoxine) 300-500 mcg IV,

then 100 mcg PO or IV qd.

-Hydrocortisone 100 mg IV loading dose, then 50-100

mg IV q8h.

Hypothyroidism in Medically Stable Patient:

-Levothyroxine (Synthroid, T4) 50-75 mcg PO qd,

increase by 25 mcg PO qd at 2-4 week intervals to

75-150 mcg qd until TSH normalized.

11. Extras: ECG, endocrine consult.

12. Labs: CBC, SMA 7&12; sensitive TSH, free T4. UA,

rheumatoid factor, ANA.

Nephrologic Disorders

Renal Failure

1. Admit to:

2. Diagnosis: Renal failure

3. Condition:

4. Vital Signs: q8h. Call physician if QRS complex

>0.14 sec; urine output <20 cc/hr; BP >160/90, <90/-

60; P >120, <50; R>25, <10; T >38.5EC.

5. Allergies: Avoid magnesium containing antacids, salt

substitutes, NSAIDS. Discontinue phosphate or

potassium supplements.

6. Activity: Bed rest.

7. Nursing: Daily weights, inputs and outputs, chart

urine output. If no urine output for 4h, in-and-out

catheterize. Guaiac stools.

8. Diet: Renal diet of high biologic value protein of 0.6-

0.8 g/kg, sodium 2 g, potassium 1 mEq/kg, and at

least 35 kcal/kg of nonprotein calories. In oliguric

patients, daily fluid intake should be restricted to less

than 1 L after volume has been normalized.

9. IV Fluids: D5W at TKO.

10. Special Medications:

-Consider fluid challenge (to rule out pre-renal azotemia

if not fluid overloaded) with 500-1000 mL NS IV

over 30 min. In acute renal failure, in-and-out

catheterize and check postvoid residual to rule out

obstruction.

-Furosemide (Lasix) 80-320 mg IV bolus over 10-60

min, double the dose if no response after 2 hours to

total max 1000 mg/24h, or furosemide 1000 mg in

250 mL D5W at 20-40 mg/hr continuous IV infusion

OR

-Torsemide (Demadex) 20-40 mg IV bolus over 5-10

min, double the dose up to max 200 mg/day OR

-Bumetanide (Bumex) 1-2 mg IV bolus over 1-20 min;

double the dose if no response in 1-2 h to total max

10 mg/day.

-Metolazone (Zaroxolyn) 5-10 mg PO (max 20 mg/24h)

30 min before a loop diuretic.

-Hyperkalemia is treated with sodium polystyrene

sulfonate (Kayexalate), 15-30 gm PO/NG/PR q4-6h.

-Hyperphosphatemia is controlled with calcium acetate

(PhosLo), 2-3 tabs with meals.

-Metabolic acidosis is treated with sodium bicarbonate

to maintain the serum pH >7.2 and the bicarbonate

level >20 mEq/L. 1-2 amps (50-100 mEq) IV push,

followed by infusion of 2-3 amps in 1000 mL of D5W

at 150 mL/hr.

-Adjust all medications to creatinine clearance, and

remove potassium phosphate and magnesium from

IV. Avoid NSAIDs and nephrotoxic drugs.

11. Extras: CXR, ECG, renal ultrasound, nephrology

and dietetics consults.

12. Labs: CBC, platelets, SMA 7&12, creatinine, BUN,

potassium, magnesium, phosphate, calcium, uric acid,

osmolality, ESR, INR/PTT, ANA.

Urine specific gravity, UA with micro, urine C&S; 1st AM

spot urine electrolytes, eosinophils, creatinine, pH,

osmolality; Wright's stain, urine electrophoresis. 24h

urine protein, creatinine, sodium.

Nephrolithiasis

1. Admit to:

2. Diagnosis: Nephrolithiasis

3. Condition:

4. Vital Signs: q8h. Call physician if urine output <30

cc/hr; BP >160/90, <90/60; T >38.5EC.

5. Activity: Up ad lib.

6. Nursing: Strain urine, measure inputs and outputs.

Place Foley if no urine for 4 hours.

7. Diet: Regular, push oral fluids.

8. IV Fluids: IV D5 ½ NS at 100-125 cc/hr (maintain

urine output of 80 mL/h).

9. Special Medications:

-Cefazolin (Ancef) 1-2 gm IV q8h

-Meperidine (Demerol) 75-100 mg and hydroxyzine

25 mg IM/IV q2-4h prn pain OR

-Butorphanol (Stadol) 0.5-2 mg IV q3-4h.

-Hydrocodone/acetaminophen (Vicodin), 1-2 tab q4-

6h PO prn pain OR

-Oxycodone/acetaminophen (Percocet) 1 tab q6h prn

pain OR

-Acetaminophen with codeine (Tylenol 3) 1-2 tabs PO

q3-4h prn pain.

-Ketorolac (Toradol) 10 mg PO q4-6h prn pain, or 30-

60 mg IV/IM then 15-30 mg IV/IM q6h (max 5

days).

-Zolpidem (Ambien) 10 mg PO qhs prn insomnia.

11. Extras: Intravenous pyelogram, KUB, CXR, ECG.

12. Labs: CBC, SMA 6 and 12, calcium, uric acid,

phosphorous, UA with micro, urine C&S, urine pH,

INR/PTT. Urine cystine (nitroprusside test), send

stones for X-ray crystallography. 24 hour urine

collection for uric acid, calcium, creatinine.

Hypercalcemia

1. Admit to:

2. Diagnosis: Hypercalcemia

3. Condition:

4. Vital Signs: q4h. Call physician if BP >160/90,

<90/60; P >120, <50; R>25, <10; T >38.5EC; or tetany

or any abnormal mental status.

5. Activity: Encourage ambulation; up in chair at other

times.

6. Nursing: Seizure precautions, measure inputs and

outputs.

7. Diet: Restrict dietary calcium to 400 mg/d, push PO

fluids.

8. Special Medications:

-1-2 L of 0.9% saline over 1-4 hours until no longer

hypotensive, then saline diuresis with 0.9% saline

infused at 125 cc/h AND

-Furosemide (Lasix) 20-80 mg IV q4-12h. Maintain

urine output of 200 mL/h; monitor serum sodium,

potassium, magnesium.

-Calcitonin (Calcimar) 4-8 IU/kg IM q12h or SQ q6-

12h.

-Etidronate (Didronel) 7.5 mg/kg/day in 250 mL of

normal saline IV infusion over 2 hours. May repeat

in 3 days.

-Pamidronate (Aredia) 60 mg in 500 mL of NS infused

over 4 hours or 90 mg in 1 liter of NS infused over

24 hours x one dose.

9. Extras: CXR, ECG, mammogram.

10. Labs: Total and ionized calcium, parathyroid

hormone, SMA 7&12, phosphate, Mg, alkaline

phosphatase, prostate specific antigen and

carcinoembryonic antigen. 24h urine calcium, phosphate.

Hypocalcemia

1. Admit to:

2. Diagnosis: Hypocalcemia

3. Condition:

4. Vital Signs: q4h. Call physician if BP >160/90,

<90/60; P >120, <50; R>25, <10; T >38.5EC; or any

abnormal mental status.

5. Activity: Up ad lib

6. Nursing: I and O.

7. Diet: No added salt diet.

8. Special Medications:

Symptomatic Hypocalcemia:

-Calcium chloride, 10% (270 mg calcium/10 mL vial),

give 5-10 mL slowly over 10 min or dilute in 50-100

mL of D5W and infuse over 20 min, repeat q20-30

min if symptomatic, or hourly if asymptomatic.

Correct hyperphosphatemia before hypocalcemia

OR

-Calcium gluconate, 20 mL of 10% solution IV (2

vials)(90 mg elemental calcium/10 mL vial) infused

over 10-15 min, followed by infusion of 60 mL of

calcium gluconate in 500 cc of D5W (1 mg/mL) at

0.5-2.0 mg/kg/h.

Chronic Hypocalcemia:

-Calcium carbonate with vitamin D (Oscal-D) 1-2 tab

PO tid OR

-Calcium carbonate (Oscal) 1-2 tab PO tid OR

-Calcium citrate (Citracal) 1 tab PO q8h or Extra

strength Tums 1-2 tabs PO with meals.

-Vitamin D2 (Ergocalciferol) 1 tab PO qd.

-Calcitriol (Rocaltrol) 0.25 mcg PO qd, titrate up to

0.5-2.0 mcg qid.

-Docusate sodium (Colace) 1 tab PO bid.

9. Extras: CXR, ECG.

10. Labs: SMA 7&12, phosphate, Mg. 24h urine

calcium, potassium, phosphate, magnesium.

Hyperkalemia

1. Admit to:

2. Diagnosis: Hyperkalemia

3. Condition:

4. Vital Signs: q4h. Call physician if QRS complex

>0.14 sec or BP >160/90, <90/60; P >120, <50;

R>25, <10; T >38.5EC.

5. Activity: Bed rest; up in chair as tolerated.

6. Nursing: Inputs and outputs. Chart QRS complex

width q1h.

7. Diet: Regular, no salt substitutes.

8. IV Fluids: D5NS at 125 cc/h

9. Special Medications:

-Discontinue ACE inhibitors, angiotensin II receptor

blockers, beta-blockers, potassium sparing

diuretics.

-Calcium gluconate (10% solution) 10-30 mL IV over

2-5 min; second dose may be given in 5 min.

Contraindicated if digoxin toxicity is suspected.

Keep 10 mL vial of calcium gluconate at bedside

for emergent use.

-Sodium bicarbonate 1 amp (50 mEq) IV over 5 min

(give after calcium in separate IV).

-Regular insulin 10 units IV push with 1 ampule of

50% glucose IV push.

-Kayexalate 30-45 gm premixed in sorbitol solution

PO/NG/PR now and q3-4h prn.

-Furosemide 40-80 mg IV, repeat prn.

-Consider emergent dialysis if cardiac complications

or renal failure.

10. Extras: ECG.

11. Labs: CBC, platelets, SMA7, magnesium, calcium,

SMA-12. UA, urine specific gravity, urine sodium, pH,

24h urine potassium, creatinine.

Hypokalemia

1. Admit to:

2. Diagnosis: Hypokalemia

3. Condition:

4. Vital Signs: Vitals, urine output q4h. Call physician if

BP >160/90, <90/60; P>120, <50; R>25, <10; T

>38.5EC.

5. Activity: Bed rest; up in chair as tolerated.

6. Nursing: Inputs and outputs

7. Diet: Regular

8. Special Medications:

Acute Therapy:

-KCL 20-40 mEq in 100 cc saline infused IVPB over 2

hours; or add 40-80 mEq to 1 liter of IV fluid and

infuse over 4-8 hours.

-KCL elixir 40 mEq PO tid (in addition to IV); max total

dose 100-200 mEq/d (3 mEq/kg/d).

Chronic Therapy:

-Micro-K 10 mEq tabs 2-3 tabs PO tid after meals (40-

100 mEq/d) OR

-K-Dur 20 mEq tabs 1 PO bid-tid.

Hypokalemia with metabolic acidosis:

-Potassium citrate 15-30 mL in juice PO qid after

meals (1 mEq/mL).

-Potassium gluconate 15 mL in juice PO qid after

meals (20 mEq/15 mL).

9. Extras: ECG, dietetics consult.

10. Labs: CBC, magnesium, SMA 7&12. UA, urine Na,

pH, 24h urine for K, creatinine.

Hypermagnesemia

1. Admit to:

2. Diagnosis: Hypermagnesemia

3. Condition:

4. Vital Signs: q6h. Call physician if QRS >0.14 sec.

5. Activity: Up ad lib

6. Nursing: Inputs and outputs, daily weights.

7. Diet: Regular

8. Special Medications:

-Saline diuresis 0.9% saline infused at 100-200 cc/h

to replace urine loss AND

-Calcium chloride, 1-3 gm added to saline (10%

solution; 1 gm per 10 mL amp) to run at 1 gm/hr

AND

-Furosemide (Lasix) 20-40 mg IV q4-6h as needed.

-Magnesium of >9.0 mEq/L requires stat

hemodialysis because of risk of respiratory failure.

9. Extras: ECG

10. Labs: Magnesium, calcium, SMA 7&12, creatinine.

24 hour urine magnesium, creatinine.

Hypomagnesemia

1. Admit to:

2. Diagnosis: Hypomagnesemia

3. Condition:

4. Vital Signs: q6h

5. Activity: Up ad lib

6. Diet: Regular

7. Special Medications:

-Magnesium sulfate 4-6 gm in 500 mL D5W IV at 1

gm/hr. Hold if no patellar reflex. (Estimation of Mg

deficit = 0.2 x kg weight x desired increase in Mg

concentration; give deficit over 2-3d) OR

-Magnesium sulfate (severe hypomagnesemia <1.0)

1-2 gm (2-4 mL of 50% solution) IV over 15 min,

OR

-Magnesium chloride (Slow-Mag) 65-130 mg (1-2

tabs) PO tid-qid (64 mg or 5.3 mEq/tab) OR

-Milk of magnesia 5 mL PO qd-qid.

8. Extras: ECG

9. Labs: Magnesium, calcium, SMA 7&12. Urine Mg,

electrolytes, 24h urine magnesium, creatinine.

Hypernatremia

1. Admit to:

2. Diagnosis: Hypernatremia

3. Condition:

4. Vital Signs: q2-8h. Call physician if BP >160/90, <7-

0/50; P >140, <50; R>25, <10; T >38.5EC.

5. Activity: Bed rest; up in chair as tolerated.

6. Nursing: Inputs and outputs, daily weights.

7. Diet: No added salt. Push oral fluids.

8. Special Medications:

Hypernatremia with Hypovolemia:

If volume depleted, give 1-2 L NS IV over 1-3 hours

until not orthostatic, then give D5W IV to replace

half of body water deficit over first 24hours

(correct sodium at 1 mEq/L/h), then remaining

deficit over next 1-2 days.

Body water deficit (L) = 0.6(weight kg)([Na serum]-

140)

140

Hypernatremia with ECF Volume Excess:

-Furosemide 40-80 mg IV or PO qd-bid.

-Salt poor albumin (25%) 50-100 mL bid-tid x 48-72

h.

Hypernatremia with Diabetes Insipidus:

-D5W to correct body water deficit (see above).

-Pitressin 5-10 U IM/IV q6h or desmopressin

(DDAVP) 4 mcg IV/SQ q12h; keep urine specific

gravity >1.010.

9. Extras: CXR, ECG.

10. Labs: SMA 7&12, serum osmolality, liver panel,

ADH, plasma renin activity. UA, urine specific gravity.

Urine osmolality, Na, 24h urine K, creatinine.

Hyponatremia

1. Admit to:

2. Diagnosis: Hyponatremia

3. Condition:

4. Vital Signs: q4h. Call physician if BP >160/90, <7-

0/50; P >140, <50; R>25, <10; T >38.5EC.

5. Activity: Up in chair as tolerated.

6. Nursing: Inputs and outputs, daily weights.

7. Diet: Regular diet.

8. Special Medications:

Hyponatremia with Hypervolemia and Edema (low

osmolality <280 mOsm/L, UNa <10 mmol/L:

nephrosis, heart failure, cirrhosis):

-Water restrict to 0.5-1.0 L/d.

-Furosemide 40-80 mg IV or PO qd-bid.

Hyponatremia with Normal Volume Status (low

osmolality <280 mOsm/L, UNa <10 mmol: water

intoxication; UNa >20: SIADH, diuretic-induced):

-Water restrict to 0.5-1.5 L/d.

-Conivaptan (Vaprisol) 20 mg IV over 30 minutes

once, followed by a continuous infusion of 20 mg

over 24 hours. If the response is insufficient,

increase dose to 40 mg/24 hours; max 4 days.

Hyponatremia with Hypovolemia (low osmolality <280

mOsm/L) UNa <10 mmol/L: vomiting, diarrhea, third

space/respiratory/skin loss; UNa >20 mmol/L:

diuretics, renal injury, RTA, adrenal insufficiency,

partial obstruction, salt wasting:

-If volume depleted, give 0.5-2 L of 0.9% saline over

1-2 hours until no longer hypotensive, then 0.9%

saline at 125 mL/h or 100-500 mL 3% hypertonic

saline over 4h.

Severe Symptomatic Hyponatremia:

If volume depleted, give 1-2 L of 0.9% saline (154

mEq/L) over 1-2 hours until no longer orthostatic.

Determine volume of 3% hypertonic saline (513

mEq/L) to be infused:

Na (mEq) deficit = 0.6 x (wt kg)x(desired [Na] - actual

[Na])

Volume of solution (L) = Sodium to be infused

(mEq)

Number of hrs (mEq/L in solution) x Number

of hrs

-Correct half of sodium deficit intravenously over 24

hours until serum sodium is 120 mEq/L; increase

sodium by 12-20 mEq/L over 24 hours (1

mEq/L/h).

-Alternative Method: 3% saline 100-300 mL over 4-6h,

repeated as needed.

9. Extras: CXR, ECG, head/chest CT scan.

10. Labs: SMA 7&12, osmolality, triglyceride, liver panel.

UA, urine specific gravity. Urine osmolality, Na.

Hyperphosphatemia

1. Admit to:

2. Diagnosis: Hyperphosphatemia

3. Condition:

4. Vital Signs: qid

5. Activity: Up ad lib

6. Nursing: Inputs and outputs

7. Diet: Low phosphorus diet.

8. Special Medications:

Moderate Hyperphosphatemia:

-Restrict dietary phosphate to 0.7-1.0 gm/d.

-Calcium acetate (PhosLo) 1-3 tabs PO tid with meals

OR

-Aluminum hydroxide (Amphojel) 5-10 mL or 1-2

tablets PO before meals tid.

Severe Hyperphosphatemia:

-Volume expansion with 0.9% saline 1-2 L over 1-2h.

-Acetazolamide (Diamox) 500 mg PO or IV q6h.

-Consider dialysis.

9. Extras: CXR PA and LAT, ECG.

10. Labs: Phosphate, SMA 7&12, magnesium, calcium.

UA, parathyroid hormone.

Hypophosphatemia

1. Admit to:

2. Diagnosis: Hypophosphatemia

3. Condition:

4. Vital Signs: qid

5. Activity: Up ad lib

6. Nursing: Inputs and outputs.

7. Diet: Regular diet.

8. Special Medications:

Mild to Moderate Hypophosphatemia (1.0-2.2 mg/dL):

-Sodium or potassium phosphate 0.25 mMoles/kg in

150-250 mL of NS or D5W at 10 mMoles/h.

-Neutral phosphate (Nutra-Phos), 2 tab PO bid (250

mg elemental phosphorus/tab) OR

-Phospho-Soda 5 mL (129 mg phosphorus) PO bidtid.

Severe Hypophosphatemia (<1.0 mg/dL):

-Na or K phosphate 0.5 mMoles/kg in 250 mL D5W or

NS, IV infusion at 10 mMoles/hr OR

-Add potassium phosphate to IV solution in place of

maintenance KCL; max IV dose 7.5 mg

phosphorus/kg/6h.

9. Extras: CXR PA and LAT, ECG.

10. Labs: Phosphate, SMA 7&12, Mg, calcium, UA.

Rheumatologic Disorders

Systemic Lupus Erythematosus

1. Admit to:

2. Diagnosis: Systemic Lupus Erythematosus

3. Condition:

4. Vital Signs: tid

5. Allergies:

6. Activity: Up as tolerated with bathroom privileges

7. Nursing:

8. Diet: No added salt, low psoralen diet.

9. Special Medications:

-Ibuprofen (Motrin) 400 mg PO qid (max 2.4 g/d) OR

-Indomethacin (Indocin) 25-50 mg tid-qid.

-Hydroxychloroquine (Plaquenil) 200-600 mg/d PO

-Prednisone 60-100 mg PO qd. Maintenance 10-20

mg PO qd or 20-40 mg PO qOD OR

-Methylprednisolone (pulse therapy) 500 mg IV over

30 min q12h for 3-5d, then prednisone 50 mg PO

qd.

-Betamethasone dipropionate (Diprolene) 0.05%

ointment applied bid.

10. Extras: CXR PA, LAT, ECG. Rheumatology consult.

11. Labs: CBC, platelets, SMA 7&12, INR/PTT, ESR,

complement CH-50, C3, C4, C-reactive protein, LE

prep, Coombs test, VDRL, rheumatoid factor, ANA,

DNA binding, lupus anticoagulant, anticardiolipin,

antinuclear cytoplasmic antibody. UA.

Acute Gout Attack

1. Admit to:

2. Diagnosis: Acute gout attack

3. Condition:

4. Vital Signs: tid

5. Activity: Bed rest with bedside commode

6. Nursing: Keep foot elevated; support sheets over

foot; guaiac stools.

7. Diet: Low purine diet.

8. Special Medications:

-Ibuprofen (Motrin) 800 mg, then 400-800 mg PO q4-

6h OR

-Diclofenac (Voltaren) 25-75 mg tid-qid with food OR

-Indomethacin (Indocin) 50 mg PO q6h for 2d, then

50 mg tid for 2 days, then 25 mg PO tid OR

-Ketorolac (Toradol) 30-60 mg IV/IM, then 15-30 mg

IV/IM q6h or 10 mg PO tid-qid OR

-Naproxen sodium (Anaprox, Anaprox-DS) 550 mg

PO bid OR

-Methylprednisolone (SoluMedrol) 125 mg IV x 1 dose

THEN

-Prednisone 60 mg PO qd for 5 days, followed by

tapering.

-Colchicine 2 tablets (0.5 mg or 0.6 mg), followed by 1

tablet q1h until relief, max dose of 9.6 mg/24h.

Maintenance colchicine: 0.5-0.6 mg PO qd-bid.

Hypouricemic Therapy:

-Probenecid (Benemid), 250 mg bid. Increase the

dosage to 500 mg bid after 1 week, then increase

by 500-mg increments every 4 weeks until the uric

acid level is below 6.5 mg/dL. Max dose 2 g/d.

Contraindicated during acute attack.

-Allopurinol (Zyloprim) 300 mg PO qd, may increase

by 100-300 mg q2weeks. Usually initiated after the

acute attack.

9. Symptomatic Medications:

-Famotidine (Pepcid) 20 mg IV/PO q12h.

-Meperidine (Demerol) 50-100 mg IM/IV q4-6h prn

pain OR

-Hydrocodone/acetaminophen (Vicodin), 1-2 tab q4-

6h PO prn pain.

-Docusate sodium (Colace) 100 mg PO qhs.

-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn

headache.

-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.

10. Labs: CBC, SMA 7, uric acid. UA with micro.

Synovial fluid for light and polarizing micrography for

crystals; C&S, Gram stain, glucose, protein, cell count.

X-ray views of joint. 24-hour urine for uric acid.

Commonly Used Drug Levels

Drug Therapeutic Range

Amikacin

Amiodarone

Amitriptyline

Carbamazepi

Desipramine

Digoxin

Disopyramide

Doxepin

Flecainide

Gentamicin

Imipramine

Lidocaine

Lithium

Mexiletine

Nortriptyline

Phenobarbita

l

Phenytoin

Procainamide

Quinidine

Salicylate

Streptomycin

Theophylline

Tocainide

Valproic acid

Vancomycin

Peak 25-30; trough <10 mcg/mL

1.0-3.0 mcg/mL

100-250 ng/mL

4-10 mcg/mL

150-300 ng/mL

0.8-2.0 ng/mL

2-5 mcg/mL

75-200 ng/mL

0.2-1.0 mcg/mL

Peak 6.0-8.0; trough <2.0 mcg/mL

150-300 ng/mL

2-5 mcg/mL

0.5-1.4 mEq/L

1.0-2.0 mcg/mL

50-150 ng/mL

10-30 mEq/mL

8-20 mcg/mL

4.0-8.0 mcg/mL

2.5-5.0 mcg/mL

15-25 mg/dL

Peak 10-20; trough <5 mcg/mL

8-20 mcg/mL

4-10 mcg/mL

50-100 mcg/mL

Peak 30-40; trough <10 mcg/mL

Extended Interval Gentamicin/Tobramycin

Therapy

GFR (mL/min) Gentamicin/Tobramycin

Dosage Frequency

>60 7 mg/kg every 24 hours

40-59 7 mg/kg every 36 hours

20-39 7 mg/kg every 48 hours

<20 Extended interval not

recommended

Each dose is administer over 60 minutes. Therapeutic

range is a peak level of 20-30 mcg/mL and a trough

level of <1.0 mcg/mL (during the 4 hours before the

next dose). Monitor renal function and hearing

status.

Drugs that Prolong the QT Interval

Amiodarone

Bepridil

Chlorpromazine

Desipramine

Disopyramide

Dofetilide

Droperidol

Erythromycin

Flecainide

Fluoxetine

Foscarnet

Fosphenytoin

Gatifolixin

Halofantrine

Haloperidol

Ibutilide

Isradipine

Mesoridazine

Moxifloxacin

Naratriptan

Nicardipine

Octreotide

Pentamidine

Pimozide

Probucol

Procainamide

Quetiapine

Quinidine

Risperidone

salmeterol

Sotalol

Sparfloxacin

Sumatriptan

Tamoxifen

Thioridazine

Venlafaxine

Zolmitriptan