Form Chh 704 – Fill Out and Use This PDF

Outpatient Hemodialysis Orders

SIGNATURE

II.

DIET: Protein_______Gm

Na+_______gm K+_______mEq. Fluids__________ml/24 hrs

III.HEPARIN:

A.Heparin Dialyzer prime to be diluted in 1000ml 0.9% normal saline.

B.Heparin bolus to be given through the venous line 1-3 minutes before Dialysis with initial dose of 3000units unless otherwise indicated. Maximum dose will be 100units/Kg/BW unless specifically ordered by patient’s physician.

C.Catheter: 5000units/ml Heparin to fill volume of catheter

D.INTERVENTIONAL RADIOLOGY or ACCESS SURGERY Patients:

1.FOR CATHETERS: Do not give Heparin on the day of placement, replacement and/or revision

2.FOR VASCULAR ACCESSES: DO give regular dose of Heparin on the day of procedure unless otherwise notified by radiology or surgery staff.

IV.	VITAL SIGNS:

A.Pre and post Dialysis: Temperature, B/P (sitting and standing) and pulse

B.Monitor B/P AND pulse a minimum of q 1 h.

V. LABORATORY:

A. ADMISSION: Pre-dialysis CBC (Anemia, unspecified), CCP and P04 (CKD-End stage renal disease), Hepatitis Panel inclusive of HbsAB, HbsAg and Anti-HCV with Reflex to Immunoblot Assay (RIBA) (Assess for Hepatitis status due to CKD- End stage renal disease), Ferritin, Serum Iron, TIBC, Transferrin Saturation NOTE: CHr may be ordered at physician discretion. (Iron deficiency, Anemia, unspecified), Intact PTH (secondary hyperparathyroidism of renal origin)

B.WITHIN 1 WEEK OF ADMISSION: Pre/Post BUN for URR (CKD-End stage renal disease)

C.MONTHLY: Pre-Dialysis CBC, CCP, P04 HbsAG if HbsAB negative,Post BUN

D.QUARTERLY: Intact PTH; Hgb A1c (diabetes with renal manifestations) on all diabetics); Ferritin, Serum Iron, TIBC, Transferrin Saturation

E.BI-MONTHLY: Hemoglobin

F. SEMI-ANNUALLY: Anti-HCV with Reflex to Immunoblot Assay (RIBA) if previous test is negative (NOTE: Patients who have been confirmed positive with RIBA do not need any further testing for hepatitis C status); HbsAB if status is negative

G.ANNUALLY: HbsAB if antibody status is positive

H.PRN: Ferritin, Serum Iron, TIBC, Transferrin Saturation if Hgb less than 11 and it has been at least three months since last test; CRP for ferritins greater than or equal to 800 at individual physician discretion.

Patient Identification

CHH-704 Page 1 of 2

Revised: 10/99, 6/0, 3/02, 5/03, 6/05, 6/06ss

VI.	HOME MEDICATIONS:
	A.	Tylenol 650mg po q 4hrs. prn for pain
	B.	Benadryl 25mg po q 6hrs. prn for itching
	C.	Periactin 4mg po q 8hrs. prn for itching
	D.	Pericolace 100mg 1 po BID prn for constipation
	E.	Immodium 1 po TID prn for diarrhea

VII. PRN MEDICATIONS:

A.Hypotension:

1.100ml bolus 0.9%NaCl IV. May Repeat as indicated if patient remains symptomatic

2.Albumin 25 gm IV for severe hypotension. May repeat X1 in 15minutes if patient remains hypotensive.

B.Muscle Cramps:

1.Concentrated Dextrose (50%) 50ml IVP for Nondiabetics.

2.Sodium profiling as indicated per extracorporeal system.

C.Seizure Activity:

1.Valium 2.5mg IV. May Repeat in 5 minutes if seizure activity persists.

2.Ativan 1mg IV. May repeat x2 every two minutes if seizure activity persists.

NOTE: NOTIFY M.D. IF ANY SEIZURE ACTIVITY OCCURS.

D.Nausea/Vomiting:

1.Phenergan 12.5mg IVP. May Repeat x 1 in 15 minutes if nausea or vomiting persists.

E.Hypoglycemia:

1.Dextrose 50% 25ml Bolus IVP. May repeat x 1 in 30 minutes if sugar remains below 60.

F.Chest Pain:

1.NTG 0.4mg SUBLINGUAL, may repeat every 5mins x 3, if chest pain persisits. If no relief, call MD.

G.Misc:

1.Benadryl 25mg IVP prn for itching or suspected drug reaction.

2.Acetaminophen 650mg po q 4hr prn pain.

H.Vaccines

1.Pneumonia Vaccine q 5 years.

2.Flu Vaccine annually

3.Hepatitis B Vaccine per protocol if antibody negative (Hepatitis status due to CKD- End stage renal disease) Note: Documentation of patient refusal for any of the above should be noted on the flu vaccination form and placed on the patient’s chart.

VIII. MISC:

A.Oxygen @2L/min PRN for Chest Pain or dyspnea.

B.Culture all wound/catheter site drainage PRN and notify MD for orders.

C.Glucoscans as indicated.

D.Epogen / Procrit / Aranesp per protocol ( Anemia, unspecified).

E.Ferrlecit per protocol (Iron deficiency, Anemia, unspecified).

F.Blood Cultures X 2 PRN temperature greater than 101 degrees F, obtaining one from access and one peripherally

(NOTIFY M.D. FOR FURTHER ORDERS).

G.CXR as indicated for Estimated Dry Weight adjustment per charge nurse (Fluid overload).

H.Hectoral / Zemplar per protocol (secondary hyperparathyroidism of renal origin).

I.TPA 2mg to each limb to dwell 30-45 min. for catheter clearance.

J.Transplant Coordinator evaluate for patient’s interest in transplant, refer to appropriate agencies, and document.

K.Transplant Coordinator evaluate for permanent access placement, refer to appropriate agencies, and document.

L.Reprocessing of dialyzer if patient consents.

M.Tuberculosis skin test, if not allergic, as needed for travel.

CHH-704 Page 2 of 2	Patient Identification
Revised: 10/99, 6/0, 3/02, 5/03, 6/05, 6/06ss