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 >38.5 C.
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 >38.5 C.
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 >38.5 C; 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 >38.5 C; 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 dia-
phragmatic 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, liver-
spleen 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
>38.5 C.
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
>38.5 C.
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 >38.5 C; 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, ultra
sound, 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 >38.5 C.
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, bloo
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 >38.5 C
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 pro-
ducts.
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 B
, 100 mcg IM for 5d, then 100-200 mcg IM
12
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 >38.5 C.
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, pre-
albumin, ferritin, INR/PTT, zinc, copper, B12, fol-
ate, 24h urine nitrogen and creatinine.
Enteral Nutrition
General Considerations: Daily weights, inputs and
outputs, nasoduodenal feeding tube. Head-of-bed at
30 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 calo-
ries/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 q8
-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
(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 placeme
nutrition consult.
Labs:
Daily labs: SMA7, osmolality, CBC, cholesterol,
triglyceride. SMA-12
Weekly labs when indicated: Protein, Mg, INR/PT
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 physicia
BP >160/90,<90/60; P >120,<50; R>25,<10; T
>38.5 C.
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. Increa
rate by 25-50 mL/hr at 24 hr intervals as tolerated u
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 15-4
mL PO bid-qid, titrate to produce 3 soft stools/d
-Lactulose enema 300 mL added to 700 mL of tap
ter; instill 200-250 mL per rectal tube bid-qid AN
-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 bi
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 par
response occurs, continue 0.5 mg doses until a
total of 5 mg. Flumazenil may help reverse hepa
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, al-
bumin, 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, <
/60; P >130, <50; R>25, <10; T >38.5 C; or increas
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/
9.Special Medications:
Withdrawal syndrome:
-Chlordiazepoxide (Librium) 50-100 mg PO/IV q6h
3 days OR
-Lorazepam (Ativan) 1 mg PO tid-qid.
Delirium tremens:
-Chlordiazepoxide (Librium) 100 mg slow IV push o
PO, repeat q4-6h prn agitation or tremor for 24h;
max 500 mg/d. Then give 50-100 mg PO q6h pr
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; ma
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 he-
adache.
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.
