Unique Plan Description: Gen Adm Initial Acute Agitation (JE)
Plan Selection Display: Gen Adm Initial Acute Agitation (JE)
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2020-03-03 17:48:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-09-23 00:44:06
Available at all facilities: Yes

Gen Adm Initial Acute Agitation (JE)
Admit/Discharge/Transfer
	Admit to Inpatient Status
		T;N, Anticipated LOS 2 midnight or more
		T;N
	Admit to Observation Status
		T;N
	Admit to Critical Care Inpatient Status (MH)
		T;N, Anticipated LOS 2 midnight or more
	Admit to Critical Care Observation Status (MH)
		T;N
	Board of Mental Health Hold
		
Vital Signs
	Vital Signs
		T;N, per floor routine
		T;N, Q1H
		T;N, Q2H-Sch
		T;N, Q4H-Sch
		T;N
			Comment: Vital signs and RASS Agitation Scale: Every 4 hours if score is 0 every 2 hours if score is -1 to +1, and every hour if score is > -2 or +2. RASS must be assessed with administration and titration of agitation management medications.
Activity
	Activity-As Tolerated
		T;N
		T;N, with assistance
	Bedrest
		T;N
	Up with Assistance
		T;N
	Bedrest with Bathroom Privileges
		T;N
	Bedrest with Bedside Commode
		T;N
	Up in Chair
		T;N, TIDWM
	Ambulate
		T;N, With assistance, TID
		T;N, In hall, TID
		T;N, In hall, QID
Diet
	NPO
		T;N, After Midnight
	Regular Diet
		T;N
	Sodium Restricted Diet
		T;N
	Cardiac Diet
		T;N
	Renal Diet
		T;N
	Diabetic Diet
		T;N, Calorie Level 2000 kcal, Protective Care Tray
		T;N, Calorie Level 1800 kcal, Protective Care Tray
	Clear Liquid Diet
		T;N
	Blenderized Liquid (Full) Diet
		
Laboratory
	CBC with Diff
		T;N, Stat, spec type = Blood
	INR - MH/WH/JE
		T;N, Stat, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Stat, spec type = Blood
	Magnesium Level
		T;N, Stat, spec type = Blood
	Phosphorus
		T;N, Stat, spec type = Blood
	Pregnancy Test Urine
		T;N, Stat, Stat, Urine Random, spec type = Urine
	Beta-HCG Quantitative - Pregnancy
		T;N, Stat, spec type = Blood
	Acetaminophen Level
		T;N, Stat, spec type = Blood
	PTT - MH/WH/JE
		T;N, Stat, spec type = Blood
	Lactate
		T;N, Stat, spec type = Blood
	Toxicology Screen DAU - MH/WH/JE
		T;N, Stat, Urine Random, spec type = Urine
	CK
		T;N, Stat, spec type = Blood
Diagnostic Tests
	ECG
		T;N, Stat
			Comment: if not completed already
		T+1;0600, Routine
			Comment: if not completed already
Medications
		Agitation Management: Treat agitation first Discontinue previous PRN Ativan (lorazepam) orders(NOTE)*
	Ativan
		2 mg, Injection, IV Push, Q1H, PRN agitation, duration: 48 hr
			Comment: Agitation RASS score of >/= +1 May give IM if not IV access
		4 mg, Injection, IV Push, Q1H, PRN agitation, duration: 48 hr
			Comment: Agitation RASS score of >/= +1 May give IM if not IV access
	diphenhydrAMINE
		50 mg, Injection, IV Push, Q1H, PRN agitation, duration: 48 hr
			Comment: Max 400mg. May give IM if no IV access
	Haldol  injectable
		5 mg, Injection, IM-Intramuscular, Q1H, PRN agitation, duration: 48 hr
			Comment: Max dose 20mg/24 hours
	Thorazine
		25 mg, Injection, IM-Intramuscular, Q1H, PRN agitation, duration: 48 hr
	ketamine
		1 mg/kg, Injection, IV Push, Once, PRN agitation
			Comment: Give over 2 minutes
		2 mg/kg, Injection, IV Push, Once, PRN agitation
			Comment: Give over 2 minutes
		Hypertension Management-avoid beta blockers, treat agitation first(NOTE)*
	cloNIDine
		0.1 mg, Tab, By Mouth, Q6H, PRN systolic blood pressure > (see comment), duration: 48 hr
			Comment: For SBP > 150mmHG to a maximum of 0.6mg/24hrs. If ineffective in 60 minutes, administer Hydralazine
	hydrALAZINE
		10 mg, Injection, IV Push, Q4H, PRN systolic blood pressure > (see comment), duration: 48 hr
		Tachycardia-avoid beta blockers, treat agitation first(NOTE)*
	Cardizem
		5 mg, Injection, IV Push, Q10MIN, for systolic blood pressure > (see comment), duration: 3 Dose(s)/Time(s)
			Comment: SBP > 120, must treat agitation first
Patient Care
		Hyperthermia-antipyretics not effective in methamphetamine intoxication induced muscular hyperactivity(NOTE)*
	Cooling Blanket
		T;N, For body temperature >/= 41.1 C
	Resuscitation Status
		T;N, Full Code
		T;N, No Code
	Foley Catheter
		T;N, Insert
	GI Tube
		
	Cardiac Telemetry Monitoring
		T;N
			Comment: continuously
	Glucose POC - RN
		Once
			Comment: on arrival
	Seizure Precautions
		T;N
	Straight Catheter
		T;N, Insert, Once
	Peripheral Lock-Insert
		
	Notify MD
		T;N, if following treatment of agitation patient is having symptoms of hypertension SBP >165, DBP >90 and/or tachycardia of >120 bpm.
Consults/Follow-up
	Consult Intensivist
		Reason for Referral: Ventilation
	Consult Psychiatrist

Dexmedetomidine (Precedex) protocol
Vital Signs
	Vital Signs
		Q 15min upon initiation until RASS target achieved, or when titrating medication until RASS target achieved; then every 1hr and PRN
IV Solutions
	dexmedetomidine 400 mcg/NS 100 mL
		400 mcg, EVERY BAG, 0.2 mcg/kg/hr
		100 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 0.1 mcg/kg/hr, Incremental Decrease: 0.1 mcg/kg/hr, Incremental Freq: 30 min(s), Max Dose: 1.5 mcg/kg/hr
			Comment: Begin at 0.2mcg/kg/hr and titrate to goal RASS 0 to -1 OR BIS 45-60, Notify MD if target RASS OR BIS not met at 0.7mcg/kg/hr. Hold if HR<50, SBP<100mmHg or MAP<50 and notify MD.
	dexmedetomidine 400 mcg/NS 100 mL Premix IV
		100 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 0.1 mcg/kg/hr, Incremental Decrease: 0.1 mcg/kg/hr, Incremental Freq: 30 min(s), Max Dose: 1.5 mcg/kg/hr
			Comment: Begin at 0.2mcg/kg/hr and titrate to goal RASS 0 to -1 OR BIS 45-60, Notify MD if target RASS OR BIS not met at 0.7mcg/kg/hr. Hold if HR<50, SBP<100mmHg or MAP<50 and notify MD.
		400 mcg, EVERY BAG, 0.2 mcg/kg/hr
Medications
		To use this drug, patient must have one of the following: Delirium despite treatment, Alcohol withdrawal symptoms not controlled with Alcohol Withdrawal Protocol, failure of ventilator weaning due to agitation despite the use of propofol and/or benzodiaze(NOTE)*
		Contraindications to use include: Left ventricular ejection fraction <30%, Heart rate <50, Systolic blood pressure <100mmHg despite use of vasopressors and/or fluids, Heart block(NOTE)*
Patient Care
	Notify MD
		If HR<50, SBP<100mmHg or MAP<50 and hold dexmedotomidine infusion. If target RASS (0 to -1) OR BIS 45-60 not met at 0.7mcg/kg/hr, or if patient remains delirious at 24hr

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase