Unique Plan Description: OB Magnesium Sulfate Management for Preterm Labor VC Plan Selection Display: OB Magnesium Sulfate Management for Preterm Labor VC PlanType: Medical Version: 1 Begin Effective Date: 10/17/2013 15:57 End Effective Date: Current Available at: Ascension Health VC Rehab Hosp VCH Behav Hlth VCH HH Hospice VCH Select VCH St Francis VCH St Joseph VCH St Teresa VCHSJ Assess VCHSJ SBH VCHST IP Rehab

OB Magnesium Sulfate Management for Preterm Labor VC Patient Care Vital Signs T;N, Before infusion begins, then q15 min during the first hour of infusion, then q30 min during the second hour, and then at least hourly. Intake and Output T;N, Q1hr with a cumulative running total every 24 hours, intake totals not to exceed 3000 mL. Deep Tendon Reflexes T;N, Prior to infusion and then every 2 hours and as needed Respiratory Assessment T;N, Prior to infusion and then every 2 hours and as needed Neurological Checks T;N, q2hr Urinary Catheter Insertion T;N, Indwelling Peripherally Inserted Central Catheter Insertion T;N, For use with prolonged IV therapy. Continuous Infusions Dextrose 5% in Lactated Ringers Injection Total Volume (mL): 1,000, IV, 75 mL/hr Comments: Total IV fluid rate should equal 125 mL/hr Magnesium Sulfate 20 gm/500 mL Premix (IVS)* Premix SWFI Total Volume (mL): 500, IV Comments: concentration equals 1gm/25mL magnesium sulfate IV additive 20,000 mg, EB, 2 gm/hr Magnesium Sulfate 20 gm/500 mL Premix (IVS)* Premix SWFI Total Volume (mL): 500, IV Comments: concentration equals 1gm/25mL magnesium sulfate IV additive 20,000 mg, EB, 1 gm/hr Medications magnesium sulfate 4 gm, IV Piggyback, Form: Soln-IV, Once Comments: 4 grams in 100 mL given over 20 minutes equals 300 mL per hour magnesium sulfate 6 gm, IV Piggyback, Once, Form: Soln-IV Comments: 6 grams in 150 mL given over 20 minutes equals 450 mL per hour calcium gluconate 1,000 mg, IV Push, Once, PRN Other (See Comment), Order Duration: 1 doses, Form: Vial Comments: - give if respirations < 10 breaths per minutes- give over at least 5 minutes ondansetron 4 mg, IV Push, q6hr, PRN Nausea or Vomiting docusate sodium 100 mg, Oral, BID acetaminophen 650 mg, Oral, q4hr, PRN Headache aluminum hydroxide 30 mL, Oral, q4hr, PRN GERD/Heartburn ***Give either betamethasone or dexamethasone if < 34 weeks gestation***(NOTE)* betamethasone 6 mg/mL injectable suspension 12 mg, IntraMuscular, q24hr, Order Duration: 2 doses dexamethasone 6 mg, IV Push, q12hr, Order Duration: 4 doses Laboratory Urinalysis with Culture if Indicated Urine, Routine collect, T;N Comprehensive Metabolic Panel Blood, Routine Collect, T;N ***Draw serum magnesium levels: if oxygen saturation, respiratory rate, DTRs or level of consciousness are abnormal.***(NOTE)* Magnesium Level Blood, Stat Collect, T;N Consults/Referrals Consult to Anesthesiology Consult to Neonatology Communication Orders Notify Provider Vital Signs T;N, HR greater than 100, SBP greater than 160, DBP greater than 100, RR greater than 24, RR less than 14, O2 sat less than 96, UO less than 30mL for 2 hrs, FHT less than 100 bpm or greater than 160 bpm, Changes in breath sounds suggestive or pulmonary ed

*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