Provider Orders

Admission Orders

• Admit to Step-Down Unit; anticipate ICU transfer if hemodynamic instability persists.

• Condition: Guarded.

• Allergies: None known (NKDA/NKFA).

• Diet: NPO until after endoscopy.

• Activity: Bedrest with bathroom privileges only.

• Vital Signs: Every 15 minutes × 4, then every hour × 4, then every 4 hours if stable.

• Neuro Checks: Every 2 hours for changes in mental status.

• Weights: Daily.

• I&O: Strict intake and output; record urine output hourly.

Intravenous Therapy

• 0.9% Normal Saline continuous IV infusion @ 100 mL/hr.

• Maintain two large-bore (18 gauge) IV sites for fluid and blood administration.

• If systolic BP <90 mmHg or HR >120 bpm, notify provider and bolus NS 500 mL IV over 30 minutes, may repeat ×1 if no improvement.

Continuous Infusions:

• Octreotide 50 mcg in 250 mL D5W; infuse at 10 mL/hr IV continuous.

• Pantoprazole 40 mg IV every morning (QAM).

Scheduled Medications:

• Propranolol 20 mg PO daily

• Furosemide 40 mg IV twice daily (BID).

• Multivitamin 1 tablet PO daily (when oral intake resumes).

PRN Medications:

• Lactulose 20 g PO every 4 hours PRN for ammonia >50 µmol/L.

• Ondansetron 4 mg IV every 4 hours PRN for nausea/vomiting.

• Morphine Sulfate 4 mg IV every 4 hours PRN for pain ≥6/10.

• Acetaminophen 500 mg PO every 6 hours PRN for temperature >101°F

• Type and crossmatch for 6 units PRBCs and 2 units Fresh Frozen Plasma (FFP).

• Transfuse PRBCs × 4 units if Hgb <8 g/dL

• Transfuse FFP × 2 units following the 4th unit of PRBCs.

• Use blood warmer for all transfusions.

• Monitor for transfusion reactions

Stat Labs (on admission):

• CBC with differential

• CMP

• PT/INR

• Ammonia level

• Type and crossmatch

• Lipase

• Serum lactate

• ABG if O₂ sat <92%

Repeat Labs:

• CBC, CMP, PT/INR, and ammonia every 6 hours × 24 hours, then daily.

• Hgb/Hct 1 hour post-transfusion.

• Notify provider if Hgb <8.0 g/dL, INR >2.0, or ammonia >80 µmol/L.

Diagnostics:

• Abdominal ultrasound (rule out ascites, splenomegaly, obstruction).

• EKG (evaluate tachycardia).

• Endoscopy scheduled for variceal ligation vs. sclerotherapy as soon as hemodynamically stable.

• Gastroenterology

• Nutrition Services

• Social Work

• Chemical Dependency Counselor

• Educate patient on the importance of alcohol cessation, medication adherence, and dietary restrictions (low sodium, high protein, small frequent meals).

• Review need for ongoing hepatitis C management.

• Reinforce follow-up with hepatology clinic within 1 week of discharge.