Physician Orders LEB NICU Necrotizing Entercolitis Plan [X or R] = will be ordered unless marked out. [ ] No known allergies
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1 Height: cm Weight: kg Allergies: No known allergies Physician Orders Initiate Powerplan Phase, Phase: LEB NICU Necrotizing Entercolitis Phase Admission/Transfer/Discharge Patient Status Initial Inpatient Attending Physician: Bed Type: Med Surg [x]critical Care Stepdown Other Patient Status Initial Outpatient Attending Physician: Outpatient Status/Service: OP-Ambulatory OP-Diagnostic Procedure OP-Observation Services Initial status inpatient --- For a condition/dx with severity of illness or co-morbid conditions indicating a hospital stay greater than 24 hours is required. Initial Status Outpatient Ambulatory surgery Outpatient surgery/procedure with discharge anticipated after a routine or, in some cases, extended recovery. Routine recovery after outpatient surgery is estimated at 6-8 hours. Extended routine recovery may be required for a patient to stay longer (could be overnight) to recover from anticipated sequela of surgery including effects of anesthesia, nausea, pain. For unanticipated sequela of surgery or a complicated post operative course, the patient may require a status change to inpatient. Please consult with a case manager before making this choice of status change. Examples: Initial status outpatient is generally selected for patients undergoing PCI, diagnostic caths, EP studies, ablations, pacemaker implantations, other routine surgeries. Initial status Outpatient -Observation Services Short term treatment, assessment and reassessment - estimate discharge within 24 hours In some cases (for Medicare patients), this can be extended to 48 hours. Observation Services can also be utilized when it is unclear (without additional assessment) whether the patient will require an inpatient stay. Notify Physician Once, of room number on arrival to unit Vital Signs Vital Signs, Monitor and Record T,P,R,BP, q1h X h, then q2h Activity Out Of Bed, Up Ad Lib Food/Nutrition NPO Start at: Breastmilk (Expressed), ml Breastmilk, Donor, ml LEB Formula Orders Plan- see separate sheet Patient Care Consent Signed For, Procedure: Transfusion of Blood/Blood Products Consent Signed For, Procedure: Insertion of PICC Line Isolation Precautions Intake and Output, Routine, q2h(std) Daily Weights, Routine, qeve Pediatric Bed Type NSG( NICU Bed Type NSG) Position Patient Minimal Stimulation, Routine *065*
2 Patient Care continued Measure Circumference, q4h(std), Of: Abdominal Girth Nasogastric Tube ( Replogle (NGT)), NG Tube Type: Replogle, Tube to Suction, Suction Strength: Low Intermittent O2 Sat Monitoring NSG, q1h(std) Cardiopulmonary Monitor Routine, Monitor Type: CP Monitor Nursing Communication Nursing Communication, Obtain mother's results from delivery hospital (HBBsAG, RPR, GBS, Rubella, HIV, maternal blood type, ABO, Rh Coombs. Respiratory Care LEB NICU Respiratory Plan- see separate sheet Oxygen Delivery, Special Instructions: titrate to keep O2 sat 90-95% ISTAT POC (RT Collect), Stat once, Test Select: ABG, Preferred Specimen Type: Arterial ISTAT POC (RT Collect), Stat once, Test Select: ABG, Preferred Specimen Type: Arterial, Special Instructions: draw from UAC ISTAT POC (RT Collect), Stat once, Test Select: CBG, Preferred Specimen Type: Capillary ISTAT POC (RT Collect), Stat once, Test Select: VBG, Preferred Specimen Type: Venous ISTAT POC (RT Collect), Stat once, Test Select: Electrolytes Continuous Infusions NOTE: Use D5 for infants less than 1000 grams. Use D10 for infants greater than 1000 grams Dextrose 5% in Water 1,000 ml, IV, STAT, ml/hr Dextrose 7.5% in Water 1,000 ml, IV, STAT, ml/hr Dextrose 10% in Water 1,000 ml, IV, STAT, ml/hr Dextrose 12.5% in Water ml, IV, STAT, ml/hr ml Bag (Pediatric) Dextrose 5% with 0.2% NaCl( 1,000 ml, IV, STAT, ml/hr ) D5 1/4 NS) D10 1/4 NS (Pediatric) 250 ml, STAT potassium chloride ( D5 1/4 NS 1,000 ml, IV, STAT, ml/hr D10 1/4 NS + 20 KCL 250 ml, STAT (Pediatric) potassium chloride ( D5 1/2 NS 1,000 ml, IV, STAT, ml/hr D10 1/2 NS meq/l 250 ml, IV, STAT KCL (Pediatric) 1/2 NS + heparin 1 unit/ml 500 ml, IV, Routine, ml/hr, Infuse via central or arterial line 41410
3 Continuous Infusions continued sodium bicarbonate (sodium meq, Injection, IV, once, STAT bicarbonate 4/2% intravenous solution) Sodium Chloride 0.9%( Sodium ml, IV, once, STAT, ( infuse over 30 min ), (Bolus) Chloride 0.9% Bolus ) Stock Neonatal TPN 250 ml, 250 ml, Injection, IV, q24h, Routine, add 10 meq/l Calcium Gluconate potassium chloride ( D5 1/4 NS 1,000 ml, IV, STAT, ml/hr, add 10 meq/l Calcium Gluconate D10 1/4 NS + 20 KCL 250 ml, IV, STAT, add 10 meq/l Calcium Gluconate (Pediatric) potassium chloride ( D5 1/2 NS 1,000 ml, IV, STAT, ml/hr, add 10 meq/l Calcium Gluconate D10 1/2 NS meq/l 250 ml, IV, STAT, add 10 meq/l Calcium Gluconate KCL (Pediatric) Vasoactive Medications DOPamine Drip (Pediatric) 250 ml, Central IV, Routine, Reference range: 2 to 20 mcg/kg/min Insulins Insulin Drip (Pediatric) ml, Central IV, Routine, unit/kg/hr, Reference range: 0.01 to 0.1 units/kg/hr, use most concentrated strengths Sedation Fentanyl Drip (Pediatric)( 15 ml, Central IV, Routine, Reference range: 1 to 5 mcg/kg/hr FentaNYL Drip (Pediatric)) Midazolam Drip (Pediatric) 15 ml, Central IV, Routine, Reference range: 0.01 to 0.2 mg/kg/hr Paralytics Vecuronium Drip (Pediatric) 30 ml, Central IV, Routine, Reference range: 0.02 to 0.2 mg/kg/hr Replacement Fluids 1/2 NS + 20 meq/l KCL (pediatric) 1,000 ml, IV, Routine, Replacement fluids, Replace ml : ml q4h over 4 hours 1/2 NS + 20 meq/l KCL (pediatric) 1,000 ml, IV, Routine, Replacement fluids, Replace 1/2ml : ml q4h over 4 hours Lactated Ringers 1,000 ml, IV, Routine, Replacement fluids, Replace ml : ml q4h over 4 hours Lactated Ringers 1,000 ml, IV, Routine, Replacement fluids, Replace 1/2ml : ml q4h over 4 hours Medications calcium gluconate 100 mg/kg, Ped Injectable, IV, once, Routine albuterol (albuterol 2.5 mg/3 ml 0.1 mg/kg, Inh Soln, NEB, prn, PRN Wheezing, Routine, (3mL = 2.5 (0.083%) inhalation solution) mg) albuterol (albuterol (MDI)) 2 puff, MDI, INH, q6h, PRN Wheezing, Routine, (180 mcg = 2 puffs) 41410
4 Anti-infectives LEB NICU Anti-infective Plan- see separate sheet Laboratory Newborn Screen, TN Health Routine, T+1;N, once, Type: Blood Dept CBC STAT,, once, Type: Blood CBC Routine, T+1, 0400, once, Type: Blood Basic Metabolic Panel ( BM) STAT,, once, Type: Blood Comprehensive Metabolic STAT,, once, Type: Blood Panel (CMP) Comprehensive Metabolic Panel(CMP) Routine, T+1, 0400, once, Type: Blood C-Reactive Protein ( CRP) STAT,, once, Type: Blood C-Reactive Protein ( CRP) Routine, T+1, 0400, once, Type: Blood Electrolytes STAT,, once, Type: Blood Basic Metabolic Panel ( BMP) STAT,, once, Type: Blood Magnesium Level STAT,, once, Type: Blood Phosphorus Level STAT,, once, Type: Blood Triglyceride STAT,, once, Type: Blood Lactic Acid Level STAT,, once, Type: Blood Prothrombin Time (PT) STAT,, once, Type: Blood Partial Thromboplastic Time STAT,, once, Type: Blood (PTT) Blood Culture STAT,, once, Specimen Source: Peripheral Blood, Nurse Collect Blood Culture Stat,, once, Specimen Source: Line, Arterial, Nurse Collect LEB Transfusion Less Than 4 Months of Age Plan- see separate sheet Nursing Communication, Obtain mother's type and screen results, if results not available, obtain a FIN# for the mother and place order for Type and Screen Maternal STAT on the mother's chart. Order comment: Registration forms can be obtained from the Access Department and faxed back to Once the FIN is obtained for the mother, log onto mother's chart and place the order "Type and Screen Maternal Blood", be sure to include the baby's name & FIN in the comments Chest 2VW Frontal & Lat( Chest PA & Lateral) Chest 1VW Frontal (Chest 1VW) Diagnostic Tests, Routine, Portable, Reason for Exam: Other, Enter in Comments, Comments: abdominal distention/bloody stools, Routine, Portable, Reason for Exam: Other, Enter in Comments, Comments: suspect pneumoperitoneum, Position: left lateral decubitus Abd Sing AP VW ( KUB), Routine, Portable, Reason for Exam: Pneumoperitoneum, Position; left lateral decubitus 41410
5 Diagnostic Tests continued Abd Sing AP VW ( KUB), Routine, Portable, Reason for Exam: Abdominal Distention Abd Sing AP VW ( KUB), Routine, Portable, Reason for Exam: Bloody Stools Abd Sing AP VW ( KUB) min, Routine, Portable, Reason for Exam: Pneumoperitoneum, Position; left lateral decubitus Abd Sing AP VW ( KUB) min, Routine, Portable, Reason for Exam: Abdominal Distention Abd Sing AP VW ( KUB) min, Routine, Portable, Reason for Exam: Bloody Stools Abd Sing AP VW ( KUB) min, Routine, Portable, Reason for Exam: Pneumoperitoneum, Position; left lateral decubitus Abd Sing AP VW ( KUB) + 720min, Routine, Portable, Reason for Exam: Abdominal Distention Abd Sing AP VW ( KUB) min, Routine, Portable, Reason for Exam: Bloody Stools Abd Sing AP VW ( KUB) + 18 hr, Routine, Portable, Reason for Exam: Pneumoperitoneum, Position; left lateral decubitus Abd Sing AP VW ( KUB) + 18 hr, Routine, Portable, Reason for Exam: Abdominal Distention Abd Sing AP VW ( KUB) + 18 hr, Routine, Portable, Reason for Exam: Bloody Stools Abd Sing AP VW ( KUB) + 24 hr, Routine, Portable, Reason for Exam: Pneumoperitoneum, Position; left lateral decubitus Abd Sing AP VW ( KUB) + 24 hr, Routine, Portable, Reason for Exam: Abdominal Distention Abd Sing AP VW ( KUB) + 24 hr, Routine, Portable, Reason for Exam: Bloody Stools LEB CT Abdomen w/wo Cont Plan- see separate sheet LEB CT Pelvis W/WO Cont Plan- see separate sheet LEB GI Upper W/WO Delayed Films W KUB w/delay Diet Plan- see separate sheet LEB GI Upper W/WO Delayed Films WO KUB w/delay Diet Plan- see separate sheet LEB GI Upper W Sm Bowel W Multi Serial Films w/delay Diet Plan- see separate sheet Consults/Notifications Notify Physician For Vital Signs, Oxygen Sat < 85 Of Notify Physician-Continuing Notify Nurse Practitioner For, Oxygen Sat < 85 Vital Signs Of Notify Nurse Practitioner- Continuing Physician Group Consult(, General Surgery Consult MD Group) Physician Group Consult( Consult MD Group) Physician Group Consult( Consult MD Group) 41410
6 Consults/Notifications continued NOTE: Please Physician Consult order below for Retinopathy of Prematurity Consultation at 4 to 6 weeks after birth or at 31 weeks post-menstrual age (whichever comes later) Physician Consult, Reason for Consult: Retinopathy of Prematurity consultation PICC Consult Ped - for Line Placement Nutritional Support Team Start at:, Reason: Total Parenteral Nutrition Consult Dietitian Consult, Type of Consult: Nutrition Management Lactation Consult Child Life Consult ( PT Consult Ped Eval Child & Tx( Life Physical Therapy Ped Eval & Tx) OT Ped Eval & Tx( Occupational Therapy Ped Eval & Tx) ST Ped Eval & Tx( Speech Therapy Ped Eval & Tx) Medical Social Work Consult, Reason: Assistance at Discharge Audiology Consult, Initial newborn hearing screen, Routine Pastoral Care Consult, Reason for Consult: Family Support Baptism Consult Case Management, Reason for Consult: Discharge Planning Date Time Physician's Signature MD Number 41410
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