Infectious Disease Service if Norepinephrine reaches 10 mcg/min or GREATER. Not available at Baptist Nassau. Notify Physician (BMCD)
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1 DRUG AND TREATMENT Nursing Orders Communication Order If CVP unavailable, administer fluid boluses every 30 minutes except monitor O2 requirements Comments: Every 30 minutes evaluate FiO2 and for appearance of new onset wheezing. If FiO2 increases by 10% based on decreasing arterial oxygen saturation (or an increase in O2 by nasal cannula by 2 liters) and/or new onset wheezing occurs then obtain chest x-ray and ABG, stop fluid boluses for evidence of pulmonary congestion AND call physician Blood Glucose Monitor POC Q1H Int Monitor PvO2 every hour until consistently GREATER than 35 or venous saturation GREATER than 65%. Then monitor every 2 hours Notify Pharmacy and discontinue steroids if initial cortisol level is GREATER than 25 Cooling Blanket Cooling Therapy Duration 1 times, Cooling Therapy Mode: Blanket, Target Core Temp (DegC) 38, Turn on for patient temperature GREATER than 103 degf. Turn off if patient temperature LESS than 101 degf. Central Venous Pressure (CVP) ASDIR, Pre and Post NS Bolus Fluid Challenge Central Venous Pressure (CVP) Q1H Physician for O2 sat less than 93% Vital Signs/Urine Output Temperature > or equal to degf (DEF)* Temperature > or equal to 101 degf Temperature > or equal to 102 degf Vital Signs/Urine Output SBP < 90 Call physician for PaO2 LESS than 60 mmhg; ph LESS than 7.34 Notify Change in patient status; if positive culture result Notify Physician (BMCB) Infectious Disease Service if Norepinephrine reaches 10 mcg/min or GREATER Notify Physician (BMCN) Infectious Disease Service if Norepinephrine reaches 10 mcg/min or GREATER. Not available at Baptist Nassau. Notify Physician (BMCD) Page 1 of 7
2 DRUG AND TREATMENT Infectious Disease Service if Norepinephrine reaches 10 mcg/min or GREATER Notify Physician (BMCS) Infectious Disease Service if Norepinephrine reaches 10 mcg/min or GREATER With results of lab GEN Nasogastric/Orogastric Tube Insertion (SUB)* ***Reminder: Order GEN Nasogastric/Orogastric Tube Insertion (SUB) on a separate form*** Indwelling Urinary Catheter (Foley) (SUB)* Indwelling Urinary Catheter (Foley) Nursing Orders Insert Indwelling Urinary Catheter Indwelling Urinary Catheter Care Q12H Communication Order For rise in FiO2 or new onset of wheezing: obtain portable chest x-ray and ABG, then call physician Abdominal Bladder Pressure Q4H, Notify MD for Pressure > 20 mmhg ***(NOTE)*** Select the "Transfuse Blood Previously on Hold" order below, to transfuse blood on hold. Transfuse Blood Previously on Hold Medications heparin (subcutaneous) 5,000 unit inj SUBCUT Q8H ***(NOTE)*** Lovenox is contraindicated with GFR LESS than 20 or with ESRD. Lovenox 40 mg inj SUBCUT Q24H Int Comments: Pharmacy to adjust dose based on renal function Zantac 50 mg inj IV PUSH Q8H Comments: Pharmacy to adjust dose based on renal function Protonix 40 mg inj IV PUSH Q24H Int GEN Correction Insulin (Sliding Scale) (SUB)* ***Reminder: Order GEN Correction Insulin (Sliding Scale) (SUB) on a separate form*** Solu-Cortef 100 mg inj IV PUSH Q8H Comments: First dose to be administered STAT. IF COSYNTROPIN TEST IS POSITIVE ( LESS than 10 point rise from baseline or third cortisol level is LESS than 20 mg/dl). Antibiotics ***(NOTE)*** All antibiotics should be started STAT after the Diagnosis. Page 2 of 7
3 DRUG AND TREATMENT PRN Medications Tylenol 650 mg tab PO Q4H, PRN Fever GREATER than 101 F (DEF)* 650 mg supp PR Q4H, PRN Fever GREATER than 101 F 650 mg liquid NG TUBE Q4H, PRN Fever GREATER than 101 F 650 mg tab PO Q4H, PRN Other (see comment), Clinical Instructions: For temperature GREATER than 102 degrees Fahrenheit. 650 mg supp PR Q4H, PRN Other (see comment), Clinical Instructions: For temperature GREATER than 102 degrees Fahrenheit. 650 mg liquid NG TUBE Q4H, PRN Other (see comment), Clinical Instructions: For temperature GREATER than 102 degrees Fahrenheit. IV Solutions Normal Saline Bolus 20 ml/kg IVPB bag ASDIR, PRN Other (see comment) Comments: If SBP LESS than 90 mmhg. INFUSE OVER 30 MINUTES. Normal Saline Bolus 500 ml IVPB bag Q30MINS Int, PRN Other (see comment) Comments: Check CVP after each bolus. Continue boluses every 30 minutes until MAP is GREATER than or EQUAL to 65 mmhg or CVP RISES BY 5 mmhg AND PATIENT IS OFF PRSSORS. If CVP falls after 30 minutes, resume fluid bolus if MAP has not been met If patient remains hypotensive after 1 hour, call physician for additional fluid bolus DOPamine 400 mg/dextrose (iso-osmotic) 250 ml 250 ml IV bag Rate: 5 mcg/kg/min Comments: Titrate for MAP GREATER than or EQUAL to 65. MAXIMUM dose of 20 mcg/kg/min. Levophed 8 mg/d5w 250 ml IV Set (IVS)* Dextrose 5% in Water 250 ml IV bag Rate: 2 mcg/min Comments: Start at 2 mcg/min. Titrate for MAP of 65. MAXIMUM dosage of 20 mcg/min. Simultaneously titrate off Dopamine. IF maximum dose of Levophed is reached, start Vasopressin as ordered. norepinephrine IV drip 8 mg Neo-Synephrine 50 mg/ns 250 ml IV Set (IVS)* Sodium Chloride 0.9% IV Rate: titrate, Clinical Instructions: Start at 10 mcg/min. Titrate for MAP of GREATER than or EQUAL to 65. Maximum dose of 150 mcg/min. If reach MAXIMUM dose, may add Vasopressin. Comments: Start at 10 mcg/min. Titrate for MAP of GREATER than or EQUAL to 65. Maximum dose of 150 mcg/min. If reach MAXIMUM dose, may add Vasopressin. Neo-Synephrine IV drip 50 mg Vasopressin (SHOCK) 100 units/ NS 250 ml IV Drip (IVS)* Sodium Chloride 0.9% IV iv Rate: 0.01 unit/min Comments: Maximum dose of 0.04 units/min. Once maximum dose of Levophed (20 Page 3 of 7
4 DRUG AND TREATMENT mcg/min) is reached and MAP remains LESS than 65 then start Vasopressin, ONLY as an adjunct to Levophed. vasopressin IV drip 100 unit DOBUTamine 500 mg/dextrose (iso-osmotic) 250 ml 250 ml IV premix Rate: 0.5 mcg/kg/min Comments: If sample is drawn from CVP catheter line and PvO2 is LESS than 34 or venous sat is LESS than 65% start Dobutamine. If sample is drawn from Swan and PvO2 is LESS than 31 or venous sat is LESS than 60% start DoBUTamine. Laboratory ACTH Level STAT, BLOOD, ONCE Comments: Draw with Blood Culture, Urine Culture, Sputum Culture and Wound Culture if ordered Blood Culture Timed Study, Blood - peripheral, Q15MINS Int, 2 times (DEF)* Comments: At 2 different sites. Collect with ACTH, Urine Culture, Sputum Culture and Wound Culture if ordered Timed Study, Blood - line, Q15MINS Int, 2 times Comments: At 2 different sites. Collect with ACTH, Urine Culture, Sputum Culture and Wound Culture if ordered Urine Culture STAT, Urine, CleanCatch, ONCE (DEF)* Comments: Collect with Blood Culture, ACTH, Sputum Culture and Wound Culture if ordered STAT, Urine, Catheter, ONCE Comments: Collect with Blood Culture, ACTH, Sputum Culture and Wound Culture if ordered Sputum Culture/GS STAT, SPUTUM, ONCE Comments: Collect with Blood Culture, ACTH, Urine Culture and Wound Culture if ordered Wound Culture STAT, ONCE Comments: Wound culture if appropriate D Dimer Early AM, BLOOD Lactic Acid Timed Study, BLOOD Early AM, BLOOD CBC with Differential. STAT, BLOOD, ONCE +8 Hours CBC with Differential. Timed Study, BLOOD, Q8H Int, 32 hour +40 Hours CBC with Differential. Early AM, BLOOD, DAILY, 3 times CHEM 7 Page 4 of 7
5 DRUG AND TREATMENT STAT, BLOOD, ONCE +12 Hours CHEM 7 Timed Study, BLOOD, Q12H Int, 36 hour Lipase Level Liver Profile BNP Magnesium Level C Difficile NA Amplification STAT, STOOL, ONCE (DEF)* Timed Study, STOOL, ONCE Early AM, STOOL, ONCE ORSA by PCR STAT, NARES, ONCE (DEF)* Timed Study, NARES, ONCE Early AM, NARES, ONCE Type and Screen Routine, BLOOD ***(NOTE)*** If wanting to place specific blood products on Hold, select the Adult Blood Administration subphase and select your products with a Transfusion Priority of Hold. GEN Blood Administration (SUB)* ***Reminder: Order GEN Blood Administration (SUB) on a separate form*** SUB Cosyntropin Stimulation Test(SUB)* SUB Cosyntropin Stimulation Test Non Categorized ***(NOTE)*** This plan is designed to be used as part of a larger plan not independently. Please do NOT order individually. Nursing Orders If cortisol test is positive (LESS than 10 point rise from baseline or third cortisol level is LESS than 20 mg/dl) Page 5 of 7
6 DRUG AND TREATMENT Medications cosyntropin 0.25 mg inj IV PUSH ONCE Comments: Administer IMMEDIATELY AFTER the baseline cortisol blood sample has been taken. Decadron 4 mg inj IV PUSH ONCE, STAT Comments: For use in SEPTIC SHOCK patients unresponsive to pressor therapy only Laboratory Cortisol Level Expedite/ASAP, BLOOD, ONCE Comments: Baseline.Obtain baseline serum cortisol level prior to administration of cosyntropin 0.25 mg dose. Timing is important. Label all tubes +30 Minutes Cortisol Level Comments: 30 minutes post drug.obtain serum cortisol level 30 minutes after administration of cosyntropin 0.25 mg dose. Timing is important. Label all tubes +60 Minutes Cortisol Level Comments: 60 minutes post drug. Obtain serum cortisol level 60 minutes after administration of cosyntropin 0.25 mg dose. Timing is important. Label all tubes ACTH Level Expedite/ASAP, BLOOD, ONCE Comments: Baseline ACTH level. Timing is important. Label all tubes Cortisol Level Early AM, BLOOD Comments: if LESS than 15 start Solucortef 100 mg IV Q8H Radiology XP Chest Sepsis, Stat, Pending Discharge - No, ONCE XR Abd 1 view (KUB) Portable Abdominal pain, Stat, Pending Discharge - No, Emergent Venous Doppler Low Ext Bilat Swelling, Stat, Pending Discharge - No, Emergent, BMC Downtown Respiratory ABG/VBG Notification Stat, ABG ONCE ABG/VBG Notification Timed Study, ABG Q4H ABG/VBG Notification Routine, VBG ONCE. Draw from CVP if CVP raises GREATER than 5 mmhg and venous sat is GREATER than 65% and MAP is LESS than 65. PRN Order Weaning Parameters Page 6 of 7
7 DRUG AND TREATMENT Routine, DAILY Pulse Oximetry (Continuous) Special Instructions: Urgent, continuous monitoring Comments: Q8H sensor site must be inspected. IF circulatory condition or skin integrity has changed, the sensor should be applied to a different site. Cardiology Echocardiogram -Transthoracic Sepsis, Cardiologist of Attending Physician's choice to read. EKG Standard Stat, Urgent Consults Consult Physician Critical care, Sepsis Consult Physician (BMCD) Infectious Disease, Sepsis Consult Physician (BMCB) Infectious Disease, Sepsis Consult Physician (BMCS) Infectious Disease, Sepsis Consult Physician Pulmonary, Sepsis Consult Pharmacy Kinetics Dosing Page 7 of 7
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