WEIGHT: KG HEIGHT: CM ALLERGY CAUTION sheet reviewed Code Status Full code
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1 (Page 1 of 5) Code Status Full code Status/Admit/Transfer/Discharge Surgical Procedure(s) and date performed: Cardiologist: Cardiac Surgeon: Intensivist: Patient Care CMV status Recipient CMV status Donor Measure weight daily Chest tubes to 20 cm water suction and record output Q1H Blake drain to bulb suction, strip drain and record output Q1H for 12 hours, then Q2H Nasogastric/orogastric tube to intermittent suction Monitoring Parameters Heart rate to (bpm) SpO2 to (%) Central venous pressure (CVP) to (mmhg) Mean arterial pressure (MAP) to (mmhg) Systolic blood pressure (SBP) to (mmhg) Central Venous Monitoring Lines Add heparin 2 units/ml to central line fluid if no other fluids running through lumen 0.9% Sodium Chloride at 1 ml/hr for weight LESS than 20 kg 0.9% Sodium Chloride at 2 ml/hr for weight EQUAL to or GREATER than 20 kg Arterial Monitoring Lines Add papaverine 0.12 mg/ml to arterial line fluid (peripheral arterial lines only) 0.9% Sodium Chloride with heparin 2 units/ml at 1 ml/hr for weight LESS than 20 kg 0.9% Sodium Chloride with heparin 2 units/ml at 2 ml/hr for weight GREATER than or EQUAL to 20 kg Pacemaker Settings Temporary pacemaker settings Mode Rate Atrial Pacing: Output (ma), Sensitivity (mv) Ventricular Pacing: Output (ma), Sensitivity (mv) Activity Bed rest PTN Review Date: November PTN# CTPoGv1 Exp Date: November Page 1 of 5
2 (Page 2 of 5) Medications Immunosurpression and Premedication acetaminophen mg (15 mg/kg/dose) PO/PR/NG/NJ once daily for five days; administer prior to daily thymoglobulin infusion (Maximum 1 g/dose) diphenhydramine mg (1 mg/kg/dose) IV once a day for 5 days; administer prior to daily thymoglobulin infusion (Maximum 50 mg/dose) Post Operative Day 0 (Date / / ) methylprednisolone mg (2 mg/kg/dose) IV as a single dose to be given immediately prior to Thymoglobulin infusion initiation Thymoglobulin (rabbit ATG) mg (1 to1.5 mg/kg/dose) IV infusion over 12 hours; infusion initiated 6 hours after arrival in the Pediatric Intensive Care Unit Post Operative Day 1 (Date / / ) methylprednisolone mg (1.5 mg/kg/dose) IV as a single dose to be given immediately prior to Thymoglobulin infusion initiation Post Operative Day 2 (Date / / ) methylprednisolone mg (1 mg/kg/dose) IV as a single dose to be given immediately Thymoglobulin (rabbit ATG) mg (1 to 1.5 mg/kg/dose) IV infusion over 12 hours; infusion Post Operative Day 3 (Date / / ) methylprednisolone mg (0.5 mg/kg/dose) IV as a single dose to be given immediately Post Operative Day 4 (Date / / ) methylprednisolone mg (0.25 mg/kg/dose) IV as a single dose to be given immediately PTN Review Date: November PTN# CTPoGv1 Exp Date: November Page 2 of 5
3 (Page 3 of 5) Routine Medications mupirocin 2 % topical ointment in each nostril Q12H for 10 doses or until nasal swab for staph colonization is negative nystatin 400,000 units 4 times a day swish and swallow. If patient unable to swish or swallow swab entire oral cavity ranitidine mg (1 mg/kg/dose) IV Q8H (Maximum: 50 mg/dose) co-trimoxazole mg (2.5mg TMP/kg/dose) PO Q12H at 0800 and 2000H on Monday, Wednesday and Friday (5mg TMP/kg/day on 3 days/week for PJP prophylaxis. Maximum: 160mg TMP/800mg SMX per day). Start on post operative day. valganciclovir (for patients at-risk for CMV disease) mg (7 x BSA x egfr) PO daily at 2000H (Maximum: 900 mg/dose) mycophenolate mofetil (MMF) mg (300 to 600 mg/m2/dose) IV/PO Q12H at 0800h and 2000h (Maximum: 1000 mg/dose) Start on post operative day (start within first 72 hrs after transplant, initial dose may be 1/4 to 1/2 maintenance dose) tacrolimus if patient LESS than 40 kg mg (0.025 to 0.05 mg/kg/dose) (dose to target trough 10 to 12 mcg/l) PO/NG Q12H at 0800h and 2000h. Start on post operative day Start after intestinal function return (usually 2nd or 3rd post operative day) and when urine output is adequate and normal Cr. tacrolimus if patient GREATER than or EQUAL to 40 kg mg (1 to 2 mg ) PO/NG Q12H at 0800h and 2000h Start on post operative day Start after intestinal function return (usually 2nd or 3rd post operative day) and when urine output is adequate and normal Cr. prednisone or PrednisOLONE mg (0.25 mg/kg/dose ) PO/NG Q24H (Maximum: 20 mg/day) Start on post operative day when methylprednisolone is finished PRN Medications ondansetron mg (0.15 mg/kg/dose) IV Q8H PRN nausea or vomiting (age at or above 6 months) (Maximum: 8 mg/dose) potassium chloride mmol (0.5 mmol/kg/dose) IV via central line over 60 minutes as needed for serum potassium less than 3 mmol/l calcium chloride mmol/kg/day (0 to 2 mmol/kg/day) continuous intravenous infusion to maintain serum ionized calcium in range 0.9 to 1.2 mmol/l Antibiotic Prophylaxis - Closed Skin cefazolin mg (30 mg/kg/dose) IV Q8H until chest drains removed (Maximum: 2000 mg/dose) Antibiotic Prophylaxis - Open Sternum and Skin vancomycin mg (10 mg/kg/dose) IV as a single dose, subsequent dosing frequency to be determined based in vancomycin level drawn 8 hours after first dose, discontinue once chest closed cefotaxime mg (50 mg/kg/dose) IV Q8H disconcontinue once chest closed (Maximum: 2000 mg/dose) PTN Review Date: November PTN# CTPoGv1 Exp Date: November Page 3 of 5
4 (Page 4 of 5) Analgesia and Sedation acetaminophen mg (15 mg/kg/dose) PO/PR/NG/NJ Q6H for 4 doses, then PRN for pain (Maximum PO: 75 mg/kg/24 h; Maximum PR: 80 mg/kg/24 h) morphine bolus mg (0.05 mg/kg/dose) IV Q1H PRN to maintain Multidimensional Assessment of Pain Scale (MAPS) 0 IV Infusions Analgesia, Sedation and Paralysis morphine mcg/kg/h (0 to 20 mcg/kg/h) continuous IV infusion titrated to maintain MAPS 0 dexmedetomidine mcg/kg/h (0 to 0.7 mcg/kg/h) continuous IV infusion titrated to maintain SBS -1 to 0 and MAPS 0 fentanyl 0 to 1 mcg/kg/h continuous IV infusion; further titration by physician order only cisatracurium 0 to 1 mcg/kg/min continuous IV infusion; further titration by physician order only Maintenance Fluids 50% total fluids are calculated as follows: 2 ml/kg/h for the first 10 kg, 1 ml/kg/h for the second 10 kg, 0.5 ml/kg/h for every kg above 20 kg Total maintenance fluid rate ml/hr (50% maintenance) Dextrose 5% and 0.9% Sodium Chloride IV Vasoactive Infusions milrinone mcg/kg/min (0 to 0.75 mcg/kg/min) continuous IV infusion DOPamine mcg/kg/min (0 to 10 mcg/kg/min) continuous IV infusion nitroprusside mcg/kg/min (0 to 5 mcg/kg/min) continuous IV infusion EPINEPHrine mcg/kg/min (0 to 0.1 mcg/kg/min) continuous IV infusion Nutrition NPO for 4 hours; may have sips of fluids overnight Laboratory Blood gas, arterial Q2H for 4 hours, then Q4H until 0600h Every morning at 0600h Complete blood cell count with automated white blood cell differential Every morning at 0600h Sodium level, serum PTN Review Date: November PTN# CTPoGv1 Exp Date: November Page 4 of 5
5 (Page 5 of 5) Potassium level, serum Bicarbonate level, serum Chloride, serum Urea Creatinine (Cr), serum Magnesium (Mg) level, serum Blood gas, venous Q2H for 4 hours, then Q4H until 0600h Vancomycin level 8 hours after first dose Tacrolimus trough (pre-dose) (for patients on tacrolimus) CMV PCR monitoring EBV PCR monitoring Medical Imaging Radiograph, chest on admission to ICU and morning of first postoperative day Diagnostic Tests/Procedures 12-lead ECG on admission to ICU PTN Review Date: November PTN# CTPoGv1 Exp Date: November Page 5 of 5
PICU CARD SURG Post Operative Cardiac Transplant Age LESS than 6 months (Page 1 of 5)
(Page 1 of 5) Code Status Full code Status/Admit/Transfer/Discharge Surgical Procedure(s) and date performed (if applicable): Cardiologist: Cardiac Surgeon: Intensivist: Patient Care CMV status Donor CMV
POST-OP CARDIAC SURGERY PHYSICIAN S ORDER SHEET USE BALLPOINT PEN ONLY. CARDIAC INTENSIVE CARE UNIT
PHYSICIAN S SHEET Automatically Activate, if not in agreement, cross out and initial Activated by Checking Box ALLERGIES: None known YES Patient s Height: Patient s Weight: ALL MEDICATION and INTRAVENOUS
Organ Donor Management Recommended Guidelines ADULT Brain Death (NDD)
Date: Time: = Always applicable = Check if applicable ADMISSION INSTRUCTIONS Neurological Determination of Death (NDD) has been performed by at least 2 licensed physicians Contact initiated with BC Transplant
Organ Donor Management Recommended Guidelines ADULT CARDIAC DEATH (DCD)
Date: Time: = Always applicable = Check if applicable ADMISSION INSTRUCTIONS Move to Comfort Care Note in chart. Contact initiated with BC Transplant Consent for Organ Donation obtained Code Status: Full
Pediatric Intensive Care Unit (PICU) Pediatric Diabetic Ketoacidosis (DKA) Admission Order Set
Discontinue all previous orders Weight: kg DKA admit order set is for initial management Ongoing management required based on frequent reassessment of TFI, fluid balance and lab results. Admit to PICU
Physician Orders ADULT: Kidney-Panc/PancTransplant Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase T;N, Phase: Kidney-Panc/Panc Transp Post Op Phase, When to Initiate: Kidney-Panc/Panc Transp Post Op Phase Vital Signs Vital
Physician Orders PEDIATRIC: LEB Kidney Transplant Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: LEB Kidney Transplant Post Op Phase, When to Initiate: LEB Kidney Transplant Post Op Phase Admission/Transfer/Discharge
PICU BRONCHIOLITIS PLAN
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Physician Orders ADULT: Head and Neck Postoperative Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase, Phase: Head and Neck Postoperative Phase, When to Initiate: Head and Neck Post Operative Phase, Monitor and Record T,P,R,BP,
Patient: Becky Smith DOB: 01/26/XXXX Age: 5 y/o Attending: Dr. D. Miles Allergies: NKA MR#: 203. Patient Chart #203 Becky Smith
Patient Chart #203 Becky Smith 1 Property of CSCLV CSCLV Rev: 06/04/2018 Chief Complaint: Abdominal pain. Informant: Parents. HISTORY & PHYSICAL HPI: Ill looking patient, healthy until 2 days ago when
Sample. Affix patient label within this box.
Instructions for completing orders Complete pages 1-3 for General Inpatient Orders. All pathway compatible orders (indicated by ) within the General Inpatient Orders will be followed automatically. Optional
ADULT POST NEUROLOGIC INTERVENTION ORDERS 2 of 4
9 Actual 9 Estimated DOWNTIME INTERVENTION 1 of 4 Weight kg 9 Actual 9 Estimated Height cm ALLERGIES: REFER TO ALLERGY PROFILE/ POWERCHART Admit to Dr.: Bed Type: Dx: ( ) Check, circle and/or fill in all
Sample. Affix patient label within this box.
Instructions for completing orders: Determine PRAM Clinical Score as per the Alberta Acute Childhood Asthma Pathway for Emergent/Urgent Care and select orders based on PRAM Score. Custom orders can be
PICU ADMIT DKA PLAN - Phase: Begin Immediately
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IR Central Venous Access [ ] Pre Procedure
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IR Central Venous Access [1050200001] Pre Procedure Case Request/Scheduling Procedure Enter IR Case Request if not already completed (All hospitals except Grant Medical Center) [ ] Case Request IR Lab
UMC Health System Patient Label Here. PHYSICIAN ORDERS Diagnosis
PICU GENERAL PLAN UMC Health System PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Daily Weight Patient Activity Bedrest Up Ad Lib/Activity as Tolerated Strict Intake
PHYSICIAN ORDERS Diagnosis
PICU PROCEDURE PLAN PHYSICIAN S Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Patient Care
Therapeutic Hypothermia for Post Cardiac Arrest Plan Initial Orders
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PEDIATRIC SPINE SURGERY POST-OP PLAN - Phase:.
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IDPH ESF-8 Plan: Pediatric and Neonatal Surge Annex Sample Pediatric Admission Orders 2015
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PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available ONLY at: BMC-B BMC-D BMC-N BMC-S Nursing Orders Communication Order If CVP unavailable, administer fluid boluses every 30 minutes except monitor O2 requirements Comments: Every
Acute Stroke with Alteplase Administration Order Set
Review Due Date: 2017 October PATIENT CARE DERS Weight: Adverse Reactions or Intolerances Drug No Yes (list) Food No Yes (list) _ Latex No Yes Admission Admit to Neurology service: Dr. Critical Care Diagnosis:
(31189) Hypothermia Initiation Phase One
Hypothermia Initiation Phase One Diagnosis Allergies For hypothermia tracking purposes only. Please do not uncheck.- Required Cardiac Emergency Tracking For hypothermia tracking purposes only. Consults
PEDIATRIC SPINE SURGERY POST-OP PLAN - Phase: Pediatric Spine Surgery General Orders
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*111* attach patient label here
Physician Orders ADULT [R] = will be ordered Height: cm Weight: kg Allergies: No known allergies Medication allergy(s): Latex allergy Other: Admission/Transfer/Discharge Patient Status Initial Inpatient
Standard Precautions Droplet Precautions Standard Precautions Contact Precautions Droplet Precautions Standard Precautions Neutropenic Precautions
Unique Plan Description: Neurosurgery Subarachnoid Hemorrhage Admission Adult Plan Selection Display: Neurosurgery Subarachnoid Hemorrhage Admission Adult PlanType: Medical Version: 10 Begin Effective
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Diagnosis: Allergies:
Patient Name: Diagnosis: Allergies: ICU Sepsis Version 5 1/11/17 This order set must be used with an admission order set if patient not already admitted. Nursing Orders Verify that cultures have been obtained
TRANSCATHETER AORTIC VALVE REPLACEMENT POST- OP PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies DETAILS Patient Care Vital Signs Per Unit Standards, q15min x 4, q30min x 2, then q1h x 4 until sheath discontinued. Per Unit Standards Perform Neurovascular
PHYSICIAN ORDER SET : Patient: DOB: Gender: Patient Phone #: Height: Weight:
. (Patient Sticker) CDH 208-203 Approved 2/18 - Page 1 of 5 Patient: DOB: Gender: Patient Phone #: Height: Weight: Diagnosis: ICD-10 Code: Treatment Start Date: Provider Facility Name: Ordering Provider:
Physician Orders ADULT
Admission Height (Actual) : cm Admission Weight (Actual): kg Allergies: No known allergies Medication allergy(s): Latex allergy Other: Non-Categorized ATTENTION SURGEON: Please discontinue Open Heart Post
Sample. Fractured Hip Post-Operative Orders. Legend < Mandatory fields o Optional fields. Height Allergies: List or o Up to date in electronic system
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Physician Orders ADULT: Vascular Surgery AAA Repair Open Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: AAA Repair Open Postop Phase, When to Initiate: Initiate Powerplan Phase Phase: Mechanically Ventilated Patients Phase,
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
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Height: cm Weight: kg Allergies: [ ] No known allergies [ ]Medication allergy(s): [ ] Latex allergy [ ]Other: Uncategorized [X] Initiate Powerplan Phase T;N, Phase: LEB PICU Asthma Phase When to Initiate:
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Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: AAA Endovascular PACU Phase, When to Initiate: Initiate Powerplan Phase Phase: Mechanically Ventilated Patients Phase,
PICU Therapeutic Hypothermia Post Cardiac Arrest Re Warming Phase
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INFLIXIMAB RHEUMATOLOGY LOAD DOSE (SCHEDULE WEEKS 0, 2, 6)
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Zzbeacon,Zayna [MR ]
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Physician Orders ADULT: Routine Deceased Donor Adult Plan
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ADMIT DIABETIC KETOACIDOSIS (DKA) PLAN - Phase: Begin Immediately/Emergency Center
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ALL orders are active unless: 1. Order is manually lined through to inactivate 2. Orders with check boxes ( ) are unchecked DRUG AND TREATMENT ORDERS
Available at: ALL Adult Facilities Non Categorized SUB Protocol(SUB)* SUB Protocol Lab Orders(SUB)* ED Rainbow Tubes(SUB)* ***Reminder: Order ED Rainbow Tubes (SUB) as a separate form*** Nursing Orders
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Routine, Every 2 hours, Starting today, If temperature greater than 38.5 C initiate Evaluation for Possible Sepsis Physician Order #829
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