PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
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- Rudolf Harper
- 5 years ago
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1 DRUG AND TREATMENT Non Categorized SUB Sub Phase (SUB)* Non Categorized Quality Measures STK Diet ED NPO Until Bedside Swallow Screen passed Nursing Orders Activate Code Stroke Vital Signs Q15MINS Int Neuro Checks Q15MINS Int Start IV/INT Insert 2 Large Bore IVs; one in right antecubital if possible ED Cardiac Monitor Blood Glucose Monitor POC ED_ONCE Complete NIH Stroke Scale Order CTA(CT Angio Head/Neck w/wo Contrast) and CTP(CT Cerebral Perfusion Analysis w/contrast) for NIH GREATER than 8 and symptom onset LESS than 12 hours ***(NOTE)*** Urine Pregnancy Test POC for women of child-bearing age and capacity Urine Pregnancy Test POC ED_ONCE Urinalysis with Microscopic STAT, URINE, ED_ONCE ED UA STAT, URINE, ED_ONCE Radiology CT Head w/o Contrast XR Chest *1 view AP Portable Supine AP Chest, Stat, Must be done after CT of Head. HOB flat except HOB degrees if at risk for airway obstruction, aspiration, or increased ICP. Respiratory istat Notification istat Cartridge Type: Creatinine, STAT ichem8+ Stat, ED_ONCE Page 1 of 5
2 DRUG AND TREATMENT O2 Therapy. Nasal Cannula, 2, L NC. Titrate to keep O2 saturation greater than 94% Pulse Oximetry (Continuous) Special Instructions: Keep saturation greater than 94% 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 EKG Standard Stat, CODE STROKE Consults Physician Consult Neurology, Code Stroke, STAT SUB Lab Orders Subphase (SUB)* Troponin CBC with Differential. PT INR PTT Sed Rate BMP Lipid Profile LFT's ED Rainbow Tubes (SUB)* ***(NOTE)*** May obtain extra blood tubes. Extra Blue Extra Gold Extra Green Extra Lavender Page 2 of 5
3 DRUG AND TREATMENT Extra Red ***(NOTE)*** Order CTA and CTP for NIH GREATER than 8 and symptom onset LESS than 12 hours CT Angio Head/Neck w/wo Contrast CT Cerebral Perfusion Analysis w/contrast Nursing Orders Flat in Bed HOB degrees if risk for airway obstruction, aspiration, or increased ICP Elevate Head of Bed 30 Degrees Bedside Swallow Screen - Code Stroke Raise HOB to 90 degrees briefly to perform bedside swallow screen. Consult Speech therapy if patient fails screen. Medications aspirin 300 mg supp PR ED_ONCE (DEF)* Comments: DO NOT GIVE if intracranial hemorrhage OR candidate for Alteplase. May give PO only if bedside swallow screen passed. 325 mg tab PO ED_ONCE Comments: DO NOT GIVE if intracranial hemorrhage OR candidate for Alteplase. May give PO only if bedside swallow screen passed. nicardipine (Cardene 40 mg/ 200 ml pre-mix) IV bag, Clinical Instructions: Initiate at 5 mg/hr Comments: Increase rate by 2.5 mg/hr every 5-15 minutes to a MAX dose of 15 mg/hr. Titrate to maintain BP LESS THAN 185/110 mmhg prior to alteplase bolus, then maintain BP LESS THAN 180/105 mmhg. Hold for SBP LESS THAN 160 mmhg. labetalol 500mg/100mL IV Set (IVS)* Trandate 500 mg/100 ml IV drip (undiluted) IV TITRATE Comments: Begin infusion at 1 mg/min, titrate to max dose of 4 mg/min. Titrate to maintain BP LESS than 185/110 mmhg. Hold for SBP LESS than 160 mmhg. MAX dose of 300 mg in 24 hours. If ineffective notify ordering physician. IV Solutions Sodium Chloride 0.9% (Normal Saline Bolus) 10 ml/kg IVPB bag ED_ONCE, Duration: 1 hour (DEF)* 5 ml/kg IVPB bag ED_ONCE, Duration: 1 hour Sodium Chloride 0.9% (NS) IV bag 100 ml/hour (DEF)* Comments: after initial bolus completed IV bag 50 ml/hour Comments: after initial bolus completed Page 3 of 5
4 DRUG AND TREATMENT ***(NOTE)*** If extra blood tubes have been ordered use the add on blood order below ED Add on Blood in Lab CBC BMP Partial Thromboplast Time Prothrombin INR, Troponin, Sed Rate, LFTs, Lipid Profile, Specimen in Lab ***(NOTE)*** If extra blood tubes or labs have not been ordered use subphase below SUB Lab Orders (SUB)* Troponin CBC with Differential. PT INR PTT Sed Rate BMP Lipid Profile LFT's Alcohol Serum C Reactive Protein Magnesium Level Phosphorus ***(NOTE)*** If the protocol lab tests have been ordered use subphase below SUB Additional Labs (SUB)* Alcohol Serum C Reactive Protein Page 4 of 5
5 DRUG AND TREATMENT Magnesium Level Phosphorus Toxicology Screen 12 - Urine STAT, URINE Consults Speech Therapy Consult For swallow evaluation if patient failed Bedside Swallow Screen. Consult order needs to be entered. Page 5 of 5
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
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
Available at ALL facilities Non Categorized SUB ED Chest Pain: STEMI Protocol(SUB)* SUB ED Chest Pain: STEMI Protocol Lab Orders(SUB)* ED Rainbow Tubes(SUB)* ***Reminder: Order ED Rainbow Tubes (SUB) as
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT 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***
ALL orders are active unless: 1. Order is manually lined through to inactivate 2. Orders with check boxes ( ) are unchecked DRUG AND TREATMENT ORDERS
DRUG AND TREATMENT Available at: BMC-B BMC-D BMC-N BMC-S Vital Signs Vital Signs Q4H (DEF)* Q2H Q1H Vital Signs Orthostatic Activity Activity Bedrest, for 12 hours then Up ad lib (DEF)* Bedrest, for 24
DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available at: BMC-B BMC-D BMC-N BMC-S Vital Signs Vital Signs Q4H (DEF)* Q2H Q1H Vital Signs Orthostatic Activity Activity Bedrest, for 12 hours then Up ad lib (DEF)* Bedrest, for 24
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available at: ALL Adult Facilities Non Categorized SUB ED Abdominal Pain Protocol(SUB)* ***The above subphase is available at the end of the plan*** SUB ED Abdominal Pain Protocol Lab
CBC with Differential. PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Non Categorized SUB ED Snakebite Protocol (SUB)* Non Categorized ***(NOTE)*** This plan is designed to be used as part of a larger plan, not independently. Please do NOT order individually.
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
DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available ONLY at: BMC-B BMC-D BMC-N BMC-S NEURO Intracranial Hemorrhage (Factor VII) Condition/Status Patient Status Inpatient Patient Status: Inpatient, Level of Care: Intensive Care
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
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available at: BMC-B BMC-D BMC-N BMC-S Condition/Status Patient Status Inpatient Patient Status: Inpatient, Level of Care: Med/Surg without Telemetry (1) (DEF)* Patient Status: Inpatient,
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Condition/Status Patient Status Inpatient Patient Status: Inpatient, Level of Care: Intensive Care (8) Place in Observation Patient Status: Outpatient- Refer for Observation Status,
DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available ONLY at: BMC-A BMC-B BMC-C BMC-D BMC-N BMC-S BMC-T Non Categorized SUB (SUB)* SUB Alert Protocol(SUB)* SUB Alert Protocol Lab Tests(SUB)* Quality Measure Sepsis Bundle Nursing
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
Available at: BMC-B BMC-D BMC-N BMC-S Activity Activity Bedrest with BRP, with assistance at nurse's discretion (DEF)* Ambulate with Assistance Diet Communication Order Patient to remain NPO while in PACU
Emergency Department Chest Pain, Suspected Cardiac Adult Order Set
Form Title Form Number Chest Pain, Suspected Cardiac Adult Order Set 20746 2018, Alberta Health Services, CKCM This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
ED Stroke Panel Page 1 of 2
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Physician Orders ADULT: Acute MI/Acute Coronary Syndrome Adult Plan
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UMC Health System Patient Label Here PHYSICIAN ORDERS
Weight Allergies Patient Care Vital Signs Per Unit Standards, Q5 min during critical event. Insert Peripheral Line Use 20 gauge or larger. Notify Nurse (DO NOT USE FOR MEDS) Place crash cart with cardiac
Physician Orders PEDIATRIC: LEB Stroke Admit Plan
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Neurosurgery Pre-Op [1710] Patient Name MRN. General. Nursing. Case Request [ ] Case request operating room Scheduling/ADT, Scheduling/ADT [ ] Other
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PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
Available ONLY at: BMC-B BMC-D BMC-N BMC-S Intubation Phase Notify Therapy for STAT intubation SUB Rapid Sequence Induction(SUB)* ***The above subphase is available at the end of the powerplan under the
(31189) Hypothermia Initiation Phase One
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PICU ADMIT DKA PLAN - Phase: Begin Immediately
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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
DRUG AND TREATMENT Intubation Phase Notify Therapy for STAT intubation Medications SUB Rapid Sequence Induction (SUB)* ***Reminder: Order SUB Rapid Sequence Induction (SUB) on a separate form*** lidocaine
Physician Orders PEDIATRIC: : LEB ED Trauma (Major) Plan
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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:
DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available ONLY at: BMC-B BMC-D BMC-N BMC-S Non Categorized Quality Measure Sepsis Bundle Admit to Inpatient Patient Status: Inpatient, Level of Care: Intensive Care (8), Diagnosis: Please
Physician Orders PEDIATRIC: LEB ED Hx of DKA with Hyperglycemia Plan
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Diagnosis: Allergies with reaction type:
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NURSING DEPARTMENT CRITICAL CARE POLICY MANUAL CRITICAL CARE PROTOCOLS. ACUTE CEREBROVASCULAR ACCIDENT TPA (ACTIVASE /alteplase) FOR THROMBOLYSIS
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DATE: TIME: DATE TIME INTRAVENOS FLID and MEDICATION Status: Admit to Telemetry Admit to Progressive Care nit Transfer to Progressive Care nit Note: Discontinue Previous Orders Transfer to Telemetry nit
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When to Consider a Transfer: Hemorrhagic Stroke Large volume intracerebral hematoma greater than 5cm on CT Concern for expanding hematoma Rapidly declining mental status, especially requiring intubation
LIFEGIFT BRAIN DEATH PLAN
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Physician Orders ADULT: Atrial Fib/Flutter Plan
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Physician Orders ADULT Order Set: Respiratory Failure Orders
[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 Attending
Physician Orders ADULT: Medical Response Team Standing Orders Protocol Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase When to Initiate: Other-See Special Instructions, If MRT is notified per MD, Condition H or any associate, review and Initiate
EFFECTIVE DATE: 01/2007 REVISED: 07/2008, 6/11, 3/12, 8/12, 1/15. Purpose:
1 TITLE/DESCRIPTION: DEPARTMENT: PERSONNEL: Rapid Response Team (RRT) Patient Care Services RN s and RT s EFFECTIVE DATE: 01/2007 REVISED: 07/2008, 6/11, 3/12, 8/12, 1/15 Purpose: A group of select health
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
Physician Orders PEDIATRIC: LEB Oral Maxillofacial Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: LEB Oral Maxillofacial Postop Phase, When to Initiate: LEB Oral Maxillofacial Post Op Phase Admission/Transfer/Discharge
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Physician Orders PEDIATRIC: LEB DKA Diabetes Mellitus Admit Plan
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Physician Orders ADULT: Asthma and Bronchitis Plan
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Physician Orders LEB PICU Status Epilepticus Plan. [ ] No known allergies
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Height: cm Weight: kg Allergies: [ ] No known allergies [ ] Initiate Powerplan Phase T;N, Phase: LEB PICU Admit Phase Admission/Transfer/Discharge [ ] Admit Patient to Dr. [ ] Admit Status: [ ] Inpatient
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ALL orders are active unless: 1. Order is manually lined through to inactivate 2. Orders with check boxes ( ) are unchecked
Available at: BMC-B BMC-D BMC-N BMC-S Condition/Status ***(NOTE)***For purpose of this DKA Regimen, DKA is considered clear only when the CO2 is GREATER than 18 meq/l and the anion gap is LESS than 12
PEDIATRIC LIFEGIFT BRAIN DEATH PLAN
PHYSICIAN S Diagnosis Weight Allergies Admit/Discharge/Transfer THIS PLAN IS TO BE ED ONLY ON THE LIFEGIFT ENCOUNTER, WITH DR LIFEGIFT AS THE ATTENDING. Patient Status Pt Status: Inpatient (Inpatient only
Physician Orders Pediatric: LEB ED Asthma Plan
LEB ED Triage Standing SOB/Wheeze Asthma Non Categorized Criteria: Patients greater than 2 years of age with a history of asthma or airway active disease or two or more previous illnesses treated with
INPATIENT INTERVENTIONAL RADIOLOGY PLAN - Phase: Pre-Procedure Orders
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Physician Orders ADULT: Kidney-Panc/PancTransplant Post Op Plan
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Hypothermia Short Set-Critical Care HYPOTHERMIA SS- CRITICAL CARE
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IDPH ESF-8 Plan: Pediatric and Neonatal Surge Annex Sample Pediatric Admission Orders 2015
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ADMIT DIABETIC KETOACIDOSIS (DKA) PLAN - Phase: Begin Immediately/Emergency Center
- Phase: Begin Immediately/Emergency Center Weight PHYSICIAN S Allergies Admit/Discharge/Transfer Patient Status Requested Location: MICU, Pt Status: Inpatient (LOS > 2 midnights) Requested Location: 5E
OHSU HEALTH CARE SYSTEM PRACTICE GUIDELINES
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PEDIATRIC SPINE SURGERY POST-OP PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies DETAILS Patient Care Patient Activity Bedrest Maintain Surgical Drain Maintain JP Drain, Measure Output q12h, and PRN Convert IV to INT when tolerating
Physician Orders ADULT: Renal Transplant Admit Plan
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Physician Orders ADULT: Sickle Cell Inpatient Plan
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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
Physician Orders ADULT: Head and Neck Postoperative Plan
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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
NEUROSURGERY ICU PLAN
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Physician Orders ADULT: PCI Post Procedure Plan
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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
Gabapentin Research Pain Study for Ortho Total Knee Replacement Post-Op Plan - PACU Ortho Phase
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Chest Pain Acute Coronary Syndrome Version 4 4/10/17 This order set is designed to be used with an admission set or for a patient already admitted
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Therapeutic Hypothermia for Post Cardiac Arrest Plan Initial Orders
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Atrial Fibrillation Version 2 11/4/15 This order set must be used with an admission order set if patient not already admitted.
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DONATION AFTER CARDIAC DEATH PLAN
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Admit date (YYYY/MM/DD): Cardiologist On-Call: Diagnosis: Lab Tests. CBC, Electrolytes, Urea, Creatinine, Glucose, INR, PTT, Urinalysis
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Canadian Stroke Best Practices Initial ED Evaluation of Acute Stroke and Transient Ischemic Attack (TIA) Order Set (Order Set 1)
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PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT *****ALSO ORDER SUB ACUTE DKA IV FLUIDS REGIMEN & SUB ACUTE ELECTROLYTE REPLACEMENT on separate forms ***** Condition/Status For purpose of this DKA Regimen, DKA is considered clear
Pediatric Outpatient Surgery Plan - Diagnostic/Pre-Op Orders
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Sample. Affix patient label within this box.
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DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Acute Diabetic Ketoacidosis Condition/Status ***(NOTE)*** For purpose of this DKA Regimen, DKA is considered clear only when the CO2 is GREATER than 18 meq/l and the anion gap is LESS
Physician Orders ADULT: Vascular Surgery AAA Endovascular Post Op Plan
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Physician Orders PEDIATRIC: LEB NEURO Epilepsy Monitoring Unit Admit Plan
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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
STROKE NEUROINTERVENTION PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Notify Nurse (DO NOT USE FOR MEDS) Right Lower Extremity-Check peripheral pulse distal to the cath site. If
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ADMIT STROKE NEUROINTERVENTION PLAN - Phase: Begin Immediately
- Phase: Begin Immediately PHYSICIAN S Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Pt
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THROMBOLYTIC THERAPY FOR PERIPHERAL OCCLUSION
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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
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Med Stroke Admission Order Set (2367) [2367] Admission Admit [4398] Admit to [NUR35N10145] Unit: Level of care: FYI, Starting today, Cardiac Monitor (Single Response) [34406] Cardiac monitor is not indicated
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
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DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available ONLY at: BMC-B BMC-D BMC-N BMC-S Pre-Op Nursing Orders Communication Order Confirm patient has brought corresponding films for surgery (e.g. back films for back surgery, brain
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Thrombolysis Delivery, Care, and Monitoring Documentation & Pathways Need to follow locally agreed policies and procedures Follow thrombolysis pathway? Need to complete Sits database Weight Dose matters!
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
Available at: BMC-A BMC-B BMC-C BMC-D BMC-N BMC-S BMC-T BMC-W PACE Nursing Orders Patient Education Instruct patient to bring corresponding films to surgery (e.g. back films for back surgery, brain films
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