PICU BRONCHIOLITIS PLAN

Transcription

1 PICU BRONCHIOLITIS PLAN Diagnosis Weight PHYSICIAN S Allergies Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Patient Care Code Status Code Status: Full Code Code Status: DNR - Do Not Resuscitate Code Status: DNI - Do Not Intubate Code Status: DNR/DNI - Do Not Resuscitate or Intubate Code Status: Partial Resuscitative Effort Vital Signs Per Unit Standards Daily Weight Patient Activity Bedrest Up Ad Lib/Activity as Tolerated Strict Intake and Output Per Unit Standards q1h q2h q4h Insert Peripheral Line Insert Urinary Catheter Foley, To: Dependent Drainage Bag Insert Gastric Tube Nasogastric - NG, To: Low Intermittent Suction Orogastric - OG, To: Low Intermittent Suction Nasogastric - NG, To: Low Constant Suction Orogastric - OG, To: Low Constant Suction Set Up for Central Line Placement Single Lumen Catheter, Supplies at Bedside: Insertion Tray Double Lumen Catheter, Supplies at Bedside: Insertion Tray Triple Lumen Catheter, Supplies at Bedside: Insertion Tray Set Up for Arterial Line Placement Apply Sequential Compression Device Communication Notify Provider of VS Parameters Notify Provider (Misc) Reason: Pain score greater than 4 Dietary Oral Diet Regular Diet Order Taken by Signature: Page: 1 of 15 PICU Bronchiolitis Plan Version: 7 Effective on: 12/21/15

2 PICU BRONCHIOLITIS PLAN PHYSICIAN S NPO Diet NPO NPO, Except Meds NPO, Except Ice Chips NPO, Except Meds, Except Ice Chips IV Solutions NS (Normal Saline) IV, 10 ml/hr IV, 20 ml/hr IV, 30 ml/hr IV, 40 ml/hr IV, 50 ml/hr D5 1/2 NS IV, 10 ml/hr IV, 20 ml/hr IV, 30 ml/hr IV, 40 ml/hr IV, 50 ml/hr D5 1/2 NS + 20 meq KCl/L IV, 10 ml/hr IV, 20 ml/hr IV, 30 ml/hr IV, 40 ml/hr IV, 50 ml/hr Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. phenylephrine nasal (phenylephrine 0.125% nasal drops) 2 drop, intra-nasal, nasal drop, q12h, x 3 days 2 drop, intra-nasal, nasal drop, q8h, x 3 days prednisolone (prednisolone 5 mg/5 ml oral liquid) 1 mg/kg, PO, ONE TIME 1 mg/kg, PO, liq, Daily 1 mg/kg, PO, liq, BID GI Prophylaxis ranitidine (ranitidine pediatric) 2 mg/kg, PO, liq, BID Recommended maximum dose is 300 mg/day. 4 mg/kg, PO, liq, BID Recommended maximum dose is 300 mg/day mg/kg,, syringe, q8h, [2 mg/kg/day] Diluent NS. Infuse over 30 min. Dose + 3 ml overfill. Recommended maximum dose is 200 mg/day 1.33 mg/kg,, syringe, q8h, [4 mg/kg/day] Diluent NS. Infuse over 30 min. Dose + 3 ml overfill. Recommended maximum dose is 200 mg/day Respiratory racepinephrine (racepinephrine 2.25% inhalation solution) 0.5 ml, inhalation, neb, ONE TIME 0.5 ml, inhalation, neb, q3h, PRN wheezing Order Taken by Signature: Page: 2 of 15 PICU Bronchiolitis Plan Version: 7 Effective on: 12/21/15

3 PICU BRONCHIOLITIS PLAN PHYSICIAN S ipratropium (ipratropium pediatric) 250 mcg, inhalation, soln, q20min, x 3 dose 250 mcg, inhalation, soln, q4h, PRN wheezing 250 mcg, inhalation, soln, q2h, PRN wheezing 500 mcg, inhalation, soln, q30min, x 3 dose 500 mcg, inhalation, soln, q4h, PRN wheezing 500 mcg, inhalation, soln, q2h, PRN wheezing albuterol (albuterol inhalation pediatric) 0.05 mg/kg, inhalation, soln, q4h, PRN wheezing 0.05 mg/kg, inhalation, soln, q4h 0.05 mg/kg, inhalation, soln, q2h, PRN wheezing 0.05 mg/kg, inhalation, soln, q2h 0.1 mg/kg, inhalation, soln, q4h, PRN wheezing 0.1 mg/kg, inhalation, soln, q4h 0.1 mg/kg, inhalation, soln, q2h, PRN wheezing 0.1 mg/kg, inhalation, soln, q2h Analgesics/Anti-Pyretics acetaminophen (acetaminophen pediatric) 10 mg/kg, per tube/po, liq, q6h, PRN pain-mild (scale 1-3)/fever ***Do not exceed 2,600 mg of acetaminophen from all sources in 24 hours if under the age of 12 years. For all others do not exceed 4,000 mg of acetaminophen from all sources in 24 hour*** 10 mg/kg, per tube/po, liq, q4h, PRN pain-mild (scale 1-3)/fever ***Do not exceed 2,600 mg of acetaminophen from all sources in 24 hours if under the age of 12 years. For all others do not exceed 4,000 mg of acetaminophen from all sources in 24 hour*** 15 mg/kg, per tube/po, liq, q6h, PRN pain-mild (scale 1-3)/fever ***Do not exceed 2,600 mg of acetaminophen from all sources in 24 hours if under the age of 12 years. For all others do not exceed 4,000 mg of acetaminophen from all sources in 24 hour*** 15 mg/kg, rectally, supp, q8h, PRN pain-mild (scale 1-3)/fever ***Do not exceed 2,600 mg of acetaminophen from all sources in 24 hours if under the age of 12 years. For all others do not exceed 4,000 mg of acetaminophen from all sources in 24 hour*** ibuprofen (ibuprofen pediatric) 5 mg/kg, per tube/po, liq, q6h, PRN pain-mild (scale 1-3)/fever ***Do not exceed 1200 mg of ibuprofen from all sources in 24 hours if under the age of 12 years. For all others do not exceed 3200 mg of 10 mg/kg, per tube/po, liq, q6h, PRN pain-mild (scale 1-3)/fever ***Do not exceed 1200 mg of ibuprofen from all sources in 24 hours if under the age of 12 years. For all others do not exceed 3200 mg of Analgesics Order Taken by Signature: Page: 3 of 15 PICU Bronchiolitis Plan Version: 7 Effective on: 12/21/15

4 PICU BRONCHIOLITIS PLAN PHYSICIAN S morphine (morphine pediatric) 0.05 mg/kg, IVPush, inj, q4h, PRN pain-severe (scale 8-10) 0.1 mg/kg, IVPush, inj, q4h, PRN pain-severe (scale 8-10) fentanyl (fentanyl pediatric) 1 mcg/kg, IVPush, inj, q4h, PRN pain-severe (scale 8-10) 1 mcg/kg, IVPush, inj, q2h, PRN pain-severe (scale 8-10) 2 mcg/kg, IVPush, inj, q4h, PRN pain-severe (scale 8-10) 2 mcg/kg, IVPush, inj, q2h, PRN pain-severe (scale 8-10) Laboratory POC PT with INR CBC with Differential Prothrombin Time with INR PTT Comprehensive Metabolic Panel Amylase Level Lipase Level C Reactive protein Urinalysis Culture Urine Culture Blood Culture Sputum with Gram Stain Culture Respiratory with Gram Stain Flu A B H1N1 by PCR Respiratory Direct Viral Panel by DFA Rapid RSV Detection MRSA Rapid Nasal Screen by PCR Diagnostic Tests DX Chest Single View DX Chest PA & Lateral Order Taken by Signature: Page: 4 of 15 PICU Bronchiolitis Plan Version: 7 Effective on: 12/21/15

5 PICU BRONCHIOLITIS PLAN PHYSICIAN S DX Chest Special View (DX Chest Lateral Decub) EKG-12 Lead Pediatric TTE Respiratory Oxygen Therapy Via: Nasal cannula, Keep sats greater than %: 90 Via: Simple mask, Keep sats greater than %: 90 Via: Venturi mask, Keep sats greater than %: 90 Via: Nonrebreather mask, Keep sats greater than %: 90 Via: Blow-by Via: High Flow Nasal Cannula Via: Trach collar, Keep sats greater than %: 90, Heated and Humidified Heliox Administration Chest Physiotherapy Target Lung Area(s): All lung areas, QID Target Lung Area(s): All lung areas, TID Target Lung Area(s): All lung areas, 6x/day Arterial Blood Gas Additional Tests: Electrolytes COOX (Carboxyhemoglobin) Lactate, Daily For 3 days Capillary Blood Gas Consults/Referrals Consult Dietitian...Additional Orders Order Taken by Signature: Page: 5 of 15 PICU Bronchiolitis Plan Version: 7 Effective on: 12/21/15

6 PICU CONTINUOUS MED INFUSION PLAN PHYSICIAN S IV Solutions Standard Concentration DOBUTamine 100 mg/50 ml D5W (NI/PI) Final concentration= 2 mg/ml. (2,000 mcg/ml). Usual maintenence dose range is mcg/kg/min. Recommended maximum dose is 40 mcg/kg/min. DOPamine 80 mg/50 ml D5W (NI/PI) Final concentration = 1.6 mg/ml (1600 mcg/ml). Usual maintenance dose range is 1-20 mcg/kg/min. Recommended maximum dose is 50 mcg/kg/minute. EPINEPHrine 1.25 mg/50 ml NS (Pedi) Final concentration = mg/ml (25 mcg/ml). Usual maintenance dose range is mcg/kg/min. milrinone 5 mg/50 ml NS (Pedi) Final concentration = 0.1 mg/ml (100 mcg/ml). Usual loading dose 50 mcg/kg given over 10 minutes. Usual maintenence dose range is mcg/kg/min. isoproterenol 1.6 mg/50 ml NS (Pedi) Final concentration = mg/ml (32 mcg/ml). Usual maintenence dose range is mcg/kg/min. lidocaine 200 mg/50 ml NS (PICU) Final concentration = 4 mg/ml (4,000 mcg/ml). Usual maintenence dose range is mcg/kg/min. Order Taken by Signature: Page: 6 of 15 PICU Bronchiolitis Plan Version: 7 Effective on: 12/21/15

7 PICU CONTINUOUS MED INFUSION PLAN PHYSICIAN S nitroprusside 5 mg/50 ml D5W (NICU) Final Concentration = 0.1 mg/ml (100 mcg/ml). Usual maintenance dose range is mcg/kg/min. Recommended maximum dose is 10 mcg/kg/min. norepinephrine 0.8 mg/50 ml NS (Pedi) Final Concentration = 16 mcg/ml. Usual maintenance dose range is mcg/kg/min. Recommended maximum dose is 2 mcg/kg/min. Maximum Concentration DOBUTamine 200 mg/50 ml D5W (NI/PI) Final concentration= 4 mg/ml (4,000 mcg/ml). Usual maintenence dose range is mcg/kg/min. Recommended maximum dose is 40 mcg/kg/min. DOPamine 160 mg/50 ml D5W (NI/PI) Final concentration = 3.2 mg/ml (3200 mcg/ml). Usual maintenance dose range is 1-20 mcg/kg/min. Recommended maximum dose is 50 mcg/kg/min. EPINEPHrine 2.5 mg/50 ml NS (Pedi) Final concentration = 0.05 mg/ml (50 mcg/ml). Usual Dose Range is mcg/kg/min. milrinone 10 mg/50 ml NS (Pedi) Final concentration = 0.2 mg/ml (200 mcg/ml). Usual maintenence dose range is mcg/kg/min. Order Taken by Signature: Page: 7 of 15 PICU Bronchiolitis Plan Version: 7 Effective on: 12/21/15

8 PICU CONTINUOUS MED INFUSION PLAN PHYSICIAN S isoproterenol 3.2 mg/50 ml NS (Pedi) Final concentration = mg/ml (64 mcg/ml). Usual maintenence dose range is mcg/kg/min. lidocaine 400 mg/50 ml NS (PICU) Final concentration = 8 mg/ml (8,000 mcg/ml). Usual maintenence dose range is mcg/kg/min. nitroprusside 10 mg/50 ml D5W (NICU) Final Concentration = 0.2 mg/ml (200 mcg/ml). Usual maintenance dose range is mcg/kg/min. Recommended maximum dose is 10 mcg/kg/min. norepinephrine 1.6 mg/50 ml NS (Pedi) Final Concentration = 32 mcg/ml. Usual maintenance dose range is mcg/kg/min. Recommended maximum dose is 2 mcg/kg/min. Minimum Concentration DOBUTamine 50 mg/50 ml D5W (NI/PI) Final concentration= 1 mg/ml (1,000 mcg/ml). Usual maintenence dose range is mcg/kg/min. Recommended maximum dose is 40 mcg/kg/min. DOPamine 40 mg/50 ml D5W (NI/PI) Final concentration= 0.8 mg/ml (800 mcg/ml). Usual maintenance dose range is 1-20 mcg/kg/min. Recommended maximum dose is 50 mcg/kg/minute. Order Taken by Signature: Page: 8 of 15 PICU Bronchiolitis Plan Version: 7 Effective on: 12/21/15

9 PICU CONTINUOUS MED INFUSION PLAN PHYSICIAN S EPINEPHrine 0.5 mg/50 ml NS (Pedi) Final concentration= 0.01 mg/ml (10 mcg/ml). Usual maintenance dose range is mcg/kg/min. isoproterenol 0.8 mg/50 ml NS (Pedi) Final concentration = mg/ml (16 mcg/ml). Usual maintenence dose range is mcg/kg/min. Order Taken by Signature: Page: 9 of 15 PICU Bronchiolitis Plan Version: 7 Effective on: 12/21/15

10 PICU MECHANICAL VENTILATION AND NEUROMUSCULAR BLOCKADE PLAN PHYSICIAN S Patient Care Patient Activity Bedrest, HOB elevation degrees Obtain Specialty Bed Order: Rotorest Perform Oral Care Per Unit Standards, May use oral care kits. DO NOT use plaque solution, brush teeth without. Suction Patient Per VAP Guidelines Perform Neurological Checks q1h q1h, until NMBA infusion rate has not changed for 4 hours, then q2h. q2h Insert Gastric Tube Nasogastric - NG Dobhoff Tube Apply Peripheral Nerve Stimulator Monitoring Brain Function Monitoring Type: Brain Z Type: 5 Lead EEG Type: SEDline Type: Invos Guideline VAP Prevention Guidelines ***See Reference Text*** Pediatric Neuromuscular Blocking Agent G (Pediatric Neuromuscular Blocking Agent Guidelines) ***See Reference Text*** Communication Notify Nurse (DO NOT USE FOR MEDS) Do not perform wake up trials while patient is on a paralytic. Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. ocular lubricant (Lacri-Lube S.O.P. ophthalmic ointment) 1 app, both eyes, ophth oint, as needed, PRN dry eyes ocular lubricant (Artificial Tears) 1 drop, both eyes, ophth soln, as needed, PRN dry eyes Paralytic Order Taken by Signature: Page: 10 of 15 PICU Bronchiolitis Plan Version: 7 Effective on: 12/21/15

11 PICU MECHANICAL VENTILATION AND NEUROMUSCULAR BLOCKADE PLAN PHYSICIAN S vecuronium 0.05 mg/kg, IVPush, inj, ONE TIME 0.08 mg/kg, IVPush, inj, ONE TIME 0.1 mg/kg, IVPush, inj, ONE TIME vecuronium 30 mg/30 ml NS (Pedi) rocuronium 0.3 mg/kg, IVPush, inj, ONE TIME 0.45 mg/kg, IVPush, inj, ONE TIME 0.6 mg/kg, IVPush, inj, ONE TIME 1.2 mg/kg, IVPush, inj, ONE TIME rocuronium 30 mg/30 ml NS (Pedi) Respiratory Ventilator Settings Ventilator Settings APRV Ventilator Settings HFOV CPAP BiPAP SiPAP Arterial Blood Gas End Tidal CO2 Monitoring Weaning Parameters Order Taken by Signature: Page: 11 of 15 PICU Bronchiolitis Plan Version: 7 Effective on: 12/21/15

12 PICU SEDATION AND PAIN MED PLAN PHYSICIAN S IV Solutions NS IV, ml/hr Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. Initial Dose Analgesia morphine (morphine pediatric) 0.1 mg/kg, IVPush, inj, ONE TIME 0.2 mg/kg, IVPush, inj, ONE TIME fentanyl (fentanyl pediatric) 0.5 mcg/kg, IVPush, inj, ONE TIME 1 mcg/kg, IVPush, inj, ONE TIME Sedation midazolam (midazolam pediatric) 0.05 mg/kg, IVPush, inj, ONE TIME 0.1 mg/kg, IVPush, inj, ONE TIME PENTobarbital (PENTobarbital pediatric) 1 mg/kg, IVPush, inj, ONE TIME LORazepam (LORazepam pediatric) 0.05 mg/kg, IVPush, inj, ONE TIME 0.1 mg/kg, IVPush, inj, ONE TIME propofol 1 mg/kg, IVPush, inj, ONE TIME ketamine (ketamine pediatric) 0.5 mg/kg, IVPush, inj, ONE TIME 1 mg/kg, IVPush, inj, ONE TIME Continuous Infusion Analgesia morphine 30 mg/30 ml NS (PICU) Order Taken by Signature: Page: 12 of 15 PICU Bronchiolitis Plan Version: 7 Effective on: 12/21/15

13 PICU SEDATION AND PAIN MED PLAN PHYSICIAN S Final concentration= 1 mg/ml (1,000 mg/ml) Titrate carefully to effect. Usual maintenance dose range is mg/kg/hr. Recommended maximum dose is 0.04 mg/kg/hour. Start at rate: mg/kg/hr fentanyl 250 mcg/25 ml NS (NI/PI) Final concentration = 10 mcg/ml. Usual dose range for neonates is mcg/kg/hr. Usual dose range for infants and children is 1-3 mcg/kg/hr. Recommended maximum dose is 5 mcg/kg/hour. Start at rate: mcg/kg/hr Sedation Order midazolam 10 mg/20 ml for patients LESS than 1 year of age. midazolam 10 mg/20 ml NS (NI/PI) Final concentration = 0.5 mg/ml. Usual dose range is mg/kg/hr. ***Sedative medications should only be given after pain is adequately controlled*** Start at rate: mg/kg/hr Oder midazolam 50 mg/50 ml for patients GREATER than or EQUAL to 1 year of age. midazolam 50 mg/50 ml NS (PICU) Final concentration: 1 mg/ml (1,000 mcg/ml). Usual maintenance dose range is mg/kg/hr. Titrate to desired effect. ***Sedative medications should only be given after pain is adequately controlled*** Start at rate: mg/kg/hr PENTobarbital 250 mg/50 ml NS (PICU) Final concentration = 5 mg/ml (5,000 mcg/ml). Usual loading dose is 1 mg/kg. Usual maintenance dose range is 1-3 mg/kg/hr. Notify physician if administered dose (rate) is outside normal range. ***Sedative medications should only be given after pain is adequately controlled*** Start at rate: mg/kg/hr dexmedetomidine 200 mcg/50 ml (PICU) Order Taken by Signature: Page: 13 of 15 PICU Bronchiolitis Plan Version: 7 Effective on: 12/21/15

14 PICU SEDATION AND PAIN MED PLAN PHYSICIAN S Final concentration = 4 mcg/ml. Usual maintenance dose range is mcg/kg/hr. Notify physician if administered dose (rate) is outside normal range. ***Sedative medications should only be given after pain is adequately controlled*** Start at rate: mcg/kg/hr LORazepam 5 mg/50 ml D5W (PICU) Start at rate: mg/kg/hr propofol 200 mg/20 ml (PICU) Start at rate: mg/kg/hr IV ketamine 250 mg/50 ml NS (PICU) Final concentration = 5 mg/ml (5,000 mcg/ml). Usual maintenance dose range is 5-20 mcg/kg/min. Notify physician if administered dose (rate) is outside normal range. ***Sedative medications should only be given after pain is adequately controlled*** Laboratory ***If patient remains on propofol infusion after 48 hours monitor triglycerides now and every 3 days until propofol discontinued.*** Triglycerides Notify Provider (Misc) (Notify Provider of Results) Reason: Triglyceride Level greater than 400 mg/dl. Order Taken by Signature: Page: 14 of 15 PICU Bronchiolitis Plan Version: 7 Effective on: 12/21/15

15 PEDIATRIC CENTRAL IV FLUSH PLAN PHYSICIAN S Patient Care Flush CVL catheter with heparin solution every 12 hours even with a continuous infusion. Upon completion of medication administration, the CVL will be flushed with 3 ml of normal saline followed by heparin flush as ordered. Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. sodium chloride (Normal Saline Flush) 3 ml, IVPush, as needed, PRN flush Upon completion of medication. May give up to 5 ml as needed. CVL s will be flushed with 3 ml of normal saline followed by heparin flush as ordered. ***Use 10 units/ ml for patients weighing LESS than 18 kg*** ***4-10 kg use 1.5 ml*** ***if GREATER than 10 kg use 3 ml*** heparin flush (heparin flush 10 units/ml injection (PEDI)) 1.5 ml, IVPush, syringe, q12h, PRN flush, after saline flush. Flush CVL catheter with heparin solution every 12 hours even with a continuous infusion. 3 ml, IVPush, syringe, q12h, PRN flush, after saline flush. Flush CVL catheter with heparin solution every 12 hours even with a continuous infusion. ***Use 100 units/ml for patients weighing GREATER than or EQUAL to 18 kg**** heparin flush (heparin flush 100 units/ml injection) 3 ml, IVPush, syringe, q12h, PRN flush, after saline flush. Flush CVL catheter with heparin solution every 12 hours even with a continuous infusion. ***For Terminal Flush*** heparin flush (heparin flush 100 units/ml injection) 1.5 ml, IVPush, inj, ONE TIME after continuous fluids are discontinued. 3 ml, IVPush, inj, ONE TIME after continuous fluids are discontinued. Order Taken by Signature: Page: 15 of 15 PICU Bronchiolitis Plan Version: 7 Effective on: 12/21/15