UMC Health System Patient Label Here. PHYSICIAN ORDERS Diagnosis

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1 PHYSICIAN S Diagnosis Weight Allergies Admit/Discharge/Transfer Patient Status Requested Location: NICU, Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Pt Status: Inpatient (Inpatient only procedure) Pt Status: Outpatient (Post procedure monitoring) Patient Condition Acuity Level Critical Acuity Level Intermediate Acuity Level Grower Code Status Code Status: Full Code Code Status: DNR/AND (Allow Natural Death) Code Status: Care Limitation Notify Provider/Primary Team of Pt Admit Notify: NICU Team/Provider, Upon Arrival to Floor/Unit Notify: NICU Team/Provider, Now Notify: NICU Team/Provider, In AM Patient Care Bathe Patient Per Unit Standards Initiate Neonate Discharge Requirements (NICU) ***See Policy and Procedure*** Consult Lactation Specialist Continuous Telemetry (Intermediate Care) Continuous Pulse Oximetry (NICU) Spec Instr: ***See Policy and Procedure*** Daily Weight per unit standards Insert Gastric Tube Orogastric - OG, To: Gravity Measure Patient Per Unit Standards Obtain Infant Bed Bed Type: Isolette Bed Type: Radiant Warmer Bed Type: Open Crib Order Taken by Signature: 1 of 13

2 PHYSICIAN S POC Blood Sugar Check q1h, Notify provider if blood sugar is less than 50. q3h, Notify provider if blood sugar is less than 50. q6h, Notify provider if blood sugar is less than 50. q12h, Notify provider if blood sugar is less than 50. with labs. Strict Intake and Output Per Unit Standards Maintain Total Fluids (Total Fluid Goal (NICU)) Vital Signs Per Unit Standards Newborn Screen Draw 24 hrs Insert Central Line (NICU) Line Type: PAL-Peripheral Arterial Line Line Type: PICC Line Type: UAC-Umbilical Artery Catheter Line Type: UVC-Umbilical Venous Catheter Confirm Central Line Placement (NICU) (Cleared for Use Central Line (NICU)) Line Type: PAL-Peripheral Arterial Line Line Type: PICC Line Type: UAC-Umbilical Artery Catheter Line Type: UVC-Umbilical Venous Catheter Insert Peripheral Line Isolation Type of Isolation: Contact, Implement contact isolation precautions on all transport patients until culture results negative at 24h, 48h and 72h reports. Communication Notify Provider of VS Parameters Temp Greater Than F, Temp Less Than 97.5 F, If patient on Whole Body Cooling Measures temperature parameters do not apply. Notify Provider (Misc) (Notify Provider of Results) Reason: Abnormal results Notify Provider (Misc) Limit Stimuli Dietary NPO Diet NPO Infant Nutrition (NICU) Infant Dietary Feeding (NICU) Infant Driven 33wks gestation (Infant Driven 33wks gestation (NICU)) Ad Lib Feeding, PRN IV Solutions Order Taken by Signature: 2 of 13

3 PHYSICIAN S Bolus Fluids NS (NS bolus) ml/kg, IVPB, ivpb, ONE TIME, Infuse over 1 hr D10W (D10W bolus) 2 ml/kg, IVPB, iv soln, ONE TIME, Infuse over 5 min Continuous Fluids D5W IV, ml/hr D10W IV, ml/hr For central line access, select fluid with heparin 0.25 unit/ml D10W with heparin 0.25 units/ml 250mL IV, ml/hr Final concentration: D10W with heparin 0.25 units/ml 62.5 units, Every Bag Arterial Line Fluid heparin flush (heparin flush 0.25 units/ml-1/2 NS 50 ml (neonatal)) intra-arterial, 0.5 ml/hr for arterial line. sodium acetate w heparin in sterile wate (sodium acetate w heparin in sterile water 50mL- neonatal) intra-arterial, 0.5 ml/hr 3.85 meq, Every Bag 12.5 units, Every Bag Peripheral & Central Line Patency heparin flush (heparin flush PF (1 ml syr) 0.25 units/ml-1/2 NS inj (neonatal)) 0.5 ml, IVPush, inj, as needed, PRN flush 1 ml syringe for PAL (Peripheral Arterial Line). heparin flush (heparin flush PF (10 ml syr) 0.25 units/ml-1/2 NS inj (neonatal)) 0.5 ml, IVPush, inj, as needed, PRN flush 10 ml syringe for UVC, UAC, PICC and Broviac. Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. Antibiotics ampicillin (ampicillin neonatal) 100 mg/kg, IVsyr, kit, q12h, x 4 dose gentamicin (gentamicin neonatal) 4 mg/kg, IVsyr, syringe, q24h, x 2 dose Must wait at least 2 hours after ampicillin administration to administer gentamicin. 4 mg/kg, IVsyr, syringe, q36h, x 1 dose Must wait at least 2 hours after ampicillin administration to administer gentamicin. 4.5 mg/kg, IVsyr, syringe, q36h, x 1 dose Must wait at least 2 hours after ampicillin administration to administer gentamicin. 5 mg/kg, IVsyr, syringe, q48h, x 1 dose Must wait at least 2 hours after ampicillin administration to administer gentamicin. Order Taken by Signature: 3 of 13

4 PHYSICIAN S Antiviral Agents acyclovir (acyclovir neonatal) 20 mg/kg, IVsyr, syringe, q8h Antifungals **If birth weight LESS than 1,000 grams** If ordering fluconazole, select ALL 3 orders: fluconazole (fluconazole neonatal) 3 mg/kg, IVsyr, syringe, q72h, x 5 dose Fluconazole regimen: Give every 72 hours for 2 weeks, then every 48 hours for 2 weeks, then every 24 hours for 2 weeks. fluconazole (fluconazole neonatal) 3 mg/kg, IVsyr, syringe, q48h, x 7 dose Fluconazole regimen: Give every 72 hours for 2 weeks, then every 48 hours for 2 weeks, then every 24 hours for 2 weeks. fluconazole (fluconazole neonatal) 3 mg/kg, IVsyr, syringe, q24h, x 14 dose Fluconazole regimen: Give every 72 hours for 2 weeks, then every 48 hours for 2 weeks, then every 24 hours for 2 weeks. Misc Meds erythromycin ophthalmic (erythromycin ophthalmic neonatal) 1 app, left eye, ophth oint, ONE TIME Apply at time of admission. erythromycin ophthalmic (erythromycin ophthalmic neonatal) 1 app, right eye, ophth oint, ONE TIME Apply at time of admission. beractant (beractant neonatal) 4 ml/kg, intra-tracheal, susp, ONE TIME Vitamin K: Order 0.5 mg for birth weight LESS than 1,500 grams; 1 mg for birth weight GREATER than or EQUAL to 1,500 grams. phytonadione (Vitamin K1 neonatal) 0.5 mg, IM, inj, ONE TIME For birth weight LESS than 1,500 grams. 1 mg, IM, inj, ONE TIME For birth weight GREATER than or EQUAL to 1,500 grams. Central Nervous System Stimulants Caffeine Loading Dose: caffeine (caffeine neonatal) 20 mg/kg, IVsyr, syringe, ONE TIME, [caffeine citrate] FOR IV USE ONLY. Loading Dose. Infuse over 30 minutes. Continued on next page... Order Taken by Signature: 4 of 13

5 PHYSICIAN S Caffeine Maintenence Dose: caffeine (caffeine neonatal) 10 mg/kg, IVsyr, syringe, q24h FOR IV USE ONLY. Start maintenance dose 24 hours after initial loading dose. Infuse over 10 minutes. Intraventricular Hemorrhage Prevention **If less than 26 weeks or less than 1,000 grams and NO hydrocortisone administered** Select both orders if ordering indomethacin:.medication Management (Notify Nurse and Pharmacy) NOW, Start date Notify attending physician with lab results prior to administering indomethacin if platelets LESS than 100 K/uL, or creatinine GREATER than 1.5 mg/dl, or urine output LESS than 1 ml/kg/hr. indomethacin (indomethacin neonatal) 0.1 mg/kg, IVsyr, inj, q24h, x 3 dose Notify attending physician with lab results prior to administering indomethacin if platelets LESS than 100 K/uL, or creatinine GREATER than 1.5 mg/dl, or urine output LESS than 1 ml/kg/hr. Laboratory Testing for Dr Tonk Comment: Chromosomes & microarray You must enter the date and time you want labs to be drawn on every lab order that is timed. Hematology CBC with Differential Timed, Comment: Draw at 6 hours of life. CBC with Differential CBC with Differential Timed, Every AM for 2 days Chemistry Bilirubin Total Timed C Reactive protein (CRP) C Reactive protein (CRP) Timed, q24h for 2 days Ionized Calcium Level Chemistry Panels Renal Function Panel Next Day in AM Order Taken by Signature: 5 of 13

6 PHYSICIAN S Microbiology/Virology Culture Blood Culture Respiratory with Gram Stain Tracheal Aspirate ***If intubated and prior to surfactant only, Order Culture Respiratory with Gram Stain*** Culture VRE Screen Rectal Swab **** Surface culture of rectum for VRE on all transport patients.**** HSV Type 1 and 2 DNA Quantitative PCR MRSA Screen Culture Eye Only one eye required to be cultured. **** Surface culture of Eye, Nare and Umbilicus for MRSA on all transport patients.**** MRSA Screen Culture Nares Only one nare required to be cultured. **** Surface culture of Eye, Nare and Umbilicus for MRSA on all transport patients.**** MRSA Screen Culture Umbilicus **** Surface culture of Eye, Nare and Umbilicus for MRSA on all transport patients.**** Blood Bank To order blood type and screen, you must order BB Blood Type (ABO/Rh) Neonate and BB Antibody Screen. BB Blood Type (ABO/Rh) Neonate ****To order blood type and screen, you must order BB Blood Type (ABO/Rh) Neonate and BB Antibody Screen.**** BB Antibody Screen ****To order blood type and screen, you must order BB Blood Type (ABO/Rh) Neonate and BB Antibody Screen.**** Drugs of Abuse Meconium Drug Screen Routine Urine Random Drug Screen Diagnostic Tests Radiography DX Pedi Chest/Abd DX Pedi Chest/Abd DX Abdomen AP (KUB) Order Taken by Signature: 6 of 13

7 PHYSICIAN S DX Abdomen AP (KUB) STAT, Portable, check for line placement DX Pedi Chest/Abd STAT, Portable, check for line placement Ultrasound US Echoencephalogram Physical Medicine and Rehab Consult Occ Therapy for Eval & Treat for (Consult Occ Therapy for Eval & Treat for Neonatal) Neurological Issues, Patients born at less than or equal to 30 weeks, initiate OT at 2 weeks of life. Prematurity, Patients born at less than or equal to 30 weeks, initiate OT at 2 weeks of life. Other, Patients born at less than or equal to 30 weeks, initiate OT at 2 weeks of life. Consults/Referrals Social Services for Assessment and Eval (Discharge Planning Evaluation by Social Services) For NICU Admission Consult Dietitian For Other Nutrition Needs Consult Ophthalmology for ROP Special Instr: For patients born at less than or equal to 30 weeks or less than 1500 grams birth weight. Consult MD Service: Ophthalmology, ***NOT for ROP***...Additional Orders Order Taken by Signature: 7 of 13

8 NICU PARENTERAL NUTRITION PLAN PHYSICIAN S Patient Care NICU Total Parenteral Nutrition Policy/Procedure ***See Reference Text*** POC Blood Sugar Check q12h, Until TPN is discontinued. POC Urinalysis Automated w/o Microscopy Communication Notify Provider (Misc) Reason: POC Blood Glucose is LESS than 50 mg/dl or GREATER than 150 mg/dl. IV Solutions Parenteral Nutrition parenteral nutrition solution (Starter TPN 10% Dextrose with heparin 0.25 units/ml neonatal) IV, ml/hr Starter TPN 10% Dextrose with heparin 0.25 units/ml. Recommended max rate is 80 ml/kg/day. Please fill out paper form to order TPN. Continuous Fluids D10W IV, ml/hr D5W IV, ml/hr Laboratory You must enter the date and time you want labs to be drawn on every lab order that is timed, Chemistry Bilirubin Direct Bilirubin Direct Timed, q24h 2 days Bilirubin Total Bilirubin Total Timed, q24h 2 days Comprehensive Metabolic Panel (CMP) Comprehensive Metabolic Panel (CMP) Timed, q24h 2 days Magnesium Level Magnesium Level Timed, q24h 2 days Order Taken by Signature: 8 of 13

9 NICU PARENTERAL NUTRITION PLAN PHYSICIAN S Phosphorus Level Phosphorus Level Timed, q24h 2 days Triglycerides Triglycerides Timed, q24h 2 days Order Taken by Signature: 9 of 13

10 NICU PROCEDURE PLAN PHYSICIAN S Patient Care Confirm Central Line Placement (NICU) Line Type: PAL-Peripheral Arterial Line Line Type: PICC Line Type: UAC-Umbilical Artery Catheter Line Type: UVC-Umbilical Venous Catheter Insert Central Line (NICU) Line Type: PAL-Peripheral Arterial Line Line Type: PICC Line Type: UAC-Umbilical Artery Catheter Line Type: UVC-Umbilical Venous Catheter Insert Peripheral Line Maintain Chest Tube Protective Positioning (NICU) Set Up for Lumbar Puncture Set Up for Circumcision Set Up for Chest Tube Communication Obtain Consent Consent for: PICC Line Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. lidocaine (lidocaine 1% preservative-free injectable solution) 0.5 ml, locally, inj, ONE TIME petrolatum topical (petrolatum topical ointment) 1 app, topical, oint, 12x/day, PRN wound care Apply with each diaper change. Diagnostic Tests DX Pedi Chest/Abd STAT, Line placement DX Chest Portable STAT, Line placement DX Abdomen AP (KUB) STAT, Portable, Line placement Order Taken by Signature: 10 of 13

11 NICU RESPIRATORY PLAN PHYSICIAN S Patient Care Room Air Trials (NICU) Keep O2 Sat Greater Than: 90%, Spec Instr: Reapply oxygen if O2 parameter is not met. Wean Nasal Cannula to Room Air (NICU) Keep Sats Greater Than: 90% Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. Select the order below for as needed nebulized treatments: albuterol (albuterol-inhalation neonatal) 0.1 mg/kg, inhalation, soln, q3h, PRN wheezing 0.1 mg/kg, inhalation, soln, q4h, PRN wheezing 0.1 mg/kg, inhalation, soln, q6h, PRN wheezing 0.1 mg/kg, inhalation, soln, q12h, PRN wheezing Select the orders below for scheduled nebulized treatments: albuterol (albuterol-inhalation neonatal) 0.1 mg/kg, inhalation, soln, q3h 0.1 mg/kg, inhalation, soln, q4h 0.1 mg/kg, inhalation, soln, q6h 0.1 mg/kg, inhalation, soln, q8h 0.1 mg/kg, inhalation, soln, q12h budesonide (budesonide-inhalation neonatal) 0.25 mg, inhalation, neb, q12h Diagnostic Tests DX Chest Portable Respiratory Chest Physiotherapy q4h q6h q8h Nasal CPAP Nitric Oxide Administration Oxygen Therapy ***See Policy and Procedure*** Ventilator Settings Ventilator Settings HFOV I-Time (%): 33% Arterial Blood Gas Capillary Blood Gas Mixed Venous Blood Gas Order Taken by Signature: 11 of 13

12 NICU SEDATION AND PAIN MED PLAN PHYSICIAN S Patient Care Sedation Level (NICU) Sedation Level: None Sedation Level: Light Sedation Sedation Level: Deep Sedation Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. Analgesics Mild Pain: acetaminophen (acetaminophen neonatal) 15 mg/kg, PO, liq, q6h, PRN pain-mild (scale 1-3) Moderate Pain: morphine (morphine neonatal) 0.05 mg/kg, IVPush, inj, q4h, PRN pain-moderate (scale 4-7) fentanyl (fentanyl neonatal) 0.5 mcg/kg, IVPush, inj, q4h, PRN pain-moderate (scale 4-7) Severe Pain: morphine (morphine neonatal) 0.1 mg/kg, IVPush, inj, q4h, PRN pain-severe (scale 8-10) fentanyl (fentanyl neonatal) 1 mcg/kg, IVPush, inj, q4h, PRN pain-severe (scale 8-10) For pain score of 8 or greater, consider ordering continuous infusion. fentanyl 250 mcg/25 ml NS (neonatal) - F (fentanyl 250 mcg/25 ml NS (neonatal) - Fixed Rate) IVsyr Final concentration = 0.01 mg/ml (10 mcg/ml). Provider order required for ALL rate changes. Start at rate: mcg/kg/hr Sedatives LORazepam (LORazepam neonatal) 0.1 mg/kg, IVPush, inj, q2h, PRN sedation midazolam (midazolam neonatal) 0.1 mg/kg, IVPush, inj, q2h, PRN sedation Slow IVPush over 10 minutes. Continuous Infusion: midazolam 10 mg/20 ml NS (neonatal) - Fi (midazolam 10 mg/20 ml NS (neonatal) - Fixed Rate) IVsyr Final concentration: 0.5 mg/ml (500 mcg/ml). Provider order required for ALL rate changes. Start at rate: mg/kg/hr Order Taken by Signature: 12 of 13

13 NICU NUTRITION PANEL PLAN PHYSICIAN S Laboratory You must enter the date and time you want labs to be drawn on every lab order that is timed. Chemistry Bilirubin Direct Timed, Comment: draw at 24 hours of life Bilirubin Direct Timed, Every AM 2 days Phosphorus Level Timed, Comment: draw at 24 hours of life Phosphorus Level Timed, Every AM 2 days Comprehensive Metabolic Panel Timed, Comment: draw at 24 hours of life Comprehensive Metabolic Panel Timed, Every AM 2 days Order Taken by Signature: 13 of 13