PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
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1 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 title of the subphase.*** lidocaine 100 mg inj IV PUSH ONCE, Clinical Instructions: for Mechanical Ventilator Intubation Radiology XR Chest *1 view AP Portable Post intubation, Stat, Pending Discharge - No, ONCE, Wet read immediately to be called to nurse Stat, 30 minutes post intubation Ventilator Initial Setup Ventilator Maintenance Phase Ventilator Weaning Assessment DAILY06 Initiate Precautions to Prevent Ventilator Associated Pnuemonia Sedation Vacation: Hold all analgesics and sedations daily at 0800 until RASS-2 Enteral Tube Insertion Enteral Tube Type: Orogastric, Tube Drainage Method: Low Intermittent Suction, Additional Instructions: As needed Please obtain STAT ABG draw, PRN, for oxygen saturation LESS than 92% and call results to physician GEN Venous Thromboembolism Prophylaxis (VTE)(SUB)* ***Reminder: Order GEN Venous Thromboembolism Prophylaxis (VTE) (SUB) on a separate form*** chlorhexidine (Chlorhexidine 0.12% Vent Oral Care Kit) 1 dose PO mouthwash BID Comments: For oral cleaning if patient is intubated. Page 1 of 6
2 pantoprazole (Protonix) 40 mg inj IV PUSH DAILY lansoprazole (Prevacid Solu Tab) 30 mg tab soluble OG TUBE DAILY propofol (Diprivan 1000mg/100 ml premix bottle) 100 ml IV bottle Rate: 10 mcg/kg/min Comments: Begin infusion at 10 mcg/kg/min and then titrate by 10 mcg/kg/min every 5 min until RASS-2 is achieved; MAX rate 80 mcg/kg/min; Assess sedation level Q4H and 30 minutes after each dose changeif RASS -1 to +4 increase propofol by 10 mcg/kg/min every 10 min until RASS- 2 is achieved;if RASS -3 to -5 decrease propofol by 10 mcg/kg/min every 10 min until RASS-2 is achieved;procedure for daily awakening or weaning: reduce propofol rate by 50%; if after 30 min the patient is not over agitated reduce by 50% again; if patient becomes overly agitated resume infusion and titrate rate to desired RASSReassess every 48 hours for continued use;consider pain medication for increased agitation and to optimize sedation lorazepam (Ativan 100 mg/d5w 100 ml IV drip) IV bag 2 mg/hour Comments: Start at 2 mg/hr and titrate in increments of 2 mg every 10 minutes to RASS-2 up to maximum of 8 mg/hr. Assess sedation level Q4H and 30 minutes after each dose change Fentanyl 2,500 mcg / 250 ml IV Set (IVS)* Sodium Chloride 0.9% IV bag Rate: 25 mcg/hour Comments: Begin infusion at 25 mcg/hr and then titrate by 25 mcg/hr every hour until RASS-2 is achieved; MAX rate 250 mcg/hr;assess sedation level Q4H and 30 minutes after each dose changebolus Rates: 12.5 mcg every 5 min for pain score 2 to 3 (mild); 25 mcg every 5 min for pain score 4 to 6 (moderate); 50 mcg every 5 min for pain score 7 to 8 (severe); give boluses over 2 minprocedure for daily awakening or weaning: reduce fentanyl rate by 50%; if after 30 min the patient is not over agitated reduce by 50% again; if patient becomes overly agitated administer 50 mcg bolus over 2 min and titrate rate up to desired RASS. fentanyl IV drip 2,500 mcg midazolam (Versed 100 mg/ns 100 ml IV drip) 100 ml IV bag Rate: 2 mg/hour Comments: Begin infusion at 2 mg/hr and titrate by 2 mg/hr every 10 min to achieve RASS of -2; MAX infusion rate 8 mg/hr; Assess sedation level Q4H and 30 minutes after each dose changeif RASS -1 to +4 increase by 2 mg/hr every 10 min until RASS-2 is achieved; bolus for breakthrough agitation 2 mg every 10 min; If RASS -3 to -5 hold infusion until RASS-2 is achieved and restart at 50% of the previous rate;procedure for daily awakening or weaning: reduce rate by 50%; if after 30 min the patient is not over agitated reduce by 50% again; if patient becomes overly agitated administer 2 mg bolus and titrate rate up to desired RASS;Consider pain medication for increased agitation and to optimize sedation dexmedetomidine (Precedex 200 mcg / 50 ml premix) IV premix Rate: 0.2 mcg/kg/hr Comments: Begin infusion at 0.2 mcg/kg/hr and titrate by 0.1 mcg/kg/hr every 30 min until RASS- 2 is achieved; MAX rate 1.2 mcg/kg/hr;assess sedation level Q4H and 30 minutes after each dose changeprocedure for daily awakening or weaning: reduce Predex rate by 50%; if after 30 Page 2 of 6
3 min the patient is not over agitated reduce by 50% again;avoid Precedex bolusesprecedex is intended as an adjunctive treatment with a benzo, do not infuse by itself;consider pain medication for increased agitation and to optimize sedation; morphine 2 mg inj IV PUSH Q2H, PRN Pain Moderate Comments: Titrate to RASS-2. Assess sedation level Q4H and 30 minutes after each dose lorazepam (Ativan) 1 mg inj IV PUSH Q4H, PRN Agitation Comments: Titrate to RASS-2. Assess sedation level Q4H and 30 minutes after each dose midazolam (Versed) 2 mg inj IV PUSH Q2H, PRN Agitation Comments: Titrate to RASS-2. Assess sedation level Q4H and 30 minutes after each dose NEURO Neuromuscular Blockade(SUB)* ***Reminder: Order NEURO Neuromuscular Blockade (SUB) on a separate form.*** Radiology XR Chest *1 view AP Portable failure, Routine, Pending Discharge - No, DAILY, Daily while intubated for respiratory failure Mode; AC, Rate; 10, Fi02; 1, PEEP; 5, Tidal Volume: 8 ml/kg of ideal body wt (DEF)* Mode; PRVC, Rate; 10, Fi02; 1, PEEP; 5, Tidal Volume: 8 ml/kg of ideal body wt Routine, Daily while intubated Consults Nutrition Consult TPN (DEF)* Tube Feeding Weaning & Extubation Phase ASDIR, Q5MINS x 4, then Q15MINS x 2, then Q30MINS x 2. See Order Comments for additional instructions Comments: During weaning process: monitor and document HR, rhythm, BP, respiratory rate, level of consciousness, tidal volume, oxygen saturation, and signs of intolerance (see Ventilator Weaning Intolerance Criteria-Reference Text order) If patient meets pre wean criteria (Wean Assessment Score greater than 17 and RASS-2) coordinate for mechanical vent weaning with RT. Confirm cuff leak test greater than 110 ml (pre-deflation VTe - postdeflation VTe) prior to extubation Ventilator Weaning Intolerance Criteria-Reference Text Notify Provider Routine, Must call physician prior to ventilator extubation Hold IV sedation except Precedex (unavailable at Baptist Beaches and Baptist Nassau) (DEF)* Page 3 of 6
4 For Baptist Beaches and Nassau, see Order Comments Comments: Reduce Propofol rate by 50%; if after 30 min the patient is not over agitated reduce by 50% again; if patient becomes overly agitated resume infusion and titrate rate up to desired RASS; When desired RASS achieved, check NIF, and respiratory rate. Once NIF greater than 20, FVC greater than 8 ml/kg and respiratory rate less than 30, place patient on : Pressure Support 0 cm, CPAP 5 cm, and FIO2 50% for a 30 minute breathing trial Extubate Patient Extubate to venti mask at current FIO2 if patient meets pre wean criteria Extubate Patient Extubate to Bipap 12/5 setting if patient meets pre wean criteria Extubate Patient Extubate to room air if patient meets pre wean criteria Routine, May increase FiO2 to maintain O2 sat greater than 92% but not to exceed FiO2 of 50%. If ph less than 7.35 and/or PO2 less than 60, resume previous ventilator settings for next 24 hours Routine, Obtain ABG 30 minutes post mechanical ventilator wean or sooner if patient exhibits signs of intolerance. Call results to physician (DEF)* Results of ABG study obtained post mechanical ventilator wean or sooner if patient exhibits intolerance Trache Weaning Phase ASDIR, Q5MINS x 4, then Q15MINS x 2, then Q30MINS x 2. See Order Comments for additional instructions Comments: During weaning process: monitor and document HR, rhythm, BP, respiratory rate, level of consciousness, tidal volume, oxygen saturation, and signs of intolerance (see Ventilator Weaning Intolerance Criteria-Reference Text order) Hold IV sedation except Precedex during ventilator weaning (unavailable at Baptist Beaches and Baptist Nassau) (DEF)* For Baptist Beaches and Nassau, see Order Comments. Comments: Reduce Propofol rate by 50%; if after 30 min the patient is not over agitated reduce by 50% again; if patient becomes overly agitated resume infusion and titrate rate up to desired RASS; When desired RASS achieved, check NIF, and respiratory rate. Once NIF greater than 20, FVC greater than 8 ml/kg and respiratory rate less than 30, place patient on : Pressure Support 0 cm, CPAP 5 cm, and FIO2 50% for a 30 minute breathing trial Ventilator Weaning Intolerance Criteria-Reference Text Notify Physician If weaning intolerance and patient placed back on ventilator at PRE Weaning settings Notify Physician If weaning intolerance and patient placed back on ventilator at PRE Weaning settings or if ph is LESS than 7.34 or PaO2 of LESS than 60mmHg. Radiology Page 4 of 6
5 XR Chest *1 view AP Portable Early AM, Pending Discharge - No, STAT in AM for post discontinuation of mechanical ventilator see order comment Comments: Therapy to conduct T-piece trial at current Fi02. If tolerated, ABG in 30mins and call results to physician. For any respiratory signs of weaning intolerance (see criteria) place patient back on ventilator at PRE WEANING settings and call physician. see order comment Comments: Therapy to place patient on VOLUME TARGETED Pressure Support with target goal of 240 ml Vte. Call physician if Vte is LESS than 280ml. Place back on PRE WEANING ventilator settings for signs of ventilator weaning intolerance (see criteria). ABG after 30mins of volume targeted pressure support and call physician with results if ph is LESS than 7.34 or PaO2 of LESS than 60mmHg Once patient meets extubation criteria and physician approval obtained, discontinue Mechanical Ventilator and place on trach collar to equal O2 used during Mechanical Ventilator use. No neck rotation or movement x 4 hours O2 Therapy. 92, Titrate to O2 sat of 92% with heated humidification (post mechanical ventilator extubation) (DEF)* 92, Titrate to O2 sat of 92% with cooled humidification (post mechanical ventilator extubation) Routine, Obtain ABG 30 minutes post discontinuation of mechanical ventilator or sooner if patient exhibits signs of intolerance. Call results to physician +120 Hours Remove sutures 5 days post tracheostomy Post-Extubation Phase ASDIR, Q5MINS x 4, then Q15MINS x 2, then Q30MINS x 2, then Q1H. See Order Comments for additional instructions Comments: Post Extubation: monitor and document HR, rhythm, BP, respiratory rate, level of consciousness, tidal volume, oxygen saturation, and signs of intolerance (see Ventilator Weaning Intolerance Criteria-Reference Text order), and stridor. Diet NPO NPO times 4 hours then clear liquids and advance as tolerated post mechanical ventilator extubation Notify Physician If patient exhibits signs/symptoms of aspiration while eating/drinking, make NPO and notify physician Page 5 of 6
6 Notify Provider ABG Results Special Instructions: Call physician for PaO2 LESS than 60 mmhg; ph LESS than 7.34 albuterol (Proventil Neb 0.083%) 2.5 mg neb inh NEB Q4H RT, Duration: 72 hour albuterol-ipratropium (DuoNeb) 3 ml NEB neb inh Q4H RT, Duration: 72 hour (DEF)* 3 ml INHALE neb inh Q4H RT, Duration: 72 hour Incentive Spirometry Routine, Q1H while awake. Therapy to initiate and perform patient education first Routine, 30 minutes post mechanical ventilator extubation or sooner if stridor or patient exhibits signs of intolerance. Call physician for PaO2 LESS than 60 mmhg; ph LESS than 7.34 O2 Therapy. Venti Mask, Equal to current FiO2 (DEF)* Nasal Cannula, Titrate FiO2 to maintain oxygen saturation greater than or equal to 92% Oxygen Mask, Titrate FiO2 to maintain oxygen saturation greater than or equal to 92% BIPAP Consults Consult Speech Therapy for post mechanical ventilator extubation swallow evaluation SUB Rapid Sequence Induction(SUB)* Non Categorized ***(NOTE)*** Adjust doses to reflect actual amount given midazolam (Versed) 1 mg inj IV PUSH ONCE Comments: From RSI kit; usual recommended dose 0.03 mg/kg succinylcholine (Anectine) 200 mg inj IV PUSH ONCE Comments: From RSI kit; usual recommended dose 0.6 mg/kg rocuronium (Zemuron) 10 mg inj IV PUSH ONCE Comments: From RSI kit; usual recommended dose 1 mg/kg etomidate (Amidate) 20 mg inj IV PUSH ONCE Comments: From RSI kit; usual recommended dose 0.3 mg/kg Page 6 of 6
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 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
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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
PICU BRONCHIOLITIS PLAN
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PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
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
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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
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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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***
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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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[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
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
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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
Physician Orders ADULT: Kidney-Panc/PancTransplant Post Op Plan
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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
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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,
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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
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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
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