Crit Vent Bundle for Mechanical Ventilation (337) [337] Physician - Also, enter Critical Care Admission Orders
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1 Crit Vent Bundle for Mechanical Ventilation (337) [337] Physician - Also, enter Critical Care Admission Orders Initial Vent Settings (Single Response) [6360] If no previous orders and no choice made by physician, then A/C Rate 12 will be followed. IBW (Ideal Body Weight) calculation: If patient 5 feet or taller, use IBW calculation below. Pharmacy to assist if necessary. Male 50 kg +2.3 kg (ht in inches - 60) Female 45.5 kg kg + (ht in inches - 60) Initial vent settings: A/C. [RSP ] Initial vent settings: SIMV. [RSP ] Mode: CMV (AC) Set Respiratory Rate: 12 Pressure Support _ cm H2O: 0 PEEP (cmh2o): 8 FiO2: 100 Adjust to keep sats greater than or equal to: 92 Tidal Volume (consider): 6-8 ml per kg of IBW Tube Compensation: OFF CPAP _ cm H2O: CONTINUOUS, Starting today For 1 Occurrences, Qty-1 STAT, Normal Mode: SIMV Set Respiratory Rate: 12 Pressure Support _ cm H2O: 8 PEEP (cmh2o): 8 FiO2: 1 Adjust to keep sats greater than or equal to: 92 Tidal Volume (consider): 6-8 ml per kg of IBW Tube Compensation: ON CPAP _ cm H2O: CONTINUOUS, Starting today For 1 Occurrences, Qty-1 Consult [6361] Physical Therapy Consult [PT ] Please do not evaluate and treat patient unless intubated for greater than 24 hours. If intubated less than 24 hours discontinue consult order., What type of evaluation should be performed? EVAL + TREAT What is the reason for treatment/test? Critical Care Vent Bundle What, if any, range of motion restrictions does the patient have? FYI, Starting today For 1 Page 1 of 5
2 Patient Care [6362] Intubate patient [NUR35N10084] NG/OG tube placement for gastric decompression [NUR35N10824] Remove OG tube with extubation. Check with provider if NG. [NUR35N10826] Place order for portable chest xray immediately post-intubation. [NUR35N10176] ABG's minutes after initiation of mechanical ventilation. [RSP ] Elevate HOB degrees unless contraindicated. [NUR35N10368] Respiratory Therapist to assess patient's ventilatory status and make ventilator changes based on Respiratory Care Ventilator Policy in consultation with nursing. [NUR35N10074] Assess patient's ability to follow commands (daily wake-up) at least twice daily unless otherwise directed by physician. [NUR35N10139] RN/RT to collaboratively conduct spontaneous breathing trial (SBT). [NUR35N10139] Additional tests: ONCE, Starting today For 1 Degrees: FYI, Starting today For 1, Qty-1 Page 2 of 5
3 Assess for spontaneous breathing trial (SBT) twice daily. [NUR35N11494] Conduct SBT when criteria met. [NUR35N10639] Provide patient and family with Mechanical Ventilation educational handout. [NUR35N10036] SBT Criteria: -Respiratory rate less than 30 -Heart rate greater than 50, less than 120 -Normothermic greater than 97, less than BP systolic greater than 90 -SPO2 greater than or equal to 90 -ETCO2 stable trend -FiO2 less than or equal to.50 -Peep less than or equal to 5 cm H2O -Not on multiple vasopressors -Norepinephrine less than or equal to 7 mcg/min -Condition necessitating mechanical ventilation has improved. -Alert to voice -Minimal secretions -No significant pulmonary disease -Cough, gag reflex -No continuous IV drip for sedation except Precedex -If applicable, Glasgow coma score greater than or equal to 9,, FYI, Starting today For 1 Education - Pulmonary disorders, procedures, self-care: FYI, Starting today For 1 Ventilator Weaning [6363] Ventilator Settings when patient ready for SBT: [NUR35N11494] Pressure Support 0-12 cm H2O with apnea ventilation on. Respiratory Therapy to adjust Pressure Support., Tube Compensation: ON Mode: SIMV Set Respiratory Rate: 0 CPAP _ cm H2O: 5 FYI, Starting today For 1 Page 3 of 5
4 SBT Failure Criteria [NUR35N11494] If patient is tolerating SBT after 30 minutes to 1 hour, extubate. [NUR35N11494] ABGs before extubation. Call physician with results. [NUR35N10077] After extubation, begin oxygen and wean FiO2 to maintain SpO2 greater than or equal to 90. [NUR35N10976] SBT Failure Criteria: -HR increases by 20 from baseline -RR greater than 30 -BP Systolic increases by 30 from baseline -ETCO2 changes from trend by greater than 20 -Heart rhythm change -Respiratory distress noted -Change in LOC noted -FiO2 change by.20 from baseline -Pressure support greater than 12 cm H2O If one or more of the SBT failure criteria present; place the patient back on the previous ventilator settings.,, FYI, Starting today For 1 Name of this Protocol (Single Response) [6364] Critical Care Vent Bundle for Mechanical Ventilation (337) [NUR35N10857] Stress Ulcer Prophlaxis Protocol Stress Ulcer Prophlaxis Protocol [4953] If any of the following conditions are present, then begin Famotidine: (1) Coagulopathy: platelet count less than 50,000 cubic mm; INR greater than 1.5; (2) Mechanical ventilation expected or actual greater than 48 hours; (3) Sepsis; (4) Patients with history of UGI ulcer and or bleed within 1 year; (5) Patients with Glasgow Coma Scale less than 10; (6) Brain or spinal cord injury patients; (7) Patients receiving high dose corticosteroids defined as: (a) Hydrocortisone greater than 250 mg per day; (b) Prednisone greater than 60 mg per day; (c) Methylprednisolone greater than 50 mg per day; (8) Patients currently receiving NSAIDS Famotidine PO/IV/NG Panel [133426] famotidine (aka: PEPCID) tablet [10104] famotidine (aka: PEPCID) 20 mg/2 ml iv soln [79217] "Or" Linked Panel 20 mg, oral, BID 20 mg, intravenous, BID If unable to take oral or via feeding tube. Dilute in 5-10 ml NS & administer over at least 2 min Page 4 of 5
5 famotidine (aka: PEPCID) oral suspension [16880] Pantoprazole (Protonix) 40mg IV/PO - if patient is allergic to famotidine or any H2 blocker medication [163789] pantoprazole (aka: PROTONIX) injectable [5924] Pantoprazole (Protonix) 40 mg tabs [12095] Lansoprazole (Prevacid) 30 mg Oral Suspension - if patient is allergic to famotidine or any H2 blocker medication and NG present [414114] No Stress Ulcer Prophylaxis indicated at this time/already receiving adequate medications. [NUR35N11185] VORB/TORB order - Paper order scanned to pharmacy [NUR35N10176] 20 mg, feeding tube, BID For 1 If unable to take oral. Contact pharmacy if needed. "Or" Linked Panel 40 mg, intravenous, DAILY If unable to take oral 40 mg, oral, DAILY 30 mg, g-tube, DAILY Routine, Hospital, FYI, Starting today, Qty-1 Name of this Protocol (Single Response) [4954] Stress Ulcer Prophylaxis Protocol [NUR35N10505], Qty-1 Disclaimer: The policies and procedures posted on CentraNet are for internal use only. They may not be copied by independent companies or organizations that have access to CentraNet, as CentraCare Health System cannot guarantee the relevance of these documents to external entities. Page 5 of 5
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