PEDIATRIC LIFEGIFT BRAIN DEATH PLAN
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- Randolf Gibson
- 5 years ago
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1 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 procedure) Before this Code Status order can be placed, any previous code status order must be cancelled. Code Status Code Status: Full Code Patient Care Vital Signs Core Body Temperature Monitoring Maintain body temp degrees Farenheit. Utilize Hyper/Hypothermia blanket prn Set Up for Arterial Line Placement Arterial Pressure Monitoring Set Up for Central Line Placement Central Venous Pressure Monitoring Strict Intake and Output Insert Gastric Tube Nasogastric - NG Orogastric - OG Sump Other Gastric Tube to Suction Method: Low Intermittent Suction Insert Urinary Catheter Foley, To: Dependent Drainage Bag Urinary Catheter Care Foley to dependent drainage bag. Daily Foley care. Record Urinary Catheter Output Communication Page 1 of 8
2 PHYSICIAN S Notify Provider of VS Parameters SBP Greater Than 90, SBP Less Than 60, Newborn SBP Greater Than 100, SBP Less Than 74, Infant SBP Greater Than 112, SBP Less Than 80, Toddler SBP Greater Than 120, SBP Less Than 104, School Age SBP Greater Than 140, SBP Less Than 94, Adolescent Notify Nurse (DO NOT USE FOR MEDS) Urinalysis to be ED, collected, and sent to lab q12h Notify Nurse (DO NOT USE FOR MEDS) Prior to initiating the vasopressin and insulin drips, approval must be given by the LifeGift Coordinator. IV Solutions D5W D5 1/2 NS D5 1/2 NS + 20 meq KCl/L LR NS Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. albuterol (albuterol 2.5 mg/3 ml (0.083%) inhalation solution) 2.5 mg, inhalation, soln, q4h Continuous Infusion DOPamine 160 mg/50 ml D5W (NI/PI) IVsyr, Titrate Final concentration= 3.2 mg/ml (3200 mcg/ml). Mixed in syringe. Usual Dose Range is 2-20 mcg/kg/min. Notify LifeGift coordinator if administered dose (rate) is greater than the usual dose range. Continued on next page... Page 2 of 8
3 PHYSICIAN S Start at rate: mcg/kg/min norepinephrine 1.6 mg/50 ml NS (Pedi) IVsyr, Titrate Final concentration = mg/ml (32 mcg/ml). Usual Dose Range is mcg/kg/min. administered dose (rate) is greater than the usual dose range. Start at rate: mcg/kg/min Notify LifeGift coordinator if phenylephrine 10 mg/250 ml NS IV, Titrate Final concentration = 0.04 mg/ml (40 mcg/ml). Usual Dose Range is mcg/kg/min. Notify LifeGift coordinator if administered dose (rate) is greater than the usual dose range. Start at rate: mcg/kg/min Antimicrobials piperacillin-tazobactam (piperacillin-tazobactam pediatric) 90 mg/kg, IVsyr, syringe, q8h, [80 mg piperacillin per kg] Diluent NS. Give over 30 min. Dose + 3 ml overfill mg/kg, IVsyr, syringe, q8h, [100 mg piperacillin per kg] Diluent NS. Give over 30 min. Dose + 3 ml overfill. vancomycin (vancomycin pediatric) 15 mg/kg, IVsyr, syringe, q6h, Infuse over 90 min, [60 mg/kg/day], Pharmacy to dose meropenem (meropenem pediatric) 20 mg/kg, IVsyr, syringe, q8h Diluent NS. Infuse over 30 min. Dose + 3 ml overfill. levofloxacin 10 mg/kg, IVPB, ivpb, q12h, Infuse over 60 min, Age less than or equal to 5 years 10 mg/kg, IVPB, ivpb, q24h, Infuse over 60 min, Age greater than 5 years fluconazole (fluconazole pediatric) 3 mg/kg, IVsyr, syringe, q24h, Infuse over 2 hr Infuse over 1-2 hr. Dose + 3 ml overfill. 6 mg/kg, IVsyr, syringe, q24h, Infuse over 2 hr Infuse over 1-2 hr. Dose + 3 ml overfill. micafungin (micafungin pediatric) 1.5 mg/kg, IVPB, ivpb, q24h 3 mg/kg, IVPB, ivpb, q24h Hormonal Therapy Protocol - Initiation potassium chloride 0.5 meq/kg, IVPB, ivpb, ONE TIME, Infuse over 1 hr, Not to exceed 40 meq/dose Mix in 250 ml. Give ONLY if most recent potassium level is below 4. Infuse over 1 hour. Administer Hormonal Therapy Protocol in the following order: 1)-KCl replacement (if ordered). Allow to infuse completely. 2)-hydrocortisone IVPush initial dose 3)- levothyroxine bolus 4)-levothyroxine continuous infusion 5)-insulin infusion Continued on next page... Page 3 of 8
4 PHYSICIAN S 1 meq/kg, IVPB, ivpb, ONE TIME, Infuse over 1 hr, Not to exceed 40 meq/dose Mix in 250 ml. Give ONLY if most recent potassium level is below 4. Infuse over 1 hour. Administer Hormonal Therapy Protocol in the following order: 1)-KCl replacement (if ordered). Allow to infuse completely. 2)-hydrocortisone IVPush initial dose 3)- levothyroxine bolus 4)-levothyroxine continuous infusion 5)-insulin infusion ***Select both a ONE TIME and a SCHEDULED hydrocortisone order below*** hydrocortisone (hydrocortisone pediatric) 1 mg/kg, IVsyr, syringe, ONE TIME, Infuse over 1 min Do not refrigerate. Dose + 3 ml overfill. Administer Hormonal Therapy Protocol in the following order: 1)-KCl replacement (if ordered). Allow to infuse completely. 2)-hydrocortisone IVPush initial dose 3)- levothyroxine bolus 4)-levothyroxine continuous infusion 5)-insulin infusion 2 mg/kg, IVsyr, syringe, ONE TIME, Infuse over 1 min Do not refrigerate. Dose + 3 ml overfill. Administer Hormonal Therapy Protocol in the following order: 1)-KCl replacement (if ordered). Allow to infuse completely. 2)-hydrocortisone IVPush initial dose 3)- levothyroxine bolus 4)-levothyroxine continuous infusion 5)-insulin infusion hydrocortisone (hydrocortisone pediatric) 1 mg/kg, IVsyr, syringe, q12h, Infuse over 1 min Do not refrigerate. Dose + 3 ml overfill. Start 12 hours after the initial hydrocortisone bolus. 2 mg/kg, IVsyr, syringe, q12h, Infuse over 1 min Do not refrigerate. Dose + 3 ml overfill. Start 12 hours after the initial hydrocortisone bolus. levothyroxine (levothyroxine pediatric) 5 mcg/kg, IVPush, inj, ONE TIME, Age less than 6 months Levothyroxine dose for infants less than 6 months = 5 mcg/kg bolus, followed by 1.4 mcg/kg/hr infusion. Administer Hormonal Therapy Protocol in the following order: 1)-KCl replacement (if ordered). Allow to infuse completely. 2)-hydrocortisone IVPush initial dose 3)- levothyroxine bolus 4)-levothyroxine continuous infusion 5)-insulin infusion 4 mcg/kg, IVPush, inj, ONE TIME, Age 6-12 months Levothyroxine dose for infants 6-12 months = 4 mcg/kg bolus, followed by 1.3 mcg/kg/hr infusion. Administer Hormonal Therapy Protocol in the following order: 1)-KCl replacement (if ordered). Allow to infuse completely. 2)-hydrocortisone IVPush initial dose 3)- levothyroxine bolus 4)-levothyroxine continuous infusion 5)-insulin infusion 3 mcg/kg, IVPush, inj, ONE TIME, Age 1-5 years Levothyroxine dose for children 1-5 years = 3 mcg/kg bolus, followed by 1.2 mcg/kg/hr infusion. Administer Hormonal Therapy Protocol in the following order: 1)-KCl replacement (if ordered). Allow to infuse completely. 2)-hydrocortisone IVPush initial dose 3)- levothyroxine bolus 4)-levothyroxine continuous infusion 5)-insulin infusion 2.5 mcg/kg, IVPush, inj, ONE TIME, Age 6-12 years Levothyroxine dose for children 6-12 years = 2.5 mcg/kg bolus, followed by 1 mcg/kg/hr infusion. Administer Hormonal Therapy Protocol in the following order: 1)-KCl replacement (if ordered). Allow to infuse completely. 2)-hydrocortisone IVPush initial dose 3)- levothyroxine bolus 4)-levothyroxine continuous infusion 5)-insulin infusion Continued on next page... Page 4 of 8
5 PHYSICIAN S 1.5 mcg/kg, IVPush, inj, ONE TIME, Age years Levothyroxine dose for age years = 1.5 mcg/kg bolus, followed by 0.8 mcg/kg/hr infusion. Administer Hormonal Therapy Protocol in the following order: 1)-KCl replacement (if ordered). Allow to infuse completely. 2)-hydrocortisone IVPush initial dose 3)- levothyroxine bolus 4)-levothyroxine continuous infusion 5)-insulin infusion 0.8 mcg/kg, IVPush, inj, ONE TIME, Age greater than 16 years Levothyroxine dose for age greater than 16 years = 0.8 mcg/kg bolus, followed by 0.8 mcg/kg/hr infusion. Administer Hormonal Therapy Protocol in the following order: 1)-KCl replacement (if ordered). Allow to infuse completely. 2)-hydrocortisone IVPush initial dose 3)- levothyroxine bolus 4)-levothyroxine continuous infusion 5)-insulin infusion Hormonal Therapy Protocol-Levothyroxine levothyroxine 200 mcg/500 ml 1/2 NS IV, Do NOT Titrate Infants less than 6 months: 1.4 mcg/kg/hour Infants 6-12 months: 1.3 mcg/kg/hour Children 1-5 years: 1.2 mcg/kg/hour Children 6-12 years: 1 mcg/kg/hour Children greater than 12 years: 0.8 mcg/kg/hour Administer Hormonal Therapy Protocol in the following order: 1)-KCl replacement (if ordered). Allow to infuse completely. 2)-hydrocortisone IVPush initial dose 3)- levothyroxine bolus 4)-levothyroxine continuous infusion 5)-insulin infusion Start at rate: mcg/hr Hormonal Therapy Protocol - Vasopressin vasopressin 100 units/250 ml NS IV Final concentration= 0.4 unit/ml (400 milliunits/ml). Initiate at 0.5 milliunits/kg/hour. Start at rate: units/kg/hr Hormonal Therapy Protocol - Insulin.Medication Management Start date T;N Discontinue all insulin containing products and oral hypoglycemic agents prior to initiating insulin infusion Hemoglobin A1C, Comment: Draw before starting Continuous Insulin Infusion POC Blood Sugar Check 4 times, then q2h. Start when continuous insulin infusion is initiated. insulin R 100 units/100 ml NS IV, see order comments for initiation and titration Initiate at 0.05 unit/kg/hr. Titrate by 0.01 unit/kg/hr to maintain blood glucose levels between Start at rate: units/kg/hr Laboratory BB Blood Type (ABO/Rh), Comment: LifeGift blood typing BB Antibody Screen Page 5 of 8
6 PHYSICIAN S BB Clot to Hold BB Platelet Order Quantity: 2 BB Plasma Order Quantity: 2 Comprehensive Metabolic Panel Comprehensive Metabolic Panel CBC with Differential CBC with Differential DIC Panel DIC Panel CK CK CKMB CKMB Troponin T Troponin T Magnesium Level Magnesium Level Phosphorus Level Phosphorus Level Bilirubin Direct Page 6 of 8
7 PHYSICIAN S Bilirubin Direct LDH LDH GGT GGT Amylase Level Amylase Level Lipase Level Lipase Level Urinalysis Urine,, Comment: urinalysis must be ordered every 12 hours. Culture Urine Culture Blood Blood,, Comment: Draw 2 bottles, each one from a seperate site. Culture Sputum with Gram Stain, Comment: If unable to obtain, notify LifeGift Coordinator Diagnostic Tests DX Chest Portable STAT EKG-12 Lead STAT, with STAT read Echo Transthoracic (TTE) with contrast i (Echo Transthoracic (TTE) with contrast if needed) STAT Respiratory Suction Patient PRN Notify RT Oxygen Challenge: Increase FiO2 to 100%, PEEP to 5. Wait 30 min, draw ABG. Then decrease FiO2 to 40%. Wait 30 min, draw ABG. Page 7 of 8
8 PHYSICIAN S ***Ventilator Settings Must Be Entered Below*** Ventilator Settings Arterial Blood Gas STAT Arterial Blood Gas Routine, q4h Notify RT Arterial Blood Gas 30 minutes after any ventilator change. Page 8 of 8
LIFEGIFT BRAIN DEATH PLAN
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 procedure)
DONATION AFTER CARDIAC DEATH PLAN
DONATION AFTER CARDIAC DEATH PLAN Diagnosis Weight Allergies Patient Care Core Body Temperature Monitoring Maintain body temp 96-99 degrees Farenheit. Utilize Hyper/Hypothermia blanket prn Insert Gastric
PICU Therapeutic Hypothermia Post Cardiac Arrest Re Warming Phase
Arrest Re Warming Phase Weight Allergies Patient Care ***After 24 hours initiate re warming (or after 72 hours for an infant less than one month old)*** PICU Re Warming Protocol ***See Reference Text***
PICU ADMIT DKA PLAN - Phase: Begin Immediately
- Phase: Begin Immediately Diagnosis Weight Allergies Admit/Discharge/Transfer Patient Status Requested Location: PICU, Pt Status: Inpatient (LOS > 2 midnights) Requested Location: PICU, Pt Status: Observation
PICU BRONCHIOLITIS PLAN
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
UMC Health System Patient Label Here. PHYSICIAN ORDERS Diagnosis
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
PHYSICIAN ORDERS Diagnosis
PICU PROCEDURE PLAN PHYSICIAN S Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Patient Care
UMC Health System Patient Label Here. PHYSICIAN ORDERS Diagnosis
PICU GENERAL PLAN UMC Health System PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Daily Weight Patient Activity Bedrest Up Ad Lib/Activity as Tolerated Strict Intake
PEDIATRIC CYSTIC FIBROSIS PLAN - Phase:.
PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Per Unit Standards, with Sleeping SpO2 nightly until sat greater than 92% Daily Weight Every AM In AM on Monday, Wednesday,
Therapeutic Hypothermia for Post Cardiac Arrest Plan Initial Orders
Arrest Plan Initial Orders Weight Allergies Therapeutic Hypothermia Guidelines ***Required to continue with ordering Plan.*** Strict Intake and Output q1h, throughout cooling and re warming. Set Up for
Organ Donor Management Recommended Guidelines ADULT Brain Death (NDD)
Date: Time: = Always applicable = Check if applicable ADMISSION INSTRUCTIONS Neurological Determination of Death (NDD) has been performed by at least 2 licensed physicians Contact initiated with BC Transplant
(31189) Hypothermia Initiation Phase One
Hypothermia Initiation Phase One Diagnosis Allergies For hypothermia tracking purposes only. Please do not uncheck.- Required Cardiac Emergency Tracking For hypothermia tracking purposes only. Consults
Organ Donor Management Recommended Guidelines ADULT CARDIAC DEATH (DCD)
Date: Time: = Always applicable = Check if applicable ADMISSION INSTRUCTIONS Move to Comfort Care Note in chart. Contact initiated with BC Transplant Consent for Organ Donation obtained Code Status: Full
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
Diagnosis: Allergies:
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
Pediatric Outpatient Surgery Plan - Diagnostic/Pre-Op Orders
Pediatric Outpatient Surgery Plan - Diagnostic/Pre-Op Orders Diagnosis Weight PHYSICIAN S Allergies Admit/Discharge/Transfer Request for Outpatient Services Location: Outpatient Surgery Communication Misc
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
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 ADULT: Kidney-Panc/PancTransplant Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase T;N, Phase: Kidney-Panc/Panc Transp Post Op Phase, When to Initiate: Kidney-Panc/Panc Transp Post Op Phase Vital Signs Vital
Physician Orders PEDIATRIC: : LEB ED Trauma (Major) Plan
LEB ED Standing Orders Trauma (Major) Ph Non Categorized Criteria: Patients between 0-18 years of age that present with a Major Trauma that meet LeBonheur Trauma stat or Trauma Alert Guidelines.(NOTE)*
TRANSCATHETER AORTIC VALVE REPLACEMENT POST- OP ADMIT PLAN - Phase: Begin Immediately/PACU Phase
- Phase: Begin Immediately/PACU Phase PHYSICIAN S Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Requested Location: CICU Patient Condition Acuity Level Critical Acuity Level
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
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
Physician Orders ADULT: Routine Deceased Donor Adult Plan
Initiate Orders Phase Non Categorized NOTE: Nurse - confirm PM Discharge disposition set to "Donor and or Life Support" on hospital encounter. Enter these orders on new OP encounter created by Access/Registration
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 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
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
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 Hx of DKA with Hyperglycemia Plan
LEB ED Triage Hx of DKA w Hyperglycemia Non Categorized Criteria for use: Patients less than 18 years of age with known or suspected Diabetes Mellitus and blood glucose greater than 300mg/dL.(NOTE)* Vital
PEDIATRIC SPINE SURGERY POST-OP PLAN - Phase: Pediatric Spine Surgery General Orders
- Phase: Pediatric Spine Surgery General Orders PHYSICIAN S Diagnosis Weight Allergies Patient Care Patient Activity Bedrest Maintain Surgical Drain Maintain JP Drain, Measure Output q12h, and PRN Convert
UMC Health System Patient Label Here. PHYSICIAN ORDERS Diagnosis
GI BLEED PLAN UMC Health System Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Notify Provider of VS Parameters Daily Weight Patient Activity Up Ad Lib/Activity as Tolerated Assist
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
UMC Health System Patient Label Here. PHYSICIAN ORDERS Diagnosis
Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards q12h q12h, Temperature Only - Every Shift and PRN Patient Activity Assist as Needed, Bed Position: As Tolerated, elevate to patient
Physician Orders. LEB NICU Sepsis Plan [X or R] = will be ordered unless marked out.
![Physician Orders. LEB NICU Sepsis Plan [X or R] = will be ordered unless marked out.](/thumbs/77/75931338.jpg "Physician Orders. LEB NICU Sepsis Plan [X or R] = will be ordered unless marked out.")
Height: cm Weight: kg Allergies: [ ] No known allergies [ ] Latex allergy [ ]Other: [ ] Initiate Powerplan Phase, Phase: LEB NICU Sepsis Phase Admission/Transfer/Discharge [ ] Patient Status Initial Inpatient
** Medication exercises ** NICU Phase II
** Medication exercises ** NICU Phase II A) Baby A has had a bowel resection six hours ago. She weighs 3 kg. Post-op, she is quite agitated and she is on a fentanyl drip at 2 micrograms/kg/hr (#1). She
INPATIENT INTERVENTIONAL RADIOLOGY PLAN - Phase: Pre-Procedure Orders
- Phase: Pre-Procedure Orders DETAILS Patient Care Obtain Consent If one is not present on chart today. Vital Signs Per Policy Insert Peripheral Line T;N, Start IV on right side If left radial access is
Physician Orders PEDIATRIC: LEB DKA Diabetes Mellitus Admit Plan
Initiate Orders Phase Non Categorized R Powerplan Open Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: Admit DKA Two-Bag Calculations Phase, When to Initiate: Initiate Powerplan Phase Phase:
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
PEDIATRIC PICU TRAUMA PLAN EKM - Phase: PICU Trauma Plan
- Phase: PICU Trauma Plan Diagnosis Weight Allergies DETAILS Patient Care Vital Signs Per Unit Standards Daily Weight Perform Neurological Checks q15min q30min q1h Special Instructions, with Vital Signs
LOOP procurement coordinators, retrieval physicians, attending physicians
PEDIATRIC MANAGEMENT GUIDELINES CL-135.012 I. POLICY STATEMENT: It is the policy of Lifeline of Ohio Organ Procurement (LOOP) to follow pediatric guidelines for organ procurement. Pediatric donors differ
IDS. Pediatric Donor Management
IDS Guidelines for Clinical Management of Organ Donors: Weight < 40 kg Organ Perfusion & Hormonal Replacement Guidelines: Normal HR, SBP: (see chart below) Urinary output of 1-3 cc/kg/hr CVP 6-10 mmhg
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
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
NEUROSURGERY ICU PLAN
NEUROSURGERY ICU PLAN PHYSICIAN S Diagnosis Weight Allergies DETAILS Patient Care Vital Signs Per Unit Standards Per Unit Standards, including cerebral perfusion pressure (CPP) and end tidal CO2. Perform
PICU TRAUMA PLAN - Phase:.
- Phase:. UMC Health System PHYSICIAN S Diagnosis Weight Allergies DETAILS Patient Care CR Monitoring Vital Signs Per Unit Standards Daily Weight Perform Neurological Checks q15min q30min q1h Special Instructions,
Card Open Heart POD1 POD3 Plan Post Op Day 1
Day 1 PHYSICIAN S Weight Allergies Admit/Discharge/Transfer Transfer Patient Transfer to: Floor, Pt Status: Inpatient (LOS > 2 midnights) Vital Signs q2h, POD 1 Vital Signs q2h for 24 hours then per unit
Physician Orders LEB PICU Status Epilepticus Plan. [ ] No known allergies
![Physician Orders LEB PICU Status Epilepticus Plan. [ ] No known allergies](/thumbs/80/82315048.jpg "Physician Orders LEB PICU Status Epilepticus Plan. [ ] No known allergies")
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
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
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
Bariatric Surgery Post Op Plan PACU Phase
Bariatric Surgery Post Op Plan PACU Phase PHYSICIAN S Weight Allergies Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Code Status
PEDIATRIC ARGININE CLONIDINE STIMULATION TEST PLAN
Diagnosis Weight Allergies Patient Care Arginine Clonidine Stimulation Test Guid (Arginine Clonidine Stimulation Test Guidelines) See Reference Guidelines. Vital Signs Routine, q1h, With BP, During the
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
THROMBOLYTIC THERAPY FOR PERIPHERAL OCCLUSION
THROMBOLYTIC THERAPY FOR PERIPHERAL OCCLUSION PHYSICIAN S Diagnosis Weight Allergies Admit/Discharge/Transfer ***PROVIDER MUST CHECK MEDICATION LIST PRIOR TO PLACING THESE S*** Patient Care Vital Signs
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
UMC Health System Patient Label Here PHYSICIAN ORDERS
Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards q12h q12h, Temperature Only - Every Shift and PRN Patient Activity Assist as Needed, Bed Position: As Tolerated, elevate to patient
Neurosurgery Pre-Op [1710] Patient Name MRN. General. Nursing. Case Request [ ] Case request operating room Scheduling/ADT, Scheduling/ADT [ ] Other
![Neurosurgery Pre-Op [1710] Patient Name MRN. General. Nursing. Case Request [ ] Case request operating room Scheduling/ADT, Scheduling/ADT [ ] Other](/thumbs/96/128298591.jpg "Neurosurgery Pre-Op [1710] Patient Name MRN. General. Nursing. Case Request [ ] Case request operating room Scheduling/ADT, Scheduling/ADT [ ] Other")
Neurosurgery Pre-Op [1710] Patient Name MRN General Case Request [ ] Case request operating room Scheduling/ADT, Scheduling/ADT Inpatient Only Procedure (Single Response) ( ) Admit to Inpatient Diagnosis:
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
BARIATRIC SURGERY POST-OP PLAN - Phase: PACU Phase
- Phase: PACU Phase Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Pt Status: Inpatient (Inpatient
Hypothermia Short Set-Critical Care HYPOTHERMIA SS- CRITICAL CARE
Hypothermia Short Set-Critical Care HYPOTHERMIA SS- CRITICAL CARE Inclusion Criteria all must be present Cardiac arrest with return of spontaneous circulation (ROSC) ROSC within 60 mins of witnessed arrest;
OPEN AAA/MAJOR ABDOMINAL POST-OP PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Maintain Gastric Tube Maintain Nasogastric - NG, Low Intermittent Suction Maintain Nasogastric - NG, Low Constant
Physician Orders ADULT: Asthma and Bronchitis Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase, Phase: Asthma and Bronchitis Phase, When to Initiate: Asthma and Bronchitis Phase Non Categorized Problem: Asthma Problem:
Physician Orders PEDIATRIC: LEB Critical Care Respiratory Plan
LEB Critical Care Respiratory Plan Patient Care Cardiopulmonary Monitor T;N Routine, Monitor Type: End Tidal Co2 (DEF)* T;N Routine, Monitor Type: Transcutaneous Co2 Respiratory Care Initiate Pediatric
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***
CARD THORACOTOMY PRE-OP PLAN
CARD THORACOTOMY PRE-OP PLAN PHYSICIAN S Diagnosis Weight Allergies Patient Care Perform Oral Care Perform night before surgery. Brush teeth with toothpaste, then swish and spit 15 ml chlorhexidine mouth
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
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
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
IDPH ESF-8 Plan: Pediatric and Neonatal Surge Annex Sample Pediatric Admission Orders 2015
Purpose: To provide guidance to practitioners caring for pediatric patients who need inpatient hospital care during a disaster. Disclaimer: This guideline is not meant to be all inclusive, replace an existing
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
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. Title: LEB PICU Asthma Plan [X or R] = will be ordered unless marked out.
![Physician Orders: Pediatric. Title: LEB PICU Asthma Plan [X or R] = will be ordered unless marked out.](/thumbs/71/65974412.jpg "Physician Orders: Pediatric. Title: LEB PICU Asthma Plan [X or R] = will be ordered unless marked out.")
Height: cm Weight: kg Allergies: [ ] No known allergies [ ]Medication allergy(s): [ ] Latex allergy [ ]Other: Uncategorized [X] Initiate Powerplan Phase T;N, Phase: LEB PICU Asthma Phase When to Initiate:
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
Routine, Every 2 hours, Starting today, If temperature greater than 38.5 C initiate Evaluation for Possible Sepsis Physician Order #829
Height Weight Allergies General Vital Signs [X] Frequent vital signs Indication: Q15 minutes x (# of occurrences): 4 Q30 minutes x (# of occurrences): 4 Q1 hour x (# of occurrences): Q2 hours x (# of occurrences):
Pediatric Intensive Care Unit (PICU) Pediatric Diabetic Ketoacidosis (DKA) Admission Order Set
Discontinue all previous orders Weight: kg DKA admit order set is for initial management Ongoing management required based on frequent reassessment of TFI, fluid balance and lab results. Admit to PICU
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
** Medication exercises ** NICU Phase II
** Medication exercises ** NICU Phase II A) Baby A has had a bowel resection six hours ago. She weighs 3 kg. Postop, she is quite agitated and she is on a fentanyl drip at 2 micrograms/kg/hr (#1). She
CARD OPEN HEART PRE-OP PLAN
PHYSICIAN S Diagnosis Weight Allergies Patient Care Perform Oral Care Per Unit Standards, Perform night before surgery. Brush teeth with toothpaste. Peridex mouth wash (15 ml swish and spit). chlorhexidine
IV Acetaminophen Pain Study for Neurosurgery Post Op Non ICU Admit Plan Begin Immediately/PACU
Post Op Non ICU Admit Plan Begin Immediately/PACU PHYSICIAN S Weight Allergies Admit/Discharge/Transfer Request Patient Bed Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights) Patient Condition
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
ENT THYROIDECTOMY/PARATHYROIDECTOMY POST OP ADMIT PLAN - Phase: Begin Immediately/PACU
- Phase: Begin Immediately/PACU Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Pt Status:
Vitals/Hemodynamic Stability
UNYTS Pediatric Donor Management Guidelines Obtain an accurate weight on the pediatric donor. Most everything you order will be based on the child s weight Vitals/Hemodynamic Stability Vital Signs - Acceptable
GENERAL SURGERY PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Daily Weight Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest Bedrest Bathroom Privileges
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.
ENT THYROIDECTOMY/PARATHYROIDECTOMY POST OP PLAN - Phase: Begin Immediately/PACU
- Phase: Begin Immediately/PACU PHYSICIAN S Diagnosis Weight Allergies Laboratory Calcium Level STAT Outpatient/PACU, T;N PTH Intact STAT Outpatient/PACU, T;N 1 of 7 - Phase: When Patient Arrives to Room
Sample. Affix patient label within this box.
Instructions for completing orders Complete pages 1-3 for General Inpatient Orders. All pathway compatible orders (indicated by ) within the General Inpatient Orders will be followed automatically. Optional
Q1HR (DEF)* Q2HR Intra-Abdominal Pressure Notify Provider if greater than 15mmHg, Q4HR Activity Activity Bedrest, Constant Indicator (DEF)* Bedrest
Unique Plan Description: ICU General Admission Adult Plan Selection Display: ICU General Admission Adult PlanType: Medical Version: 28 Begin Effective Date: 4/13/2015 03:46 End Effective Date: Current
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,
SEPSIS PLAN - Phase:.
- Phase:. UMC Health System PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Patient Activity Bedrest Bedrest Bathroom Privileges Bedrest Up to Bedside Commode Only Up
PHYSICIAN ORDERS Diagnosis
GENERAL UROLOGY PLAN PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Strict Intake and Output Per Unit Standards q4h q12h Patient Activity Assist as Needed Up in Chair,
Gabapentin Research Pain Study for Ortho Total Knee Replacement Post-Op Plan - PACU Ortho Phase
Total Knee Replacement Post-Op Plan - PACU Ortho Phase Diagnosis Weight Allergies Admit/Discharge/Transfer Patient Status Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights) Patient Condition
GENERAL MEDICINE PLAN
GENERAL MEDICINE PLAN PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Daily Weight Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest Bedrest Bathroom
PHYSICIAN SIGNATURE DATE TIME
DRUG AND TREATMENT Condition/Status Patient Status (WCH) Patient Status: Inpatient Update Resident Team C (DEF)* A B X Vital Signs Vital Signs Q4H, Do not wake for vitals 2300-0700 (DEF)* DAILY Q4H Blood
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
Patient: Becky Smith DOB: 01/26/XXXX Age: 5 y/o Attending: Dr. D. Miles Allergies: NKA MR#: 203. Patient Chart #203 Becky Smith
Patient Chart #203 Becky Smith 1 Property of CSCLV CSCLV Rev: 06/04/2018 Chief Complaint: Abdominal pain. Informant: Parents. HISTORY & PHYSICAL HPI: Ill looking patient, healthy until 2 days ago when
DOWNTIME Physician Order CARD CHF Heart Failure
DOWNTIME Physician Clinical Category ADT/Comm unication Patient Status ASC Extended Recovery Observation Services Inpatient Admission CCU Admit as Inpatient History and Physical by House Physician Vital
OB/GYN ANTEPARTUM PLAN
OB/GYN ANTEPARTUM PLAN PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Patient Activity Up Ad Lib/Activity as Tolerated Bedrest STRICT Bedrest Up to Bedside Commode Only
RITUXIMAB RHEUMATOLOGY VASCULITIS
. PHYSICIAN (Patient Sticker) ORDER SET : CDH 208-237 Approved - Page 1 of 5 Patient: DOB: Gender: Patient Phone #: Height: Weight: Diagnosis: ICD-10 Code: Treatment Start Date: Provider Facility Name:
Hypothermia in Neonates with HIE TARA JENDZIO, DNP(C), RN, RNC-NIC
Hypothermia in Neonates with HIE TARA JENDZIO, DNP(C), RN, RNC-NIC Objectives 1. Define Hypoxic-Ischemic Encephalopathy (HIE) 2. Identify the criteria used to determine if an infant qualifies for therapeutic
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
UMC Health System Patient Label Here. PHYSICIAN ORDERS Diagnosis
COPD PLAN UMC Health System PHYSICIAN S Diagnosis Weight Allergies DETAILS Patient Care Vital Signs Per Unit Standards Daily Weight Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest