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 Code Status Code Status: Full Code Code Status: DNR/AND (Allow Natural Death) Code Status: Care Limitation Vital Signs Per Unit Standards Patient Activity Up Ad Lib/Activity as Tolerated Bedrest Insert Peripheral Line Insert Straight Cath For specimen collection. Set Up for Lumbar Puncture Communication Obtain Consent Dietary NPO Diet NPO Oral Diet Regular Diet Clear Liquid Diet, Advance as tolerated to Regular IV Solutions NS (Normal Saline) IV, 20 ml/hr IV, 50 ml/hr IV, 100 ml/hr Laboratory CBC with Differential Comprehensive Metabolic Panel Urinalysis Culture Urine Culture Blood Culture CSF with Gram Stain CSF Cell Count and Differential CSF Glucose Level CSF Protein Order Taken by Signature: Page 1 of 5
PICU PROCEDURE PLAN PHYSICIAN S DETAILS...Additional Orders Order Taken by Signature: Page 2 of 5
PEDIATRIC CENTRAL IV FLUSH PLAN PHYSICIAN S DETAILS Patient Care 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. 3 ml, IVPush, syringe, q12h, PRN flush, after saline flush. ***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. ***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 3 of 5
PICU PROCEDURAL SEDATION MED PLAN PHYSICIAN S DETAILS IV Solutions NS IV, ml/hr Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. midazolam (midazolam pediatric) 0.25 mg/kg, PO, liq, ONE TIME 0.5 mg/kg, PO, liq, ONE TIME 10 mg, PO, liq, ONE TIME 0.05 mg/kg, IVPush, inj, ONE TIME Recommended maximum dose is 10 mg. 0.1 mg/kg, IVPush, inj, ONE TIME Recommended maximum dose is 10 mg. ketamine (ketamine pediatric) PO, inj, ONE TIME Recommended maximum dose is 1 mg/kg. Injectable formulation to be given orally. IVPush, inj, ONE TIME Recommended maximum dose is 1 mg/kg. propofol IVPush, inj, ONE TIME Recommended maximum dose is 3 mg/kg. fentanyl (fentanyl pediatric) 0.5 mcg/kg, IVPush, inj, ONE TIME Recommended maximum dose is 50 mcg. 1 mcg/kg, IVPush, inj, ONE TIME Recommended maximum dose is 50 mcg. Continued on next page... Order Taken by Signature: Page 4 of 5
PICU PROCEDURAL SEDATION MED PLAN PHYSICIAN S DETAILS lidocaine (lidocaine 4% inhalation solution) 2 ml, inhalation, soln, ONE TIME, PRN shortness of breath or wheezing lidocaine (lidocaine 1% preservative-free injectable solution) 0.05 ml/kg, locally, inj, ONE TIME lidocaine topical (lidocaine 2% topical gel with applicator) 1 app, topical, jelly, ONE TIME lidocaine-prilocaine topical (lidocaine-prilocaine 2.5%-2.5% topical cream) 1 app, topical, cream, ONE TIME famotidine 0.5 mg/kg, IVPush, inj, ONE TIME Recommended maximum of 20 mg/dose. 1 mg/kg, IVPush, inj, ONE TIME Recommended maximum of 20 mg/dose. 20 mg, IVPush, inj, ONE TIME ondansetron 0.1 mg/kg, PO, liq, q4h, PRN nausea/vomiting 0.1 mg/kg, PO, liq, q8h, PRN nausea/vomiting 0.1 mg/kg, IVPush, inj, q4h, PRN nausea/vomiting 0.1 mg/kg, IVPush, inj, q8h, PRN nausea/vomiting Titratable Continuous Infusions dexmedetomidine 200 mcg/50 ml (PICU) - T (dexmedetomidine 200 mcg/50 ml (PICU) - Titratable) IVsyr, Max titration: 0.2 mcg/kg/hr every 30 minutes, Max dose: 0.7 mcg/kg/hr Final concentration = 4 mcg/ml. Start at rate: mcg/kg/hr Fixed Rate Continuous Infusions dexmedetomidine 200 mcg/50 ml (PICU) - F (dexmedetomidine 200 mcg/50 ml (PICU) - Fixed Rate) IVsyr Final concentration =4 mcg/ml. Physician order REQUIRED for ALL rate changes. Start at rate: mcg/kg/hr Order Taken by Signature: Page 5 of 5