Date Pediatric Order Set 0 through 16 yrs age Time 1. [ ] Place in Observati: [ ] Mitored Telemetry Bed [ ] Unmitored Bed OR [ ] Admit to Inpatient: [ ] Med-Surg Telemetry Mitor [ ] Med-Surg 2. Diagnosis: Admit to: Dr 3. Code Status: [ ] See Completed Code Sheet * ote: o Code verbal order may ly be taken in emergency situatis 4. Labs: [ ] CBC, U/A, Chem 7, PT, PTT [ ] Amylase and lipase [ ] Blood Cultures times site(s) [ ] CMP [ ] BP [ ] Fasting Lipid Profile (if not de as outpatient- within last 3 mths) [ ] Throat Culture [ ] Other [ ] MRSA screens for all patients readmitted within 7 days, nursing home patients, persal care home residents and group home residents. (Maintain ctact precautis until negative result obtained.) 5. Studies: [ ] Portable Chest X-Ray arrival if not de in ER 6. O2 via ; L/min.; [ ] Ctinuous [ ] prn [ ] Maintain SaO2 % 7. SVs: [ ] Dueb Q hr [ ] W/A [ ] prn [ ] Other Q hr [ ] W/A [ ] prn 8. Vital Signs [ ] Med-Surg (4hr) [ ] Observati (q 2hr) [ ] euro Signs q hr 9. Activity: [ ] Absolute bed rest [ ] B.S. Commode [ ] BRP [ ] Elevate HOB 45-90 [ ] Ad lib 10. Diet: [ ] PO [ ] Clear Liquids [ ] Age Appropriate Regular Diet [ ] ADA Diet Calories 11. Chart I & O [ ] 12. Weigh Daily [ ] 13. IV soluti: Rate [ ] Saline Lock with routine flush 14. Csults: [ ] Dr [ ] Dietary [ ] SS [ ] PT [ ] OT Physician Signature
Pediatric Admissi Order Set Allergies Date/Time Code Key Rx Prescripti Bottle? Unsure or Questiable Ph Pharmacist Called ER ER Documentati L Written or Printed List V Verbalized List Patient Height Patient Weight lbs = KG Pre-existing [ ] Renal Impairment [ ] Hypertensi [ ] Diabetes Mellitus Cditis: [ ] Liver Impairment [ ] Pregnant [ ] Breast Feeding Pre-admissi Medicatis: Include all over-the-counter and herbal medicatis. All Medicatis must be reviewed prior to discharge and circled es or o C O D E while Inpatient Date/Time Medicatis (All medicati calculatis to be checked by two Rs and calculated Kg weight) [ ] Tylenol Tablets / Elixir / Suppository mg po/rectal q 4 hours prn Alternate with [ ] Ibuprofen Tablets or Elixir mg po q 6 hours prn For pain or temperature greater than Date & Time GEERAL ORDERS Date & Time MEDICATIO ORDERS
Date & Time GEERAL ORDERS Date & Time MEDICATIO ORDERS Allergies
Pediatric Vital Signs (Please place this page in Bedside Chart for vital sign reference) Vital signs remain relatively cstant throughout adult life. However, as infants and children grow and age, the normal range changes. Refer to the two following tables for normal vital signs for this pediatric admissi. Age (years) Respiratory Rate (breaths/min) Heart Rate (beats/min) <1 30-60 100-160 1-2 24-40 90-150 2-5 22-34 80-140 6-12 18-30 70-120 >12 12-16 60-100 Lower Limits of Systolic Pressure 0-28 Days: 60mmHg 1-12 Mths: 70mmHg 1-10 ears: 70mmHg + (2 times age in years) Age Heart Rate Blood Pressure (mmhg) Respiratory Rate (breaths/min) Premature 120-170 55-75 / 35-45 40-70 0-3 mo 100-150 65-85 / 45-55 35-55 3-6 mo 90-120 70-90 / 50-65 30-45 6-12 mo 80-120 80-100 / 55-65 25-40 1-3 yr 70-110 90-105 / 55-70 20-30 3-6 yr 65-110 95-110 / 60-75 20-25 6-12 yr 60-95 100-120 / 60-75 14-22 >12 yr 55-85 110-135 / 65-85 12-18 Source: http://www.emedicinehealth.com/pediatric_vital_signs/article_em.htm 03/18/11
Pediatric Orders Date Time 1. patient all medicatis circled es and enter Medicati Card 2. patient to: [ ] Home [ ] Home Health [ ] Hospice [ ] Other: 4. Diet Instructis: [ ] As tolerated [ ] Low sodium diet [ ] If diabetic, Calorie ADA Diet [ ] Other: 5. Instructis: [ ] Return to School / / [ ] ote Provided [ ] Homebound Schooling 6. Treatments / Other 7. Outpatient Lab: [ ] es [ ] o If yes Specify Type Date / Time 8. Home Oxygen [ ] Oxygen Liter Flow /min 9. Appointment with Dr. Locati Please call office immediately to schedule a return visit in Phe umber 10. Report to Physician: [ ] Short of Breath [ ] Fever [ ]Swelling [ ]ausea [ ]Vomiting [ ]Pain [ ] Excessive Diarrhea 11. [ ] Fax Orders and Patient Medicati List to Office. 12. [ ] Patient and family discharge educati 13. Vaccine Status: [ ] Follow-up in office for a vaccinati if patient is a candidate and did not receive while in the hospital Revised 2/12 Physician Signature