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, the previous Code Status order must be cancelled. Code Status Code Status: Full Code Patient Care Vital Signs Core Body Temperature Monitoring Maintain body temp 96-99 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 Notify Provider of VS Parameters SBP Greater Than 180, SBP Less Than 90 Notify Nurse (DO NOT USE FOR MEDS) Urinalysis to be ED, collected, and sent to lab q12h 1 of 7
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 400 mg/250 ml D5W - Titratable Start at rate: mcg/kg/min IV, Max dose: 50 mcg/kg/min norepinephrine 4 mg/250 ml NS - Titratab (norepinephrine 4 mg/250 ml NS - Titratable) IV, Max dose: 60 mcg/min Final concentration = 0.016 mg/ml (16 mcg/ml). Start at rate: mcg/min phenylephrine 10 mg/250 ml NS - Titratab (phenylephrine 10 mg/250 ml NS - Titratable) IV, Max dose: 180 mcg/min Final concentration = 0.04 mg/ml (40 mcg/ml). Start at rate: mcg/min Antimicrobials piperacillin-tazobactam 3.375 g, IVPB, ivpb, q6h, Infuse over 30 min vancomycin 1,000 mg, IVPB, ivpb, q12h, Infuse over 90 min meropenem 1 g, IVPB, ivpb, q8h, Infuse over 3 hr levofloxacin 500 mg, IVPB, ivpb, q24h, Infuse over 60 min 2 of 7
fluconazole 400 mg, IVPB, ivpb, q24h, Infuse over 2 hr micafungin 100 mg, IVPB, ivpb, q24h, Infuse over 1 hr Hormonal Therapy Protocol - Initiation potassium chloride 40 meq, IVPB, ivpb, ONE TIME, Infuse over 1 hr 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)-levothyroxine 20 mcg bolus. 3)-hydrocorti sone 100 mg IVPush 4)-D50W 25g IVPush 5)-insulin regular 20 units IVPush 6)- levothyroxine 20 mcg, IVPush, inj, ONE TIME ***Select both hydrocortisone orders below*** hydrocortisone 100 mg, IVPush, inj, ONE TIME hydrocortisone 50 mg, IVPush, inj, q6h Start 6 hours after the initial hydrocortisone bolus. glucose (D50) 25 g, IVPush, syringe, ONE TIME insulin regular 20 units, IVPush, inj, ONE TIME Continued on next page... 3 of 7
Hormonal Therapy Protocol-Levothyroxine levothyroxine 200 mcg/500 ml 1/2 NS IV, Do NOT Titrate Start at rate: mcg/hr Hormonal Therapy Protocol - Vasopressin vasopressin 1 units, IVPush, inj, ONE TIME Give prior to starting vasopressin continuous infusion. vasopressin 40 units/100 ml NS - Fixed R (vasopressin 40 units/100 ml NS - Fixed Rate) Start at rate: units/hr IV Hormonal Therapy Protocol - Insulin.Medication Management 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. ***LifeGift beginning insulin infusion rate reference*** Blood Glucose < or equal to 121 mg/dl = consult LifeGift coordinator for instructions. Blood Glucose >121-150 mg/dl = 1 units/hr / //Blood Glucose >151-200 mg/dl = 2 units/hr Blood Glucose >201-250 mg/dl = 3 units/hr / //Blood Glucose >251-300 mg/dl = 4 units/hr Blood Glucose >301-350 mg/dl = 5 units/hr / //Blood Glucose >351 mg/dl = 6 units/hr Titrate insulin infusion according to the LifeGift insulin titration protocol. insulin R 100 units/100 ml NS IV See LifeGift beginning insulin infusion rate reference & continuous insulin infusion titration protocol for instructions. 100 units, Every Bag LifeGift Continous Insulin Infusion Titr (LifeGift Continous Insulin Infusion Titration Protocol) Adjust insulin infusion according to the LifeGift titration protocol q2hr. See reference text for LifeGift titration protocol Laboratory 4 of 7
BB Blood Type (ABO/Rh) Comment: LifeGift blood typing BB Antibody Screen BB Clot to Hold BB PRBC Blood 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 Troponin T Troponin T Magnesium Level Magnesium Level Phosphorus Level Phosphorus Level Bilirubin Direct 5 of 7
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 Routine EKG-12 Lead, with read. Echo Transthoracic (TTE) with contrast i (Echo Transthoracic (TTE) with contrast if needed) 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. 6 of 7
***Ventilator Settings Must Be Entered Below*** Ventilator Settings Arterial Blood Gas Arterial Blood Gas Routine, q4h Notify RT Arterial Blood Gas 30 minutes after any ventilator change. 7 of 7