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 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 Page 1 of 8
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
PHYSICIAN S Start at rate: mcg/kg/min norepinephrine 1.6 mg/50 ml NS (Pedi) IVsyr, Titrate Final concentration = 0.032 mg/ml (32 mcg/ml). Usual Dose Range is 0.05-0.1 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 0.1-0.5 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. 112.5 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
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
PHYSICIAN S 1.5 mcg/kg, IVPush, inj, ONE TIME, Age 13-16 years Levothyroxine dose for age 13-16 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 120-180 Start at rate: units/kg/hr Laboratory BB Blood Type (ABO/Rh), Comment: LifeGift blood typing BB Antibody Screen Page 5 of 8
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
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
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