PLACE LABEL HERE
BRONCHOSCOPY
ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
Diagnosis: _______________________________________________________________________________________
PRE BRONCHOSCOPY ORDERS
1.
Bronchoscopy Procedure Date: _____________________ Preferred Time: ______________
2.
 No IV access: insert INT
3.
Blood Glucose finger stick monitoring pre-procedure for diabetics
4.
Urine hCG for any menstruating female ≥ 12 years of age
5.
Oxygen per protocol # 34431
Pre-op Medications:
6.
IV Fluids:
 LR 500 ml IV at keep vein open rate
 If patient has renal insufficiency: NS 500 ml IV at keep vein open rate
 Other: ___________________________
7.
 Albuterol 2.5 mg and Atrovent (ipratropium) 0.5 mg aerosol 30 min prior to procedure
8.
 Robinul (glycopyrrolate) 0.2 mg IM x 1 dose 30 min prior to procedure
9.
 Xylocaine (lidocaine) 4%, 4 ml aerosol 15 min prior to procedure
10.
 Xopenex (levalbuterol) 0.63 mg aerosol 30 min prior to procedure
11.
 Atropine 0.4 mg IM x 1 dose, give 30 min prior to procedure
12.
 Phenergan (promethazine) 25 mg IM x 1 dose, give 30 min prior to procedure
13.
 Fentanyl 25 mcg IV x 1 dose pre procedure, after consent is signed
14.
 Other: __________________________________________________________________________________
______________
_____________
_________________________________
__________
Date
Time
Physician Signature
PID Number
BRONCHOSCOPY INTRA-PROCEDURAL MEDICATIONS (Incremented during procedure)
1.  Cetacaine (benzocaine/tetracaine/butaben) x 1 spray for < 2 sec to pharynx immediately prior to procedure x 1 dose
2.  Xylocaine (lidocaine) jelly 2%, apply topically to nares x 1 dose, immediately prior to procedure
3. Procedure Irrigant
 Xylocaine (lidocaine) 1%, 2 – 10 ml for procedure irrigation
 Xylocaine (lidocaine) 2%, 2 – 10 ml for procedure irrigation
 Xylocaine (lidocaine) 1% with epinephrine, 2 – 10 ml for procedure irrigation
 Xylocaine (lidocaine) 2% with epinephrine, 2 – 10 ml for procedure irrigation
4.  Morphine 1 - 2 mg IV q 5 min prn sedation during procedure
5.  Fentanyl 25 - 50 mcg IV q 2 min prn sedation during procedure
6.  Versed (midazolam) 0.5 - 2 mg IV q 2 min prn sedation during procedure
7.  Other: ___________________________________________________________
8.  Labetolol 10 mg IV x 1 dose prn SBP > 160 mm Hg
9. Reversal Medications, if needed
 Narcan (naloxone) 0.4 to 2 mg IV prn opioid reversal. May repeat in 2-3 min x 1 dose.
 Romazicon (flumazenil) 0.2 mg IV prn benzodiazepine reversal. May repeat in 45 seconds then q 60 seconds, up
to a max of 1 mg.
Order writer’s initials _______
Copy to pharmacy.
*3-15613*
FORM 3-15613 REV. 05/2015
Page 1 of 2
PLACE LABEL HERE
BRONCHOSCOPY
ORDERS
Order writer’s initials _______
Copy to pharmacy.
*3-15613*
FORM 3-15613 REV. 05/2015
Page 1 of 2
PLACE LABEL HERE
BRONCHOSCOPY
ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
POST BRONCHOSCOPY ORDERS
1.
2.
3.
4.
 Portable chest x-ray Reason: Status Post Bronchoscopy. Call results to: __________________________
 Blood Glucose Finger Stick monitoring post-procedure on diabetics
 Albuterol 2.5 mg aerosol x 1 prior to discharge
 Atrovent (ipratropium) 0.5 mg aerosol x 1 prior to discharge
5.  POST BRONCHOSCOPY OUTPATIENT ORDERS
NPO until 60 min after last dose of topical anesthetic or  Other: ______________________________________
May go home when discharge criteria met, per Sedation Guidelines policy # 520-29

6.  POST BRONCHOSCOPY INPATIENT ORDERS
NPO until 60 min after last dose of topical anesthetic
Return to floor when PAR score ≥ 9 or at pre-procedure level; if PAR ≤ 8 discharge by physician orders
Vital signs upon return to floor at 60 min, then per unit routine
 Activity: If ambulatory, up with help first time, then as previously ordered
 Oxygen per protocol (form # 34431)
ADDITIONAL ORDERS:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________
_____________
_________________________________
__________
Date
Time
Physician Signature
PID Number
Copy to pharmacy
FORM 3-15613 REV. 05/2015
Page 2 of 2