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).
1.
Diagnosis Same as preprocedure plan ______________ (initials)
and
Admit as Inpatient ______________________________________________(reason for admission)
Status
Place in Observation ____________________________________________(reason for observation)
PRE BRONCHOSCOPY ORDERS
2.
IV Fluids:  LR 500 ml at keep vein open rate  Other: ___________________________________________
3.
 Aerosol with Albuterol 2.5 mg and Atrovent 0.5 mg 30 minutes prior to procedure
4.
 Aerosol with Xylocaine (lidocaine) 4 %, 4 ml 15 minutes prior to procedure
5.
 Blood Glucose Monitoring pre-procedure on insulin dependent diabetics
6.
 Give IM pre-op medication 30 minutes before procedure:
 Atropine 0.4 mg IM x 1 dose
 Phenergan (promethazine) 25 mg IM x 1 dose
 Other: _______________________________________________________________________________
______________
___________________
_________________________________
__________
Date
Time
Physician Signature
PID Number
BRONCHOSCOPY INTRA-PROCEDURAL MEDICATIONS (Incremented during procedure)
 Topical anesthetic to pharynx times 2-3 sprays
 Xylocaine (lidocaine) 1-2%, 2 – 10 ml for local injection/irrigation
 O2 per nasal cannula at 1-5 L/minute
 Morphine 1 mg – 2 mg IV incremented during procedure
 Demerol (meperidine) 12.5 mg - 50 mg IV incremented during procedure
 Fentanyl 25 mcg - 50 mcg IV incremented during procedure
 Versed (midazolam) 0.5 mg – 2 mg IV incremented during procedure
Additional Orders: ________________________________________________________________________________
______________
___________________
_________________________________
__________
Date
Time
Physician Signature
PID Number
MEDICATIONS
 Narcan (naloxone) 0.4 to 2 mg IV if reversal necessary, may repeat in 2-3 minutes x 1 dose
 Romazicon (flumazenil) 0.2 mg IV if reversal necessary, may repeat in 45 seconds then q 60 seconds, up to a
maximum of 1 mg
POST BRONCHOSCOPY OUTPATIENT ORDERS
 NPO until _________________________
 Other: ______________________________________________
 May go when discharge criteria met
 Able to tolerate po fluids  Free of excessive pain  Able to walk with minimal assistance
 Blood glucose monitoring post-procedure on insulin dependent diabetics
 Portable chest x-ray, call results to ______________________________
 Nebulizer treatment ___________________________
POST BRONCHOSCOPY INPATIENT ORDERS
 Return to floor at ______________________
 NPO until _________________________________
 VS upon return to floor and again in 1 hr
 Portable chest x-ray, call results to _____________
 If ambulatory, up with help first time, then
 Oxygen per Respiratory Care Protocol (# 7504-10-01-03)
Additional Orders: ________________________________________________________________________________
______________
___________________
_________________________________
__________
Date
Time
Physician Signature
PID Number
*1-15613*
FORM 1-15613 REV. 07/2012
WHITE: Medical Record
CANARY: Pharmacy
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