Neonatal Intensive Care
General Admission Orders for Neonatal
Intensive Care
(Provider must sign all orders-check and/or fill in appropriate blanks)
Admitting Attending:______________________
Resident:_________________________
Admitting Attending Pager:_________________
Resident Pager:____________________
Nurse Practitioner:________________________
Nurse Practitioner Pager: ____________
Admit Location:__________________________
Admitting Team:___________________
Gestational Age:__________________________
Admitting Diagnosis:_______________
Birth Weight:____________gm
1.
Current Weight: ____________gm
Peds Dosing Weight: ____________gm
Nursing Orders:
a.
Document the HeRo Score at least once a shift. If score is greater than 2 and has increased by
greater than 0.5 in the previous 12 hrs, notify house officer or NNP and document.
b.
Initial state screen day of life 7 or before first transfusion, surgery, cath lab, transfer/discharge from
NICU (if not already done).
c.
Admit to open bed warmer
d.
Vital Signs & Cardiorespiratory monitoring per NICU protocol
e.
Pain Assessment q shift
f.
Blood Glucose per NICU protocol
g.
Repogle to straight drain
h.
OG tube
i.
Abstinence Score – assess and record q2-4hrs
j.
Minimal Stimulation
k.
Activity
i.
Right Side Up
ii.
Left Side Up
iii.
Prone Only
l.
Elevate HOB degrees:________
m.
Kangaroo Care per protocol
n.
NICU Thermoregulation Orders
i.
For all infants <1000g & most <1500gm
1.
Admit to Giraffe Open Bed Warmer
2.
But close down to incubator ASAP
3.
Servo Temp Control per protocol
4.
Humidity 60-80% in isolette for <1000g infants x 2 weeks
ii.
For infants >1500gm and <1800g and those with temp instability
1.
Admit to Giraffe Open Bed Warmer
2.
Wean from isolette when temp stabilized
Initials:_________ Date:_________
Page 1 of 6
Neonatal Intensive Care
General Admission Orders for Neonatal
Intensive Care
(Provider must sign all orders-check and/or fill in appropriate blanks)
2. NICU Thermoregulation Orders Continued:
a.
For larger pre-term and term infants
i. Open Bed Warmer
ii. Wean from isolette to open crib when air temp <28 C & infant >1600g
3. NICU skin care orders:
i. Initiate NICU skin care protocol
i.
Multidex Powder to ________________
ii.
Multidex Gel to ___________________
iii.
Duoderm to ______________________
ii. LBW <1000g
iv. Probe site changes q4h
v. Pectin based barriers
vi.
Aquaphor: 1 application topical q 6hrs now x 4 days apply as soon as possible after birth
vii. Burn sheets
2.
i.
ii.
Respiratory Care:
Ventilator Orders
1.
PCCU/NICU Ventilatory Support Order Sheet
2.
Adjust vent, support settings per MD order and record changes on PCCU/NICU ventilator
support order sheet
3.
Pulse oximeter, bedside: alarm limits 84%-96% target: SaO2 92%
a. if patient on room air or FiO2 21% alarm limits 85%-100%
4.
Aladdin Nasal CPAP
a. support settings per MD order and record changes on PCCU/NICU ventilator
support order sheet
NICU Oxygen Therapy Orders
1.
Oxygen titration by SaO2
a.
O2 per nasal cannula (flow in cc/min) ___________ cc/min
i. Adjust to maintain SaO2 =/>_____%
b.
O2 per nasal cannula (blended O2)1 1pm
i. O2 %_________ adjust FiO2 or flow to maintain SaO2
>/=______%
c.
O2 per nasal cannula (flow in LPM) ______LPM
i. Adjust to maintain SaO2 =/> ________%
d.
O2 per head box as directed
i. Adjust FiO2 to maintain SaO2 >/= _______%
Initials: ________ Date:_______
Page 2 of 6
Neonatal Intensive Care
General Admission Orders for Neonatal
Intensive Care
(Provider must sign all orders-check and/or fill in appropriate blanks)
a.
i.
b.
i.
2.
iii.
iv.
5.
Isolette O2
Adjust FiO2 to maintain SaO2 >/= _______%
O2 per trach collar as directed
Adjust FiO2 to maintain SaO2 >/= _______%
Oxygen (ordered litters/min or %)
a.
O2 per nasal cannula (low flow) ________cc/min
b.
O2 per nasal cannula (blended O2) % O2_________
c.
O2 nasal cannula (hi flow) ________LPM
a.
Head box concentration
i.
FiO2 .21 to 100
ii.
O2_______
b.
Trach collar concentration
i.
FiO2 .21 to 100
ii.
O2______\
RT Administered Specialty Gases:
a.
Nitric Oxide cont. inhalation
b.
Subatmospheric oxygen ________
c. S Heli-ox per face mask
d. u Heli-ox per head box
b
a
RT Administered
t Medications:
a. m Albuterol for intermittent nebulization
b. o Beractant Intratracheal: Survanta ____ml ett ______
c. s
Racepinephrine 2.25% inhalation solution ______ml inhalation now x1
p
d. h Racepinephrine 2.25% inhalation solution ______ml inhalation now x
72 hrse
e. r
Budesonide Inhalation Suspensiom: Pulmicort Respule ______mg
i
Inhalation ______
c
O
IV Fluids:
i.
D10W ______ml.hrxIV NOW
1.
From AcuDose; maintenace rate until pharmacy fluids arrive
ii.
Adjust IVF to keep total fluids @ 60ml/kg/d (total fluid rate@_____ml/hr)
iii.
NICU IV Fluids (Refer to Downtime Document- “NICU Pre-Admission Order Sheet”)
iv.
Nursing: Umbilical Arterial Cath
v.
Nursing: Umbilical Venous Cath
Initial:_________ Date:________
Page 3 of 6
2.
Neonatal Intensive Care
General Admission Orders for Neonatal
Intensive Care
(Provider must sign all orders-check and/or fill in appropriate blanks)
5.
6.
Medications:
i.
ii.
iii.
iv.
Erythromycin Eye Ointment: 0.5’ each eye x1 if not already done
Ampicillin Injection: ______mg ______stat
Gentamicin Injection Garamycin _______mg _____stat
If <1500 grams order:
1.
Phytonadione Inj: Aquamehyton 0.5 mg IM x1 if not already given
v.
If >1500gms order
1.
Phytonadione Inj: Aquamehyton 1 mg IM x1 if not already given
vi.
If <1250 grams requiring mechanical ventilation order
1.
Vitamin A 200IU/kg IM every other day: start with day of life 1
vii.
If <1250 grams and mechanical ventilation and mother did not receive Indocin within 72
hours of delivery and baby has voided and has platelet count >75K:
1.
Indocin IV over 20min @ 12hrs of age
viii.
Sucrose water 24% oral solution: Tootsweet ________ml po prn “per protocol for
procedural pain: may give one in one hour and no more than 4 times per day”
ix.
Emla cream: 1 application topical prn “topical lidocain/prilocaine 0.5gm for painful
procedure per NICU procedural pain management guidelines”
NICU Labs
i.
Obtain state screen before first blood transfusion, before going to OR or on day of life 7
ii.
Respiratory Blood Gas: Type_______________
1.
Blood Gas
2.
NA
3.
K
4.
Ionized Ca
5.
Glucose
6.
Lactate
7.
PCV/HCT
iii.
CBC/Plt Count/ Diff stat x1
iv.
Platelet Count bld stat
v.
Admission Lytes, BUN Creatine, Glucose Stat x1
vi.
Bilirubin Conjugated blood (direct) stat x1
vii.
Neonatal Bilirubin stat x1
viii.
Culture peds bld bacteria
ix.
Na, K, Cl Resp blood gas x1 stat
Initial:_________ Date:__________
Page 4 of 6
Neonatal Intensive Care
General Admission Orders for Neonatal
Intensive Care
(Physician must sign all orders-check and/or fill in appropriate blanks)
7.
NICU Labs Continued:
i.
Phosphorus inor bld stat x1
ii.
Magnesium bld stat x1
iii.
Prothrombin (PT) bld stat x1
iv.
Part thromboplastin (PTT) bls stat x1
v.
Fibrinogen bld stat x1
vi.
CMP componets
vii.
CRP stat x1
viii.
CMV viral culture & ag.det
ix.
Cord bld workup stat x1
x.
Inborn Babies
1.
Direct antiglobulin test (dat) stat x1 “on cord bld for inborn”
2.
Type & Screen (abo/rh/atby scrn) stat x1 “on cord bld for inborn”
xi.
Outborn Babies
1.
Transfuse RBC (amount)__________
(type)____________
2.
Transfuse Platelets (amount)__________ (type)____________
3.
Transfuse Plasma (amount)__________
(type)____________
xii.
Drug Screens
1.
Drug Screen Urine stat x1
2.
Drug Screen Meconium
xiii.
Maternal Labs
1. If maternal HBSAg+ or unknown for both term and preterm
1. Bathe infant before first invasive procedure if possible
2. Hepatitis B Immune Globulin 0.5ml IM x 1 @ separate site
3. Recombivax HB
2. If maternal HBSAg unknown for both tern and preterm
1. Send Maternal HBSAg
8.
NICU Diagnostic Test
i.
Peds Chest w/abd xr portable
ii.
Portable KUB
iii.
Portable Head Ultrasound
iv.
Portable ECHO 2-d pediatric
v.
Brain Imaging
vi.
EEG
vii.
EEG continuous
Initial:__________Date:_________
Page 5 of 6
9. NICU Diagnostic Test (continued)
i.
Portable lateral decubitus
ii.
Rectum prone cross table xr lat
iii.
Bone Survey XR infant
iv.
Upper Extremity xr ap/lat infant
v.
Lower Extremity x rap/lat infant
vi.
Renal Ultrasound
vii.
Abdominal Ultrasound
viii.
Pelvic Ultrasound
ix.
Spinal Canal and Content Ultrasound
x.
EKG
xi.
Brainstem aud evoked Resp (bear)
10. NICU Drug Withdrawal Orders
i.
Withdrawal Protocol
ii.
“Neonatal drug withdrawal inventory scoring q4h: if score is 8 or greater notify house officer and change
to q2hr scoring x 24hrs: if scoring less than 7 after 24hrs return to q4h scoring
Provider Signature:
Date: ____________ Time: ______________
RN Signature:__________________________________
Date: ____________ Time:
Page 6 of 6