Community Health Network
San Francisco General Hospital
Medical Center
NEUROSURGERY
ICU PEDIATRIC ADMIT ORDERS
Use this form for pediatric patients weighing < 40 kg
NAME
DRAFT
DOB
MRN
PHYSICIAN ORDER FORM
Page 1 of 6
PCP
Patient ID / Addressograph
Directions: Place a  mark or complete as appropriate
Patient weight _______ kg; Age: _______ months/years (circle one)
Date: _____________
Time: ___________ Drug Allergies_____________________________________
_____________________________________
Admit to NSU-Critical Care
Attending: __________________________ Non-Drug Allergies: _____________________________________
Resident: 327-9546 NP: 327-2207
_______________________________________
Diagnosis:________________________________________________________________________________
Procedure:__________________________________________________________________________________
Condition:
Critical
Serious
Poor
Fair
Good
Guarded
Vitals:
Q________ Neuro Checks
Q_________
Weights:
Daily
Pediatric TBI Goals:
Goals:
Glucose 60-150 mg/dL
CPP 45-60 (age specific)
+
Na 135-145
Hgb ≥ 10
PLTS ≥ 100,000
PaO2 95-100mmHg
PaCO2 35-45mmHg
INR ≤ 1.4
CVP 4-8mmHg
pH 7.35-7.45
Temp 35.0-37.0° C
RASS Target Score
0
-1
-2
-3
-4
-5
Call H.O. For:
Sjvo2 <50% >70%
CVP <4 >8
PaCO2 <35 >40
PEEP >10
FiO2 >.80
PaO2 <90
pH <7.35 >7.45
Hgb <10
Plts <100,000
INR >1.4
+
Glucose <60 >150mg/dL
Na <135 >145
Change in neurological status
ICP sustained >_______ for 5 min. despite drainage
ICP drainage > to 5 times in one hour
Urine output > 3-4ml/kg/hr or if output>input
Other: ______________________________________________________________
Call instructions continued on next page.
DATE ________ TIME _______ PHYSICIAN_____________________________________ CHN # ________ PAGER: ________
Print name
Signature
Title
DATE ________ TIME _______ UNIT CLERK __________________________________________________________________
Signature
DATE ________ TIME _______ REGISTERED NURSE ___________________________________________________________
Signature
Community Health Network
San Francisco General Hospital
Medical Center
NEUROSURGERY
ICU PEDIATRIC ADMIT ORDERS
Use this form for pediatric patients weighing < 40 kg
PHYSICIAN ORDER FORM
NAME
DOB
MRN
PCP
Page 2 of 6
Patient ID / Addressograph
Call instructions, continued:
Infant (1-6 Months)
T < 35.0C >38.0C; RR <30>60; HR <110>180; SBP <60>110; ICP >15; CPP <45; SpO2 <92%;
urine output <1ml/kg/hr
Infant (7-11 Months)
T < 35.0C >38.0C; RR <20>40; HR <110>170; SBP <70>110; ICP >15; CPP <45; SpO2 <92%;
urine output <1m/kg/hr
Toddler (1-4 Years)
T< 35.0C >38.0C; RR <20>30; HR <70>150; SBP <80>115; ICP >18; CPP <55; SpO2 <92%;
urine output <1ml/kg/hr
Preschool Age (5-8 Years)
T < 35.0C >38.0C; RR <18>25; HR <65>135; SBP <85>125; ICP >20; CPP <60; SpO2 <92%;
urine output <1ml/kg/hr
School Age (9-12 Years)
T < 35.0C >38.0C; RR <15>20; HR <60>130; SBP <90>130; ICP >20; CPP <60; SpO2 <92%;
urine output <1ml/kg/hr
Adolescent (>12 Years)
T < 35.0C >38.0C; RR <12>20; HR <60>120; SBP <90>140; ICP >20; CPP <60; SpO2 <92%;
urine output <1ml/kg/hr
Activity:
HOB 30
HOB Flat
Reverse Trendelenburg
OOB to Chair
Mobilize as Tolerated
C-Spine Precautions
Log Roll Precautions
Aspen/MiamiJ
Soft Collar
TLSO
Don/Doff TSLO Brace : _______________________________________________________________
Temperature:
<1 year of Age Obtain Rectal Temps
See Medications for Acetaminophen Orders
Cooling Blanket for T>38.0C (also note lab orders)
Warming blanket for T<35.0C
DATE ________ TIME _______ PHYSICIAN_____________________________________ CHN # ________ PAGER: ________
Print name
Signature
Title
DATE ________ TIME _______ UNIT CLERK __________________________________________________________________
Signature
DATE ________ TIME _______ REGISTERED NURSE ___________________________________________________________
Signature
Community Health Network
San Francisco General Hospital
Medical Center
NEUROSURGERY
ICU PEDIATRIC ADMIT ORDERS
Use this form for pediatric patients weighing < 40 kg
NAME
DOB
MRN
PHYSICIAN ORDER FORM
PCP
Page 3 of 6
Patient ID / Addressograph
Directions: Place a  mark or complete as appropriate
Diet:
NPO
Insert Feeding Tube
Nose (Skull Base Intact)
Mouth (Skull Base Fracture)
Nutrition Consult
Calculation Maintenance Fluids:
*4ml/kg/hr for first 10kg
*Add 2ml/kg/hr for the second 10kg
*Add 1ml/kg/hr for each kg over 20kg
IV Fluids:
NS IV @ __________________(ml/hr)
Plasmalyte IV @ __________________(ml/hr)
Other IV __________________________@ __________________(ml/hr)
Total Fluids (IV & TF) @ __________________(ml/hr)
EVD:
EVD to monitor---Drain to 10cmH2O for ICP >20 sustained for >5 minutes
EVD open at 10cmH2O with monitor checks Q___
EVD open at ________cmH2O with monitor checks Q________ Call for Drainage >________cc/hr
PbtO2 Probe:
Obtain an ABG and notify the Chief Resident or Attending for a PbtO2 of <10mmHg, >100mmHg for 30
minutes or a PbtO2 Change by 50% increase or decrease at any time during shift (even if it is still reading
within normal range)
FiO2 challenge every shift: Increase FiO2 to 100% for 20 minutes and record peak
SjvO2:
Normal Saline infusion at 10ml/hr IV to each port
RT to perform calibrations Q12 hours and PRN
Q1 hour documentation of values
Nursing:
ECG to Monitor
Art Line to Monitor
Central Venous Pressure Q______
Bilateral SCDS
Foley to Gravity
Camino to Monitor
EtCO2
Oxygen Saturation
Assess fluid balance Q12 hours; Notify H.O. if fluid balance is 10mg/kg positive or negative
DATE ________ TIME _______ PHYSICIAN_____________________________________ CHN # ________ PAGER: ________
Print name
Signature
Title
DATE ________ TIME _______ UNIT CLERK __________________________________________________________________
Signature
DATE ________ TIME _______ REGISTERED NURSE ___________________________________________________________
Signature
Community Health Network
San Francisco General Hospital
Medical Center
NEUROSURGERY
ICU PEDIATRIC ADMIT ORDERS
Use this form for pediatric patients weighing < 40 kg
PHYSICIAN ORDER FORM
NAME
DOB
MRN
PCP
Page 4 of 6
Patient ID / Addressograph
Directions: Place a  mark or complete as appropriate
NG/OGT:
Low continuous suction
Low Intermittent Suction
Other Drains:
Cranial Drain to Gravity
Jackson-Pratt drain to bulb suction
Record Drain Output Q__________
Call for >_________ cc Drain Output Q__________ or Bloody drainage
Other Orders:
Noncontrast Head CT @____________ (Pediatric Dosing)
AP/LAT T/L Spine X-rays
CT C-spine (Pediatric Dosing)
MRI C-Spine
With Gadolinium
Without Gadolinium
MRI Brain
With Gadolinium
Without Gadolinium
MRI Brain (Rapid Sequence MRI for Pediatric TBI)
KUB to Assess Feeding tube placement
Labs:
CBC, Chem 10, Serum Osmo, Coags in AM____________________
CBC, Coags Q_____________
Chem 7, Serum Osmo, Q___________
FSBS Q6 while NPO
Urine Toxicology (Upon arrival if not drawn in ED)
ETOH-Serum (Upon arrival if not drawn in ED)
Urine Pregnancy Test
Check a.m. phenytoin level on day 2 of therapy
For T>38.0C-Culture Blood x 1, Sputum and Urine (not necessary >1x/48hrs unless otherwise ordered)
Use Pediatric Tubes for all Draws
Additional Orders:
Rehabilitation Orders
See Critical Care Standing Orders
See NSU Wound Care Orders
See Ventilator Settings per ICU
DATE ________ TIME _______ PHYSICIAN_____________________________________ CHN # ________ PAGER: ________
Print name
Signature
Title
DATE ________ TIME _______ UNIT CLERK __________________________________________________________________
Signature
DATE ________ TIME _______ REGISTERED NURSE ___________________________________________________________
Signature
Community Health Network
San Francisco General Hospital
Medical Center
NEUROSURGERY
ICU PEDIATRIC ADMIT ORDERS
Use this form for pediatric patients weighing < 40 kg
PHYSICIAN ORDER FORM
NAME
DOB
MRN
PCP
Page 5 of 6
Patient ID / Addressograph
Directions: Place a  mark or complete as appropriate
Medications: Patient weight _______ kg; Age: _______ months/years (circle one)
Seizure prophylaxis:
Phenytoin (children >1 year of age):
□ Phenytoin loading dose ________ mg (20 mg/kg) IV x1 infused over 30 minutes
□ Phenytoin maintenance dose ________ mg (2.5 mg/kg/dose; MAX 100 mg) IV every 12 hours
(begin 12 hours after loading dose)
□ Discontinue phenytoin after 7 days.
Phenobarbital (children <1 year of age):
□ Phenobarbital loading dose ________ mg (15 mg/kg) IV x1 infused over 30 minutes
□ Phenobarbital maintenance dose ________ mg (5 mg/kg; Max 50mg) IV every 24 hours
(begin 12 hours after loading dose)
□ Discontinue Phenobarbital after 7 days
Bowel regimen:
Docusate:
□ Infants – children < 3 years of age: docusate 20 mg PO/FT BID (hold for loose stools)
□ Children 3 – 6 years of age: docusate 30 mg PO/FT BID (hold for loose stools)
□ Children 7 – 12 years of age: docusate 50 mg PO/FT BID (hold for loose stools)
□ Children > 12 years of age: docusate 100 mg PO/FT BID (hold for loose stools)
Senna:
□ Infants 1 month – children < 2 years of age: senna syrup 2.5 mL PO/FT at bedtime
(hold for loose stools)
□ Children 2 – 5 years of age: senna syrup 3.75 mL PO/FT at bedtime (hold for loose stools)
□ Children 6 – 12 years of age: senna syrup 7.5 mL PO/FT at bedtime (hold for loose stools)
□ Children > 12 years of age: senna syrup 10 mL PO/FT at bedtime (hold for loose stools)
Bisacodyl:
□ Children ≥ 2 years of age: bisacodyl suppository 10 mg PR daily as needed for no
bowel movement
DATE ________ TIME _______ PHYSICIAN_____________________________________ CHN # ________ PAGER: ________
Print name
Signature
Title
DATE ________ TIME _______ UNIT CLERK __________________________________________________________________
Signature
DATE ________ TIME _______ REGISTERED NURSE ___________________________________________________________
Signature
Community Health Network
San Francisco General Hospital
Medical Center
NEUROSURGERY
ICU PEDIATRIC ADMIT ORDERS
Use this form for pediatric patients weighing < 40 kg
NAME
DOB
MRN
PHYSICIAN ORDER FORM
PCP
Page 6 of 6
Patient ID / Addressograph
Directions: Place a  mark or complete as appropriate
Inotropes/Vasopressors:
□ Phenylephrine 0.05 – 0.5 mcg/kg/minute IV continuous infusion. Titrate to keep CPP > _____
and < _____, or MAP ≥ _______ mm Hg or SBP ≥ ______ mm Hg (SELECT ONE TITRATION
PARAMETER ONLY). Notify H.O. for requirements of ≥ 0.4 mcg/kg/minute.
□ Dopamine 0.5 – 20 mcg/kg/minute IV continuous infusion. Titrate to keep CPP > _____ and < _____,
or MAP ≥ _______ mm Hg or SBP ≥ ______ mm Hg (SELECT ONE TITRATION
PARAMETER ONLY). Notify H.O. for requirements of ≥ 15 mcg/kg/minute.
□ Norepinephrine 0.05 – 1 mcg/kg/minute IV continuous infusion. Titrate to keep CPP > _____
and < _____, or MAP ≥ _______ mm Hg or SBP ≥ ______ mm Hg (SELECT ONE TITRATION
PARAMETER ONLY). Notify H.O. for requirements of ≥ 0.75 mcg/kg/minute.
Antipyretics/Antiemetics:
Acetaminophen:
□ Acetaminophen ______ mg (15 mg/kg/dose; MAX 650 mg) PO/FT every 6 hours
prn temp≥ ______ C.
Total dose not to exceed ______ mg/day (75 mg/kg/day; MAX 3000 mg/day)
□ Acetaminophen suppository ______ mg (15 mg/kg/dose; MAX 650 mg) PR
(only comes as 120mg, 325mg and 650mg suppositories, round to the nearest
suppository size) every 6 hours prn temp ≥ ______C. Give if unable to administer PO/FT.
Ondansetron:
□ Infants ≥ 6 months of age – children 17 years of age: ondansetron _______ mg
(0.15 mg/kg/dose; MAX 4mg) IV every 6 hours as needed for nausea/vomiting.
Additional Medications:
(must write weight-based dosing (e.g. ___ mg/kg/dose) and the calculated mg dose for all pediatric medication orders)
□_____________________________________________________________
□_____________________________________________________________
Please see the following additional order forms:
□ Printed medication reconciliation form
□ Pediatric electrolyte replacement orders
□ Pediatric Antibiotic Order Form (AOS)
DATE ________ TIME _______ PHYSICIAN_____________________________________ CHN # ________ PAGER: ________
Print name
Signature
Title
DATE ________ TIME _______ UNIT CLERK __________________________________________________________________
Signature
DATE ________ TIME _______ REGISTERED NURSE___________________________________________________________
Signature