Neonatal Intensive Care
NICU Suspected Sepsis Orders for Neonatal
Intensive Care
(Physician must sign all orders-check and/or fill in appropriate blanks)
Admitting Attending:______________________
Resident:_________________________
Admitting Attending Pager:_________________
Resident Pager:____________________
Nurse Practitioner:________________________
Nurse Practitioner Pager: _____________
Birth Weight:____________gm
1.
2.
Current Weight:___________gm
Peds Dosing Weight:_______________gm
Nursing Orders:
a.
Kangaroo Care per protocol
b.
Vital Signs & Cardiorespiratory monitoring per NICU protocol
c.
Pain Assessment q shift
d.
Blood Glucose per NICU protocol
Respiratory Orders
a.
Adjust vent, support settings per MD order and record changes on PCCU/NICU ventilator support
order sheet
b.
Pulse oximeter, bedside: alarm limits 84%-96% target: SaO2 92%
i.
if patient on room air or FiO2 21% alarm limits 85%-100%
3.
IV Fluids
a.
NICU IV Fluids (Refer to Downtime Document- “NICU Pre-Admission Order Sheet”)
b.
TPN (Refer to Downtime TPN “Neonate / Infant Parenteral Nutrition Orders”)
c.
Adjust IV to keep fluids at _______ml.kg/d (total fluid rate at ______ml/hr)
d.
Volume Bolus with NS _________ml
4.
NICU Line Orders
a.
Peds chest w/abd xr portable
b.
May use uac/uvc, after placement confirmed
c.
PICC Line Placement
i.
Fentanyl injection:______mcg iv prn now x 24hr for PICC line insertion; IV push over 510min; may repeat 1-2 times during procedure
ii.
Heparin 10u/ml flush solution (prefilled syringe) 0.5ml flush now x 1 “for use at time of
iii.
May use after PICC line placement confirmed
iv.
PICC Care per NICU protocol
Initial:_________ Date:_______
Page 1 of 3
Neonatal Intensive Care
NICU Suspected Sepsis Orders for Neonatal
Intensive Care
(Provider must sign all orders-check and/or fill in appropriate blanks)
5.
6.
NICU Line Orders continued:
a.
PICC Line Placement Continued
i.
If indicated:
1.
Midazolam Injection: Versed 0.1mg/kg IV push over 5 minutes; may repeat x1;
during procedure
2.
EMLA Cream; 1 application topical prn now x 24 hrs; to PICC line site; cover
w/clear film wrap for 30-45 min then remove
ii.
Radiology Contrast Media
1.
Iothalamate Meglumine 43% injection: Conray 43% injection 0.26ml prn now
CONSTRAST ONLY PICC line placement
2.
Chest xr portable
b.
CVC Placement Orders
i.
Triple Lumen Kit @ bedside
ii.
Double Lumen Kit @ bedside
iii.
Single Lumen Kit @ bedside
iv.
Cordis Kit @ bedside
v.
Supplies:
1.
2 pkgs sterile towels, betadine solution, 4x4 sterile gauze squares, 1% lidocaine, 3
syringes heparin solution, extra syringes, central line dressing kit @ bedside
2.
2 sterile masks, 2 pkgs sterile gloves size _____, and 2 sterile gowns to bedside
vi.
Chest portable xr
vii.
May use CVC after placement confirmed
viii.
CVC care per NICU protocol
c.
CVC Intermittent/heplocked
i.
Heparin 10u/ml flush solution (prefilled syringe) 0.5ml flush q24hr
ii.
Heparin 10u/ml flush solution (prefilled syringe) 0.5ml prn after any medication infusion
when CVC intermittent/heplocked
iii.
When CVC intermittent/heplocked flush 0.5ml heparinized saline (10u/ml) q24h and PRN
iv.
Flush new CVC 2 hrs after and continue every 4 hrs until new fluids arrive
Nutrition
a.
NPO
Initial:____________ Date:____________
Page 2 of 3
Neonatal Intensive Care
NICU Suspected Sepsis Orders for Neonatal
Intensive Care
(Provider must sign all orders-check and/or fill in appropriate blanks)
7.
Serial Labs
a.
ABG Resp q 6hrs for 24 hrs
b.
Sodium Resp q 6hrs
c.
Potassium Resp q 6hrs
d.
Chloride Resp q 6hrs
e.
CBC/Plt Ct/ diff q6hrs
f.
PT q6 var x 24hrs
g.
PTT q6hrs stat var stat x 24hrs
h.
Fibrinogen q6hrs
8.
Diagnostic Imaging & Tests
a.
Chest xr portable
b.
Portable KUB
c.
Peds Chest w/abd xr portable _____x1
d.
Portable Head Ultrasound
e.
Portable ECHO 2-d pediatric
f.
Brain Imaging
g.
EEG
h.
EEG continuous
i.
Portable lateral decubitus
j.
Rectum prone cross table xr lat
k.
Bone Survey XR infant
l.
Upper Extremity xr ap/lat infant
m.
Lower Extremity x rap/lat infant
n.
Renal Ultrasound
o.
Abdominal Ultrasound
p.
Pelvic Ultrasound
q.
Spinal Canal and Content Ultrasound
r.
EKG
s.
Brainstem aud evoked Resp (bear)
Provider Signature:
Date: ____________ Time: ______________
RN Signature:__________________________________
Date: ____________ Time: ______________
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