PLACE LABEL HERE
NEONATAL INTERMEDIATE CARE
ADMISSION ORDERS
Neonatology Service
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).
All infants born at ≤ 326/7 weeks EGA should initially be admitted under ICU status and managed using ICU orders.
Diagnosis & Status: Admit as Inpatient _______________________________________________ (reason for admission)
Date: ______________ Time: ___________
Birth Weight: ___________ grams
Admit to intermediate status
Current Weight: __________ grams
Gestational Age: ___________ weeks
Diagnosis: 1. ___________________________ 2. ____________________________ 3. _______________________
Bed Type:
 < 1,800 grams, Incubator
 > 1,800 grams, Radiant warmer bed
Monitoring:
Vital signs q 30 min x 3, then q 3-4 hrs if stable
Cardiopulmonary monitor, set apnea alarm at 20 seconds and HR 100 – 200 bpm
Continuous pulse oximeter, record pulse ox at least q 1 hour:

Target Range 90-95 %; Alarm Limits Set at 89 and 96 %
Target Range >93 %; Alarm Limits Set at 92 and 101 %

Target Range ____ - ____%; Alarm Limits Set at _____ and _____ %
 Pulse oximetry not indicated, do not place pulse oximeter
Measurements:
Ballard exam unless conceived via in vitro fertilization
Weight on admission and then every Monday, Wednesday, and Friday if stable
Length and head circumference every Monday, plot all measurements against gestational age on growth curve
Fluids and Nutrition:
 NPO
 Strict I & O
 D10W at _______ ml/kg/day (_______ ml/hr)
 Normal saline flush 0.9% q 4 hrs for maintenance of lumens of peripheral IV lines and intermittent IV access
 May breastfeed or PO feed breast milk or term formula ad lib if no respiratory distress
 ____________________________________________________________
 ____________________________________________________________
Laboratory tests:
Blood glucose monitoring upon admission, then q 1 hr until stable, then q 4 hrs x 12 hrs, then q 12 hrs if WNL
State Metabolic Screen at 24 hours of age, before blood product transfusion, or before transfer to another facility
 If less than 24 hours on feeds repeat screen when infant is on full feeds
 Blood culture now
 CBC with diff at 6 hours of life
 CBC with diff now
 CRP at 24 hours of life
 _____________________________________________________________
Order writer’s initials _______
Copy to pharmacy
*3-16562*
FORM 3-16562 REV. 07/2015
Page 1 of 2
PLACE LABEL HERE
NEONATAL INTERMEDIATE CARE
ADMISSION ORDERS
Neonatology Service
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).
All infants born at ≤ 326/7 weeks EGA should initially be admitted under ICU status and managed using ICU orders.
Imaging:
 CXR stat if patient is in respiratory distress
 ____________________________________________________________
Medications:
Recombivax HB (Hepatitis B Vaccine) 5 mcg (0.5 mL) IM, after consent obtained
 Erythromycin ophthalmic ointment both eyes on admission, if not given at delivery
 Aquamephyton (2 mg/ml): 1 mg (0.5 ml) IM for infants greater than 1,000 grams, if not given at delivery
 Ampicillin 50 mg/kg IV q 12 hrs (_______ mg)
 Ampicillin 100 mg/kg IV q 12 hrs (_______ mg)
 Gentamicin 4.5 mg/kg IV q 36 hrs (_______ mg) for infants 30 0/7–346/7 weeks AND 0-7 days old
 Gentamicin 4 mg/kg IV q 24 hrs (_______ mg) for
 infants 300/7 - 346/7 weeks AND greater than or equal to 8 days old
 infants greater than or equal to 350/7 weeks
Gentamicin trough level just prior to 4th dose and peak level 30 min after 4th dose completed
Hold subsequent gentamicin doses if urine output less than 0.5 ml/kg/hr or trough level greater than 2 mg/dL
 Claforan (cefotaxime) 50 mg/kg IV q 12 hrs (_______ mg)
 Lactinex (lactobacillus) 125 mg/kg po/OG q 12 hrs (_______ mg), discontinue at 34 weeks corrected gestational age
 ____________________________________________________________
 ____________________________________________________________
Other:
Hearing screen, CCHD screen, and Purple Cry training before discharge
For infants less than 35 weeks at birth, CPR training before discharge
For infants less than 37 weeks at birth, upright position trial before discharge
Social services consult
Rehab consult for infants less than or equal to 34 weeks
For infants greater than or equal to 310/7 weeks AND a birth weight < 1500 grams, eye exam at 34 weeks or prior to
discharge, whichever occurs first
 ________________________________________________________________________________________
 ________________________________________________________________________________________
 ________________________________________________________________________________________
_______________
Date
______________
Time
________________________________
Physician Signature
_______________
PID Number
Copy to pharmacy
FORM 3-16562 REV. 07/2015
Page 2 of 2