PLACE LABEL HERE
NEONATAL INTENSIVE CARE UNIT (NICU)
ADMISSION 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).
All infants born at ≤ 326/7 weeks EGA should initially be admitted under ICU status and managed using ICU orders.
Diagnosis & Status: Admit to Inpatient: ______________________________________________________ (reason for admission)
Date: ______________ Time: ___________ Admit to ICU status
Birth Weight: _______________ grams
Current Weight: _____________ grams
Gestational Age: ________ weeks
Diagnosis:
1. ________________________ 2. _____________________________ 3. ____________________________
Bed Type:
 Less than 800 grams OR less than or equal to 266/7 weeks: Incubator with humidification at 80% on days of life 0-2, then 70% on
day 3, 60% on day 4, 50% on day 5, 40% on day 6, off on day 7
 800 – 1,800 grams, Incubator
 Greater than 1,800 grams, Radiant warmer bed
Monitoring:
Vital signs q 30 min x 3, then at least q 3 hours if stable
If an arterial line is in place record blood pressure at least q 1 hour
Cardiopulmonary monitor: place leads on infants greater than 1,000 grams and on those without an arterial line

set apnea alarm at 20 seconds and HR limit at 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 _____ %
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
 Total fluid intake of _______ ml/hr (includes PAL or UAC fluids)
 D10W at _______ ml/kg/day (________ ml/hr)
 Pre-mixed TPN solution (“Ready Bag”), _______ gram bag, at _______ ml/kg/day (_______ ml/hr)
 Lipids 20% @ ________ gm/kg/day (________ ml/hr)
 Arterial line fluid: NS 0.45 with heparin at: 1 unit/ml at 1 ml/hr if infant greater than 1,000 grams OR 0.5 ml/hr if less than or equal to
1,000 grams
 UVC fluid: _______________ with heparin 1 unit/ml to run at ________ ml/hr
 Heparin flush q 4 hrs for maintenance of lumens of central lines
 Normal saline flush q 4 hrs for maintenance of lumens of peripheral IV lines
 _____________________________________________________________
Imaging:
 CXR stat if patient is in respiratory distress
 CXR and Abdominal X-ray if UAC, UVC or PICC is placed
 For infants less than 28wks gestation at birth: cranial ultrasound at 3,7,and 14 days of life to evaluate for IVH (anterior fontanel view)
 For Infants less than 260/7 wks gestation at birth include mastoid fontanel view for the evaluation of posterior fossa hemorrhage with each exam.
 Repeat cranial ultrasound at 60 days of life or 1 day before discharge, whichever occurs first.
 For infants 280/7 wks – 316/7 wks gestation at birth: cranial ultrasound at 7 and 14 days of life to evaluate for IVH (anterior fontanel
view).
 Repeat cranial ultrasound at 60 days of life or 1 day before discharge, whichever occurs first.
Order writer’s initials _______
Copy to pharmacy
*3-16561*
FORM 3-16561 REV. 07/2015
Page 1 of 2
PLACE LABEL HERE
NEONATAL INTENSIVE CARE UNIT (NICU)
ADMISSION 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).
All infants born at ≤ 326/7 weeks EGA should initially be admitted under ICU status and managed using ICU orders.
Laboratory tests:
Blood glucose monitoring on 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 transfusion, or before transfer to another facility. If less than 24 hrs 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
 Type and crossmatch now
 CRP at 24 hours of life
 __________________________________________________________
 __________________________________________________________
Medications:
Recombivax HB (Hepatitis B Vaccine) 5 mcg (0.5 mL) IM, after consent obtained AND infant is at least 1,800 grams
 Curosurf (poractant alfa) Dose: 2.5 ml/kg via ETT x 1 dose
 Erythromycin ophthalmic ointment both eyes on admission, if not given at delivery
 Aquamephyton (2 mg/ml): 1mg (0.5 ml) IM for infants greater than 1,000 grams or 0.3 mg (0.15 ml) IM for infants less
than 1000 grams if not given in delivery
 Cafcit (caffeine citrate) loading dose: 20 mg/kg IV over 30 min now, then maintenance dose (started 24 hrs after
loading dose): 5 mg/kg/IV q 24 hrs
 Ampicillin 50 mg/kg IV q 12 hrs (_______ mg)
 Ampicillin 100 mg/kg IV q 12 hrs (_______ mg)
 Gentamicin 5 mg/kg IV q 48 hrs (_______ mg) for infants ≤ 29 6/7 weeks AND 0-7 days old
 Gentamicin 4 mg/kg IV q 36 hrs (_______ mg) for infants ≤ 296/7 weeks AND 8-28 days old
 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 ≤296/7 weeks AND 29 days old

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 minutes after 4 th 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:
Social services consult
Rehab consult for infants less than or equal to 34 weeks
For infants 220/7 - 266/7 weeks at birth, eye exam at 31 weeks gestational age
For infants 270/7 - 306/7 weeks at birth, eye exam at 4 weeks of age
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
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
 __________________________________________________________
____________
Date
____________
Time
______________________________________
Physician Signature
_____________
PID Number
Copy to pharmacy
FORM 3-16561 REV. 07/2015
Page 2 of 2