PLACE LABEL HERE
NEONATOLOGY SERVICE
INTENSIVE CARE 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).
Diagnosis & Status: Admit to Inpatient: _______________________________________________(reason for admission)
Date: ______________
Time: ___________
Birth Weight: _______________ grams
Diagnosis:
Admit to ICU status: Dr. Leigh / Suskin
Current Weight:_____________grams
Gestational Age:________weeks
1. ______________________ 2. ___________________________ 3. __________________________
4. ______________________ 5. ___________________________ 6. __________________________
Bed Type:
 Less than 1,000 grams – Incubator with humidification
 1,000 – 2,000 grams – Incubator
 Greater than 2,000 grams – Radiant warmer bed
Monitoring:
Vital signs q 30 min x 3, then q 2 hrs if stable
Direct assessment of vital signs at least q 8 hrs
(other recordings may be taken from monitoring equipment)
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
Measurements:
Ballard exam for EGA determination on infants less than 2.5 kg, or less than 37 weeks gestation, or those with a maternal
history of IUGR or diabetes
Weight on admission and then every Monday, Wednesday, and Friday if stable
Length and head circumference every Monday - plot all measurements on growth curve
Fluids and Nutrition:
NPO
Strict I & O
Total fluid intake includes PAL or UAC fluids
 D10W at 60 ml/kg/day for birth weight greater than 1.5 kg
 D10W at 100 ml/kg/day for birth weight 1 kg – 1.5 kg
 D10W at 110 ml/kg/day for birth weight 750 grams – 1 kg
 D10W at 120 ml/kg/day for birth weight less than 750 grams
 UAC fluid: NS 0.45 with heparin 1 unit /ml at 1 ml/hr, or at 0.5 ml/hr if less than or equal to 1,000 grams
 UVC fluid: add heparin 1 unit / ml to _________, run at ____ml/hr to maintain total intake at ______ml/kg/day
 PAL fluid: normal saline 0.45 plus 2% lidocaine 2 ml /100ml plus sodium bicarbonate 0.25 mEq /100ml plus heparin 2
units /ml at 1 ml/hr, or run at 0.5 ml/hr if less than or equal to 1,000 grams
 Heparin flush (normal saline 0.45 with heparin 1 unit / 1 ml) q 4 hrs for maintenance of lumens of all lines, other than a
peripheral IV line and intermittent IV access
 Normal saline flush 0.9% q 4 hrs for maintenance of lumens of peripheral IV lines and intermittent IV access
Send copy to pharmacy
*3-16561*
3
Order writer’s initials _______
FORM 3-16561 REV. 07/20128
Page 1 of
PLACE LABEL HERE
NEONATOLOGY SERVICE
INTENSIVE CARE ADMISSION ORDERS
Send copy to pharmacy
*3-16561*
3
Order writer’s initials _______
FORM 3-16561 REV. 07/20128
Page 2 of
PLACE LABEL HERE
NEONATOLOGY SERVICE
INTENSIVE CARE 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).
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, or before transfusion
 If less than 24 hrs on feeds, repeat screen when infant is on full feeds
 T4 and TSH at 2 weeks of age for infants less than or equal to 32 weeks gestation
 Blood culture now
 CBC with diff now and at 24 hours of life
 Chem 7, Ca ²+ and bilirubin at 12 hours of life
 Chem 7, Ca ²+ and bilirubin at 24 hours of life
 Type and crossmatch
 CRP at 24 hours of life
Imaging:
 CXR stat if patient is in respiratory distress
 CXR and KUB if UAC, UVC or PICC is placed
 Cranial ultrasound at 3 and 7 days of life for infants less than 28 weeks gestation
 Cranial ultrasound at 7 days of life for infants 28 – less than 35 weeks gestation
 __________________________________________________________
Medications:
Recombivax HB (Hepatitis B Vaccine) 5 mcg (0.5 mL) IM, after consent obtained
 Curosurf (Poractant alfa) per protocol (less than 28 weeks gestation). Dose: 2.5 ml/kg via ETT x 1 dose
 Erythromycin ophthalmic ointment both eyes on admission, if not given at delivery
 Aquamephyton (2mg/ml): 1mg (0.5ml) IM for infants greater than 1000 grams or 0.3 mg (0.15ml) IM for infants less
than 1000 grams if not given in delivery
 Cafcit (caffeine citrate) 20mg/1ml.
Loading dose: 20mg/kg/IV over 30 min
Maintenance dose (started 24 hrs after loading dose): 5mg/kg/IV q 24 hrs
 Give D10W 2ml/kg IV for blood glucose screen less than 40 mg/dL
 Repeat screen 30 min after bolus
 Repeat D10W bolus if follow- up glucose screen less than 40 mg/dL
 Call physician if more than two consecutive D10W boluses are needed, or if glucose screen greater than 200
mg/dL on more than two consecutive screens
 Ampicillin 100 mg/kg IV q 12 hrs
 Gentamicin 5 mg/kg IV q 48 hrs for infants less than 30 weeks
 Gentamicin 4.5 mg/kg IV q 36 hrs for infants 30 – 34 weeks
 Gentamicin 4 mg/kg IV q 24 hrs for all infants greater than or equal to 35 weeks
 Send Gentamicin trough level just prior to 4th dose and peak level 30 minutes 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
 Emollient to skin
Other:
Social services consult
Hearing screen before discharge
Rehab consult for infants less than or equal to 34 weeks
Eye exam at 6 wks of age all infants less than 33 wks
_________________ __________________ ______________________________________
Date
Time
Physician Signature
__________________
PID Number
Send copy to pharmacy
FORM 3-16561 REV. 07/2012
Page 3 of 3