PLACE LABEL HERE
NEONATOLOGY SERVICE
INTERMEDIATE 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 as Inpatient _______________________________________________(reason for admission)
Date: ______________ Time: ___________
Birth Weight: ___________ grams
Admit to intermediate status: Dr. Leigh / Suskin
Current Weight:__________grams
Gestational Age:___________weeks
Diagnosis: 1. __________________________ 2. ___________________________ 3. ______________________
Bed Type:
 1,000 – 2,000 grams – Incubator
 Greater than 2,000 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
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
 D10W at 60 ml/kg/day
 Normal saline flush 0.9% q 4 hrs for maintenance of lumens of peripheral IV lines and intermittent IV access
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, or before transfusion
- If less than 24 hours 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
 Chem 7, Ca ²+ and bilirubin at 12 hours of life
 Chem 7, Ca ²+ and bilirubin at 24 hours of life
 CRP at 24 hours of life
Send copy to pharmacy
*3-16562*
Order writer’s initials _______
FORM 3-16562 REV. 07/2012
Page 1 of 3
PLACE LABEL HERE
NEONATOLOGY SERVICE
INTERMEDIATE CARE ADMISSION ORDERS
Send copy to pharmacy
*3-16562*
Order writer’s initials _______
FORM 3-16562 REV. 07/2012
Page 2 of 3
PLACE LABEL HERE
NEONATOLOGY SERVICE
INTERMEDIATE 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).
Imaging:
 CXR stat if patient is in respiratory distress
 Cranial ultrasound at 7 days of life for infants less than 35 weeks gestation
 ____________________________________________________________
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 (2mg/ml): 1mg (0.5ml) IM for infants greater than 1000 grams,if not given at delivery
 Give D10W 2 ml/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 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
 _____________________________________________________________________________________
Other:
Hearing screen before discharge
Social services consult
Rehab consult for infants less than or equal to 34 weeks
Eye exam at 6 wks of age for all infants less than 33 wks
 ________________________________________________________________________________________
 ________________________________________________________________________________________
 ________________________________________________________________________________________
_________________ __________________ ______________________________________ ________________
Date
Time
Physician Signature
PID Number
Send copy to pharmacy
FORM 3-16562 REV. 07/2012
Page 3 of 3