PLACE LABEL HERE
TRAUMA SERVICE ICU
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).
1. Do you expect that the patient’s condition will require a hospital stay that will cross two midnights (includes the time
spent in outpatient- ED, surgery, OBS) and the patient has medical necessity for an inpatient admission?
 Yes, admit as inpatient, proceed to # 2 No, place in observation
2. If admitted as inpatient, Inpatient Physician Certification:
Diagnosis: ________________________________________________________________________________
Level of Care:  Critical  Intermediate  Acute Care Location/Specialty Unit Preference: ICU
3.  Telemetry: If patient Medical/Surgical, must complete form # 36084
4.  Isolation:  Contact  Droplet  Airborne For: _________________
5. Consult: _________________________
Reason: ___________________________________________
Consult: _________________________
Reason: ___________________________________________
6. Diagnostics:
 STAT On admission: ________________________________________________________________
In AM:
CBC, Chem 7, Ionized Calcium, Magnesium, Phosphorous, Lactic Acid, PT, PTT, ABG
Portable CXR Reason: Traumatic Injury
7. Follow Spinal Clearance (form # 33586) and Spinal Treatment Orders (form # 33585)
8. Vital signs q 1 hr
9. Neuro checks q  1 hr
 2 hr 4 hr
10. Intake and Output q  1 hr
 2 hr
11. O2 Protocol (form # 34431)
12. Notify admitting physician if:
Heart rate < 50 or > 120
Systolic BP < 90 or > 180
Diastolic BP > 110
Urine output < 30 ml/hr x 2 hrs
Temperature > 102°F AND a change in vital signs or clinical status
Hemoglobin is < 8.5 g/dl or drops more than 2 g/dl for 48 hrs post admit
13.  Central line in place:
Port Use: Proximal- IVFs, IVPBs; Medial- TPN, Lipids, IVFs; Distal- Blood, blood sampls, IVFs, Transducer
Sterile dressing change q 7 days and prn
Port cap change q 7 days
Normal Saline Port Flushes: 5 ml prior to blood sampling; 10 ml or more before and after meds and fluids, including
incompatible meds and fluids; 20 ml or more after viscous solutions or blood sampling and administration; 10 ml q shift
when port not in use
14.
15.
16.
17.
18.
19.
20.
Record CVP q ______ hr(s)
Foley to BSB with urometer
 Chest tubes: -20 cm continuous wall suction
If temperature < 36.5ºC (97.7ºF) institute warming measures
 NGT/OGT to low intermittent suction. Notify physician if NG/OG tube is inadvertently removed.
Diet:
 NPO
 NPO, may have sips with meds Clear liquids
Wound Care: __________________________________________________________________________
Activity:
 Bedrest
 Position or activity restrictions: _______________________
 OOB, no limitations
 Other: __________________________________________
Order writer’s initials _______
Copy to pharmacy
*3-16298*
FORM 3-16298 REV. 06/2015
Page 1 of 2
PLACE LABEL HERE
TRAUMA SERVICE ICU
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).
SCHEDULED MEDICATIONS
21. VTE prophylaxis, Initiate Venous Thromboembolism (VTE) Prophylaxis Orders (form # 33058)
 Low risk: No pharmacologic or mechanical prophylaxis, ambulate 3 times daily
 Heparin 5,000 units SQ q 8 hrs (q 12 hrs if wt < 50 kg or age > 75) begin in AM on POD # 1
or  Lovenox (enoxaparin) 40 mg SQ daily (30 mg if CrCl < 30 ml/min) begin in AM on POD # 1
and/or  Mechanical devices: SCDs

 Contraindication to pharmacologic:  Coagulopathy  Thrombocytopenia
 Active/Risk of Bleeding
 Hemorrhage
 Other__________

 Contraindication to mechanical:  BLE Trauma
 BLE Amputee  BLE Arterial Insuffiiciency
 Other: __________
22.
IVF: _________________________________________________ IV at ______________ ml/hr
 Ancef (cefazolin) 1 gm IV q 8 hrs (pharmacy to renal dose if CrCl < 30)
 Other: ___________________________________________________________
or Beta-lactam (penicillin and cephalosporin) allergy or history of MRSA only:
 

 Vancomycin, pharmacy to dose
24.
Ulcer Prophylaxis:
Pepcid (famotidine) 20 mg IV q 12 hrs
23.
Antibiotics:
PRN MEDICATIONS See policy 520-06 for range orders and pain intensity guidelines.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
 Calcium Chloride 1 gm in NS 50 ml IV q 1 hr prn infuse over 20 min
Recheck ionized Ca after infusion and repeat prn if ionized Ca < 1.12
Sedation:
 Versed (midazolam) __________ mg IV q _____ hr(s) prn. Begin at lowest dose
Severe pain: 
 Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation.
Mild pain/HA/ temp >100.5F/HA:
 Tylenol (acetaminophen) 650 mg
 po or  NG  per rectum q 4 hrs prn
 Motrin (ibuprofen) 400 mg
 po or  NG q 6 hrs prn
Nausea/Vomiting:
 Zofran (ondansetron) 4 mg IV q 6 hrs prn
 If N/V persists, add Reglan (metoclopramide) 10 mg IV or po q 6 hrs prn (5 mg if > 65 y/o)
Sleep:  Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn
Stool softener:
 Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
Constipation:
 Milk of Magnesia (MOM) 30 ml
 po or  NG daily prn
Cough:
 Robitussin (guaifenesin) 15 ml po q 4 hrs prn
CVC occlusion: Cathflo (activase, 2 mg/2 ml) IV prn x 2 doses. Instill 2 mg into occluded catheter per Lippincott
procedure: Central Venous Access Device, Declotting . If declotting unsuccessful after 120
minutes, may repeat procedure with a second dose of Cathflo 2 mg /2 ml. Notify physician if
catheter remains occluded 120 minutes after second dose.
Ionized Ca < 1.12:
ADDITIONAL ORDERS:
_______________________________________________________________________________________
______________
Date
_____________
Time
_________________________________
Physician Signature
___________
PID Number
Copy to pharmacy
FORM 3-16298 REV. 06/2015
Page 2 of 2