The following orders will be implemented. Orders with a “  ” are choices are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicatated (multipage).
1. Diagnosis Admit as Inpatient _________________________________________________(reason for admission) and Place in Observation _______________________________________________(reason for observation)
Status: Place in Outpatient ________________________________________________(diagnosis)
2. Consults: ____________________________________________________________________________________
3. Diagnostics:  Chem 7 & CBC while monitoring ICP daily
 Serum Na & Serum Osmolality q 6 hrs while on hypertonic solution
4. Vital signs, neuro checks, intake/output, ICP & CPP q 1 hr
5. Antiembolic device:  Sequential compression device  Foot pumps  TEDs
6. Ventilator settings to maintain P0
2
80-100 mmHg and PC0
2
______ mmHg
7. Maintain CPP greater than 60 mmHg. For CPP less than 60 mmHg:
 Albumin 5% 250 ml IV q 6 hrs for central venous pressure less than 6 mmHg
 DOPamine (800 mg/500 ml D5W) titrate 5-20 mcg/kg/min prn
 Neosynephrine (PHENYLephrine) (30 mg/250 ml NS) titrate 30-180 mcg/min prn
 Levophed (NORepinephrine) (4 mg/250 ml NS) titrate 2-20 mcg/min prn
8. Maintain ICP less than 20 mmHg. For ICP greater than 20 mmHg sustained for 5 min: a. Decrease environmental stimulation b. Maintain head and neck in neutral position c. HOB at 30 degrees d. Control body temperature. May use cooling blanket for temperature greater than 102º F
9. Drain CSF for increased ICP prn:
 Drain ICP to ___________ mmHg
 Continuous drain CSF at __________ ml/hr
10. Sedation/Analgesic
 Diprivan (propofol) 5 mcg/kg/min IV, increase by 5 mcg/kg/min q 10 min to maintain sedation (max 50 mcg/kg/min)
Triglyceride level q 3 days while on Diprivan (propofol)
 Versed (midazolam) 2-4 mg IV push q 1 hr prn
 Morphine 2-4 mg IV push q 1 hr prn
11. Hypertonic Solution (Hold for Serum Osmolality less than _______. Hold for Serum Sodium greater than _______ ):
 Mannitol 20% 0.25 gm/kg IV q ______ hr prn, ICP greater than 20 mmHg sustained for 5 min
 Mannitol 20% 1 gm/kg IV q ______ hr prn, ICP greater than 20 mmHg sustained for 5 min
 3% Saline IV at _______ per ml/hr
 5% Saline IV at _______ per ml/hr
12.  See Neuromuscular Blocking Agent Orders (form # 15396)
13.  Nembutal (PENTobarbital)
Loading dose ______ mg/kg IV push slow (do not exceed 50 mg/min)
 Nembutal (PENTobarbital) 2,500 mg/500 ml normal saline
Continuous infusion 1.5 mg/kg/hr IV, titrate to control ICP to _______, maximum dose 3 mg/kg/hr
14. Portable EEG daily while on barbiturate therapy or until burst suppression achieved
__________ ________________ ________________________________
Date Time Physician Signature
__________________
PID Number
1
*1-18633*
FORM 1-18633 REV. 07/2012 WHITE: Medical Record CANARY: Pharmacy Page 1 of