Download NICU ADMIT PLAN Patient Label Here

Patient Label Here
NICU ADMIT PLAN
1. Date:
2. Admit to NICU:
Time:____________________________________________________
Dr. Perez and Associates
Status:
 Critical
 Intermediate
 Grower
3. Diagnosis:
A). _____________________________________________________________________________________________
B). _____________________________________________________________________________________________
C). _____________________________________________________________________________________________
4. Admission Weight in Kg:
[Birth: Date
Time
Weight in Kg
5. Gestational Age in Weeks:
Apgars: 1 minute
5 minutes
 Small for gestation
 Average for gestation
 Large for gestation
]
10 minutes
6. Monitoring and Temperature Control
 Cardiac / Respiratory  Vital signs per NICU protocol  Minimal Stimulation
 Notify Doctor or NNP if MAP less than_______________mmhg
7.  Begin Neonate Body Cooling Protocol
8. Admission Laboratory and X-Ray
 CBC & Differential @ 6 hours of life
 Urine drug screen
 Chromosomes (testing for Dr. Tonk)
 Magnesium serum level
 Microarray
 Chest and abdomen x-ray
 Blood culture
 HSV Culture and PCR
 Arterial or capillary blood gas
 Meconium drug screen
 Blood type and screen
 Newborn Metabolic screen by TDH
 POC Blood sugar check now then every ____ hours
 Bilirubin total and direct
 CPK & Isoenzymes
 CRP
 Point of care urinalysis (automated without microscopy) q 12 hrs
 Tracheal aspirate if intubated (prior to surfactant only)
9. Laboratory/X-ray studies for second day
 CRP daily 24 hours after birth x 3
 Total serum bilirubin
 Renal Panel
 Magnesium serum level
 TPN Panel
 Chest and abdomen x ray
 Nutrition Panel
 Cranial ultrasound on ________
 CBC & Differential daily 24 hrs after birth x3
10.  Transport from another facility
 Surface cultures – eyes, nares, rectum, umbilicus
 Standard Isolation Precaution until results negative x 3
11. Respiratory support:
 Room Air
 Nasal Cannula: Flow ______lpm,
FIO2______%
 Nasal CPAP:
Peep ______CmH2O
FIO2______%
 Bubble NCPAP: cm of H20 ______FIO2 ______%
 Nasal Prong Ventilation:
Peep _______CmH2O PS______ Total PIP_______ Rate_______ Trig_______
 Read back
Order taken by Signature: ________________________________________Date/Time: _____________________________
Physician Signature__________________________________________
Date/Time_____________________________
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Patient Label Here
Ventilator settings:
 Conventional:
Mode_______ PIP limit ______PEEP ______Rate ______IT ______
Tidal Volume_______ Flow rate ______lpm PS_______ Trig_______
 HFOV: MAP ______HTZ ______Amplitude ______ IT ______Flow ______lpm
12. Medications:
 Ampicillin (100 mg/kg/dose) = ________mg IV every 12 hours x 5 doses
 Gentamicin (________mg/kg/dose) =________ mg IV every________ hours x____doses
(Review Neofax for age and frequency. Hold dose until trough results back)
(Discontinue after 2 doses if q 24 hr; after 1 dose if q 36 hr)
 BW less than 1,000 grams - Gentamicin Trough before 2nd dose and Peak after 2nd dose
 BW greater than 1,000 grams
 Gentamicin Trough before 2nd dose and Peak after 2nd dose
Or
 Gentamicin Trough before 4th dose and Peak after 3rd dose
only if continuing
beyond 2 doses
 Acyclovir (20 mg/kg) = ________mg IV every 8 hours
 Hydrocortisone (30 mg/M2 stress dose in 3 divided doses x 6 doses IV then maintenance 1 mg/kg daily IV x 4 days)
 Initial dose ________mg every 8 hours x 6 doses then ________mg daily x 4 days
 Caffeine Citrate (Loading dose 20 mg/kg, maintenance 8-10 mg/kg/day)
 Loading dose ________mg IV one time only
 Maintenance dose ________mg IV daily
 IVH (Intraventricular Hemorrhage) Prevention
 Less than 26 weeks or less than 1,000 grams and NO Hydrocortisone administered
 Indomethacin (Indocin) (0.1mg/kg/day) = ________mg IV daily x 3
(Notify attending physician with lab results prior to administering dosage)
 Fungal Prevention
 BW less than 1,000 grams
 Fluconazole (3 mg/kg) = ________mg IV every 72 hours for 2 weeks, then
every 48 hours for 2 weeks, then every 24 hours for 2 weeks.
 Vitamin K:  BW less than 1,500 grams:
0.5 mg IM
 BW greater than 1,500 grams:
1mg IM
 Erythromycin Ophthalmic Ointment to both eyes at time of admission
 Maintain patency of peripheral and central lines
 0.9% Normal Saline 10 mL syringe for peripheral line: 0.5 mL IV push PRN
 ½ Normal Saline with heparin 0.25 unit/mL 1 mL syringe for PAL: 0.5 mL IV push PRN
 ½ Normal Saline with heparin 0.25 unit/mL 10 mL syringe for UVC, UAC, PICC & Broviac: 0.5 mL IV Push PRN
 Normal Saline Bolus _______________ mL/kg for total of ______________mL
 PRN Medications: _______________________________________________________________________________
_______________________________________________________________________________
13. Continuous Intravenous fluid
 Total fluids: mL/kg/day__________
 D10W to run at _______mL/hour
(_____________mL/hour)
 D10W with heparin 0.25 unit/mL to run at _______mL/hour (for central line access)
 Read back
Order taken by Signature: ________________________________________Date/Time: _____________________________
Physician Signature__________________________________________
Date/Time_____________________________
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Patient Label Here
 Starter TPN: Glucose 5 %; Protein 3 g/ 100 mL;
Heparin 0.25 units/mL to run at ______mL/hour
If starting total fluids greater than 80ml/kg/day, run D10W at ______mL/hour.
 Starter TPN: Glucose 10 %; Protein 3 g/ 100 mL;
Heparin 0.25 units/mL to run at ______mL/hour (max rate 80 mL/kg/day)
If starting total fluids greater than 80mL/kg/day, run D10W at ______mL/hour.
14. Umbilical Arterial / Peripheral Arterial Line Fluid
 ½ Normal Saline with Heparin 0.25 units/mL to infuse at
mL/ hour.
 ½ Normal Saline with Heparin 0.5 units/mL to infuse at
mL/ hour.
 Sodium Acetate 3.85 mEq /50mL Sterile Water with Heparin 0.25 units/mL to run at _____mL/hour
15. Enteral nutrition:
 NPO and strict I&O
 O/G tube open to gravity
 Enteral feedings: EBM ________Formula ___________Cal/Oz ( ) ____ mL every 3 hours _____ad lib
 Repogle: ______ Low intermittent suction. ______Continuous suction
16. Other
 Bathe when stable
 Request Social Services consultation
Purpose: ____________________________________
17. Discharge planning:
 Begin oral feeding readiness assessment at 33 weeks PGA
 Hearing screen prior to discharge
 Consult Ophthalmology for ROP guidelines (less than 30 weeks or less than 1500 grams BW)
 CPR instructions for parents
 Car seat challenge per NICU guidelines
 Offer consultation with breast feedings specialist to mother if requested
 Occupational therapy consultation
 Identify Pediatrician for the child prior to discharge
18. Other: ____________________________________________________________________________________________
__________________________________________________________________________________________________
 Read back
Order taken by Signature: ________________________________________Date/Time: _____________________________
Physician Signature__________________________________________
Date/Time_____________________________
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