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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_____________________________ Page 1 of 3- NICU Admit Plan 08/26/2015 V-22 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_____________________________ Page 2 of 3- NICU Admit Plan 08/26/2015 V-22 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_____________________________ Page 3 of 3- NICU Admit Plan 08/26/2015 V-22