Download Trauma ICU Admission Post Op Orders

PLACE LABEL HERE
TRAUMA ICU ADMISSION
POST-OP 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).
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Diagnosis & Status: Admit as Inpatient _________________________________________________(reason for admission)
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Unit:
ICU
Consult: _________________________ Reason: ___________________________________________
Consult: _________________________ Reason: ___________________________________________
Labs:  On admission: ______________________________________________________________
 In AM: ____________________________________________________________________
 Daily: _____________________________________________________________________
X-rays  On admission: ______________________________________________________________
 Daily: _____________________________________________________________________
 Other: ____________________________________________________________________
Follow Spinal Clearance Orders (form # 13504), (must accompany patient from ED)
Vital signs and neuro checks q 1 hr
Continuous pulse oximetry - maintain 02 saturation > 93%
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
If on ventilator, see Mechanical Ventilation Initiation Orders (form # 18389)
If patient inadvertently extubated, contact Respiratory Therapy or Anesthesia to evaluate patient for
need for re-intubation
Start two large-bore (18 g or larger) extremity IVs
If central line in place, record CVP q ______ hr(s)
If central line inadvertently discontinued, start peripheral IV of D5 ½ NS at __________ ml/hr IV
Maintain HCT > ______ with PRBCs
Call Trauma Surgeon if patient requires > 2 units PRBCs in an 8 hr period
Strict I&O
Foley to BSB with urimeter
If chest tubes: -20 cm continuous wall suction
If temperature < 36.5ºC (97.7ºF):
Warm IVFs & blood products
Cover patient’s head
Warm air device
Warming lights
Warm room
Antiembolic devices:  SCD  Other: _______________________________________________
Weigh patient on admission, if possible
 NGT/OGT to low intermittent suction
Diet:
 NPO
 Clear liquids
 Sips with meds
 As tolerated
 Tube feeding formula: ________________ at ______ ml/hr per _____________________
If receiving gastric tube feedings and residual is > 150 ml, discard and resume feedings after 1 hr
If NG or OG feeding tube is inadvertently removed, replace tube, confirm placement with KUB and
resume tube feeding. If unable to confirm placement, hold and begin NS IV at feeding tube rate.
Wound Care: ________________________________________________________________________
Activity:  Bedrest
 Position or activity restrictions: ________________________
 OOB, no limitations
 Other: ___________________________________________
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Send copy to pharmacy
*3-16298*
Order writer’s Initials___________
FORM 3-16298 REV. 07/2012
Page 1 of 2
PLACE LABEL HERE
TRAUMA ICU ADMISSION
POST-OP 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
28. IVF: ____________________________________________________ IV at _________________ ml/hr
29. Antibiotic: __________________________________________________________________ x 2 doses
If > 2 doses needed, must document indication ______________________________________
30. Antacid:  Carafate (sucralfate) 1 gm  po or  NG q 6 hrs (if NG to suction, clamp x 1 hr)
 Pepcid (famotidine) 20 mg IV q 12 hrs
PRN MEDICATIONS (if > one drug is ordered, RN will decide which drug to administer based on effectiveness and tolerance)
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 Potassium Cloride (KCl) _______ mEq IV over _______ hr(s)
Recheck K after infusion and repeat prn if K < 4.0
Magnesium (Mg) < 1.8:  Magnesium sulfate 2 gm IV over ______ hr(s)
Recheck Mg after infusion and repeat prn if Mg < 1.8
Ionized Ca < 1.12:
 Calcium Chloride 1 gm in NS 50 ml IV 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
 Follow sedation orders (form # 15395)
Severe pain:
 Morphine sulfate ________ mg IV q 1 hr prn
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
 Reglan (metoclopramide) 10 mg
 po or  NG q 6 hrs prn (5 mg if > 65 y/o)
 Phenergan (promethazine) 12.5-25 mg  po or  NG q 4 hrs prn
Sleep
 Restoril (temazepam) 15-30 mg po at HS prn. If 15 mg given, may repeat x 1 dose after 2 hrs
If > 65 years old, begin with 7.5 mg po at HS, may repeat x 1 dose after 2 hrs
 Ambien (zolpidem) 5-10 mg po at HS prn. If 5 mg given, may repeat x 1 dose after 2 hrs
If > 65 year old, begin with 5 mg po at HS, may repeat x 1 dose after 2 hrs
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
Pruritis:
 Benadryl (diphenhydramine) 25-50 mg po or IV q 6 hrs prn
CVC occlusion: Follow nursing policy 6057 regarding administration
 Cathflo (alteplase) 2 mg to clotted port x 1 dose, OR
 Call Trauma Surgeon for Cathflo (alteplase) order
Potassium (K) < 4.0:
ADDITIONAL ORDERS:
________________________________________________________________________________________
______________
Date
___________________
Time
_________________________________
Physician Signature
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PID Number
Send copy to pharmacy
FORM 3-16298 REV. 07/2012
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