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attach patient label Physician Orders LEB Critical Care Respiratory Plan PEDIATRIC T= Today; N = Now (date and time ordered) Height: ___________cm Weight: __________kg [ ] No known allergies Allergies: Respiratory Care NOTE: Order Initiate Pediatric Respiratory Treatment Protocol order or choose individual orders below: Initiate Pediatric Respiratory Treatment T;N [ ] Protocol Initiate Pediatric BHH Protocol T;N [ ] Cardiopulmonary Monitor T;N Routine, Monitor Type: End Tidal Co2 [ ] Cardiopulmonary Monitor T;N Routine, Monitor Type: Transcutanous Co2 [ ] Peak Flow T;N prn PRN, Special Instructions: when patient is able to perform test [ ] Oxygen Delivery T;N, ___L/min or FiO2 ____, Titrate to keep O2 sat at =/>92% per policy [ ] Oxygen Delivery T;N, ___L/min or FiO2 ____, Titrate to keep O2 sat =/> ___% [ ] Heliox T;N, %Helium/Oxygen ____/ ____ [ ] Highflow, Nasal Cannula T;N, ___L/min, FiO2 ____ [ ] Nasal CPAP T;N, q4h, EP:____ FiO2: _____ [ ] Bubble CPAP T;N, q4h, EP:____ FiO2: _____ [ ] BiPAP T;N, q4h, O2%____ IPAP ____ EPAP_____ Rate_______ [ ] Mechanical Ventilation T; N, Mode:_____, Ventilator Rate:____(br/min) Tidal Volume ____(mL) [ ] FiO2:____ PEEP:____ Pressure Support:____ PIP:____ TI_____ Ventilator Weaning Trial Medical by RT T;N, Special Instructions: Rt-wean per unit protocol [ ] Extubate-RT T;N, Special Instructions: Extubate patient per PICU Guidelines of Care NOTE: FLOW for High Frequency Ventilation < 1000 g (6-8) LPM, 1000g - 2500 g flow (10-12) LPM, Term infant with severe meconium aspiration: flow 15-20 LPM High Frequency Ventilation T;N, FiO2: _____, MAP_______, Hz_______, Amplitude _______, TI 33% [ ] Nitric Oxide (RT) T;N, 20, optimum dose = 20 ppm [ ] Nitric Oxide (RT) T; N, _____ppm, optimum dose= 20 ppm [ ] Nitric Oxide (RT) T; N, wean by _____ppm, q_____ hours [ ] ISTAT POC (RT Collect) T;N, STAT, ABG, once, blood, obtain 30 minutes after intubation [ ] ISTAT POC (RT Collect) T;N, STAT, ABG, lactate, once, blood, obtain 30 minutes after intubation [ ] ISTAT POC (RT Collect) T;N, STAT, ABG, electrolytes, glucose, ionized calcium, Hct & Hgb,once, blood, [ ] obtain 30 minutes after intubation ISTAT POC (RT Collect) T;N, STAT, ABG, electrolytes, glucose, ionized calcium, Hct & Hgb, lactate,once, [ ] blood, obtain 30 minutes after intubation ISTAT POC (RT Collect) T;N, STAT, VBG,once, blood, obtain 30 minutes after intubation [ ] ISTAT POC (RT Collect) T;N, STAT, VBG, lactate,once, blood, obtain 30 minutes after intubation [ ] ISTAT POC (RT Collect) T;N, STAT, VBG, electrolytes, glucose, ionized calcium, Hct & Hgb,once, blood, [ ] obtain 30 minutes after intubation ISTAT POC (RT Collect) T;N, STAT, VBG, electrolytes, glucose, ionized calcium, Hct & Hgb, lactate,once, [ ] blood, obtain 30 minutes after intubation ISTAT POC (RT Collect) T;N, STAT, CBG,once, blood, obtain 30 minutes after intubation [ ] ISTAT POC (RT Collect) T;N, STAT, CBG, lactate,once, blood, obtain 30 minutes after intubation [ ] [ ] *065* 40706 PP Critical Care Respiratory-QM-0209 Page 1 of 3 attach patient label Physician Orders LEB Critical Care Respiratory Plan PEDIATRIC T= Today; N = Now (date and time ordered) [ ] ISTAT POC (RT Collect) [ ] ISTAT POC (RT Collect) [ ] [ ] ISTAT POC (RT Collect) Co-oximetry (RT Collect) [ ] Sodium Chloride 0.9% [ ] Sodium Chloride 0.9% [ ] Heparin 2 Units/ml in 500 ml NS (Pediatric) 1/4 NS with 1 unit heparin/ml [ ] Heparin 10 unit/mL flush [ ] NOTE: Continuous nebulization [ ] albuterol 0.5% inh soln [ ] albuterol 0.5% inh soln NOTE: Intermittent nebulization [ ] albuterol 0.083% inh soln [ ] albuterol 0.083% inh soln [ ] [ ] albuterol 0.083% inh soln albuterol 0.083% inh soln [ [ ] ] albuterol MDI albuterol MDI [ [ [ [ ] ] ] ] ipratropium ipratropium ipratropium fluticasone [ ] [ ] [ ] [ ] budesonide budesonide racepinephrine 2.25% inh solution sodium chloride 7% inh soln [ ] sodium chloride 7% inh soln Respiratory Care continued T;N, STAT, CBG, electrolytes, glucose, ionized calcium, Hct & Hgb,once, blood, obtain 30 minutes after intubation T;N, STAT, CBG, electrolytes, glucose, ionized calcium, Hct & Hgb, lactate,once, blood, obtain 30 minutes after intubation T;N, STAT, SVOT, frequency:__________, blood T;N, Time Study, q12h, blood Continuous Infusions 1000 mL, Injection, Intra-ARTERIAL, ___ mL/hr, Routine, T;N, Infuse via ART line, To be performed by RT 1000 mL, Injection, Central, ___ mL/hr, Routine, T;N, Infuse via CVP line, To be performed by RT 500mL,injection,IV,STAT,T:N, at____mL/hr,Infuse via central line 250 mL,IV,STAT,T:N, at____mL/hr, Infuse via central or arterial line Medications 5 mL, (10units/mL),Ped Injectable, IVPush, prn, PRN Catheter clearance, routine,T;N, peripheral or central line per nursing policy Respiratory Medications 15 mg/hr, Inh Soln, NEB, q8h, Routine, T;N, (3 mL/hr = 15 mg/hr), Dilute in NS, for continuous nebulization 30 mg/hr, Inh Soln, NEB, q8h, Routine, T;N, (6 mL/hr = 30 mg/hr), Dilute in NS, for continuous nebulization ____mg,(3 mL), Inh soln, NEB, q6h, routine,T;N (3 mL = 2.5 mg) ____mg,(3 mL), Inh soln, NEB, q6h, PRN Wheezing, routine,T;N (3 mL = 2.5 mg) ____mg,(1.5 mL), Inh soln, NEB, q6h, routine,T;N ( 1.5 mL = 1.25 mg) ____mg,(1.5 mL), Inh soln, NEB, q6h, PRN Wheezing, routine,T;N ( 1.5 mL = 1.25 mg) ____ puffs, MDI,inhaled, q6h, routine, T;N, (180 mcg = 2 puffs) ____ puffs, MDI,inhaled, q6h, PRN wheezing, routine, T;N, (180 mcg = 2 puffs) 0.125 mg, Inh soln, NEB, q8h, routine,T;N ( 0.625 mL = 0.125 mg) 0.25 mg, Inh soln, NEB, q8h, routine,T;N ( 1.25 mL = 0.25 mg) 0.5 mg, Inh soln, NEB, q8h, routine,T;N ( 2.5 mL = 0.5 mg) 2 puffs, MDI,inhaled, bid, routine, T;N, Select strength: ____44mcg/actuation ____110mcg/actuation ______220mcg/actuation 0.25 mg, Inh soln, NEB, bid, routine,T;N ( 2 mL = 0.25 mg) 0.5 mg, Inh soln, NEB, bid, routine,T;N ( 2 mL = 0.5 mg) 0.25 mL, Inh soln, NEB, q4h, PRN stridor,Routine,T;N 2 mL, Inh Soln, NEB, BID, Routine, T;N, give after bronchodilator and before airway clearance 4 mL, Inh Soln, NEB, BID, Routine, T;N, give after bronchodilator and before airway clearance 40706 PP Critical Care Respiratory-QM-0209 Page 2 of 3 attach patient label Physician Orders LEB Critical Care Respiratory Plan PEDIATRIC T= Today; N = Now (date and time ordered) [ ] dornase alfa [ ] dornase alfa [ ] [ ] sodium bicarbonate 4.2% inhalation soln acetylcysteine 20% inhalation soln [ ] tobramycin inhalation soln [ ] Methemoglobin [ ] [ ] [ ] Chest 1VW Frontal Chest PA & Lateral Echocardiogram Pediatric (0-18 yrs) [ ] Notify Physician-Continuing __________________ Date __________________ Time Respiratory Medications continued 2.5mg, Inh Soln, NEB, QDay, Routine, T;N, via PARI nebulizer (after hypertonic saline and before airway clearance) 2.5mg, Inh Soln, NEB,BID,Routine, T;N, via PARI nebulizer (after hypertonic saline and before airway clearance) 1mL, Inh Soln, lavage,q2h,PRN secretions,Routine, T;N, Mix each mL of 4.2% sodium bicarbonate with 2.25 mL sterile water. For ET suctioning. 1mL, Inh Soln,NEB,q6h,PRN secretions,Routine, T;N, Mix each mL of acetylcysteine with 0.083% albuterol inhalation soln Inhaled Antibiotics 300 mg, Inh Soln, NEB, bid, Routine, T;N Laboratory Time Study, q12h, Type: Blood, Comment: if patient on nitric oxide Diagnostic Tests T;N, routine, Reason:_____________________, Transport:Portable T;N, routine, Reason:_____________________, Transport:Portable T;N, routine, Reason:_____________________, Transport:Portable Consults/Notifications T;N, Who: ________________________, For:O2 sats less than or = 92% _________________________________________________ Physician's Signature 40706 PP Critical Care Respiratory-QM-0209 Page 3 of 3 __________________ MD Number
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