322-0782 ICU ADMIT ORDERS rev 12-09

ICU ADMIT ORDERS PRIMARY STEP-DOWNDATE: ________________________DIAGNOSIS: ____________________________________________________ALLERGIES & CODE STATUS: SEE SEPARATE FORMSPATIENT DEMOGRAPHICSADMIT MD NAME: _________________________________________________CONSULTS: ______________________________________________________________________________________________________ACTIVITIES: Bedrest with position of comfort. May be assisted to commode after first 12 hours if free of pain or shock. Bedrest with bathroom privileges as tolerated.DIET: General CCU Cardiac Diabetic Renal OtherFLUIDS:Intake and output every 8 or ________ hours Foley catheter to gravitySecondary CCU: Establish and maintain one IV access with NS at TKO; may saline lock if patient stable.Primary CCU: Establish and maintain two IV accesses with NS at TKO; may saline lock if patient stable.VITAL SIGNS: Primary: every hour Fingersticks: ______________________________________________Secondary: every two hours and PRNObtain initial blood pressure on both sides unless contraindicatedTemperature Q 8 hours or ________Daily weightContinuous cardiac monitoring with documented rhythm strips every four hours and PRN.O2 to keep saturation greater than ________MEDICATIONS: (standing orders unless crossed out)Tylenol gr X PO/PR PRN every 4 hours or ________ hours for increased temperature or painZofran 4 mg IV every four hours PRN nausea/vomitingColace 100 mg PO Q day PRN constipationNTG 0.4 mg Sublingual every five minutes times three for chest pain and call physician.Restoril 15 mg PO Q HS PRN insomnia. May repeat times one.DVT PROPH: Lovenox 40 mg subcutaneous daily Unfractionated Heparin 5,000 Units subcutaneously twice daily Sequential stockings Ted Hose - remove for half hours and reapply twice dailyLABS (if notDone in ER): CMP Magnesium Complete Blood Count with differential PT/PTT CCU set = CBC, CK, CKMB, Troponin, BMP, MagnesiumSELECT TSH for tachycardia or dysrhythmias Fasting Lipid ProfileTHE LABS 12 lead EKG on admission Cardiac enzymes with Troponin Index every 8 hrs x 3YOU 12 lead EKG daily times two Portable chest x-ray (PA) if not done in ERWANT 2D Echo/Doppler DX: __________________________________ Read by: __________________________________ Other tests: ________________________________________________________________________________________________________________________________________________________________________________________NOTIFICATION OF MED: Notify MD of any significant changes in patient statusOTHER MEDICATION ORDERS: (cross out unused lines) (SEE NEXT PAGE FOR IV DRIP SECTION)________________________________________________________________________________________________________________________________________________________________________________________________________________________________Physician signature/date/time: ______________________________________________________________________________________FORM 322-0782 12/09 (PAGE 1 OF 2)WHITE - MEDICAL RECORDFAX COPY TO PHARMACY

ICU ADMIT ORDERSPAGE TWOIV DRIPS ALLOWED IN SECONDARY ICU AT PHYSICIAN DISCRETION: Lidocaine (see order section below) Amiodarone/Cordarone (see order section below)PATIENT DEMOGRAPHICSIV DRIPS/OTHER MEDICATIONS: Dopamine 400 mg/250 ml premix at ________ mcg/min Parameters: ________________________________________ Lidocaine 2 gm/500 ml premix at ________ mg/min Parameters: ________________________________________ Metoprolol 25 mg/250 ml at ________ mg/hr Parameters: ________________________________________ Nitroglycerin 50 mg/250 ml premix at ________ mcg/min Parameters: ________________________________________ Norepinephrine 4 mg/250 ml at ________ mcg/min Parameters: ________________________________________ Amiodarone/Corarone 900 mg in 500 ml D5W at ________ mg/min Parameters: ________________________________________ADDITIONAL ORDERS: (cross out any unused lines)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________REMINDERS: for CHF patients - document LVF assessments; Diabetics - use pre-printed insulin sliding scale orders; forIschemic Stroke patients - use pre-printed Ischemic Stroke Orders; for Pneumonia patients - use pre-printed PneumoniaAdmit Orders; reconcile medications on admission and transferNURSING INTERVENTIONS IN EMERGENCY SITUATIONS, FOLLOWED BY NOTIFICATION OF MD:1. For severe respiratory distress: Stat PCXR, ABG, titrate oxygen up to 15 liters/minute PRN to maintain SpO2 greaterthan 92%.2. Stat 12 lead EKG for new onset or escalating chest pain, ST elevations, or dysrhythmias.3. Dopamine drip for symptomatic systolic blood pressure less than 80 - start at 2-5 mcg/kg/min. - titrate to keep systolicblood pressure greater or equal to 90 mm/hg.4. Initiate ACLS protocol as necessary.Physician Signature: ______________________________________________ Date: ___________________ Time: __________________FORM 322-0782 12/09 (PAGE 2 OF 2)WHITE - MEDICAL RECORDFAX COPY TO PHARMACYCCU ADMIT ORDERS