H006-21950 - SCANNED TO PHARMACY STAT MEDICATION Date:

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Unformatted text preview: SCANNED TO PHARMACY STAT MEDICATION Date: ______________________________ Time: ______________________________ Inpatient: Admit to Unit: PICU Concentrated Care Physician: __________________________________________________________________________________________________ Diagnosis: SEVERE SEPSIS / SEPTIC SHOCK Suspected Source: _________________________________________________ Condition: __________________________________________________________________________________________________ Allergies: _____________________________________________________________________________ Weight: ____________ kg Pulse Oximeter: Notify physician if O2 saturation is less than ____ or FiO2 greater than 50% Cardiac Monitoring Vital Signs & Neuro checks every 1 hour I & O Q 1 hour Diet: Strict NPO NPO except medication Activity: Strict bedrest. Head of bed at 30 degrees or reverse Trendelenburg at 30 degrees. Foley catheter to gravity drainage Laboratory Tests: If not done in Emergency Department, check all that apply: Pediatric Sepsis Panel: Includes CBC with manual differential, Blood Glucose, CRP, Venous Blood Gas with Ionized Calcium, Lactic Acid, CMP, PT, PTT, Fibrinogen, Cath Urinalysis, Cath Urine Culture, Blood Culture x 1 prior to Antibiotics Blood culture from line x 1 NP Swab for viruses DFA (Adenovirus, Influenza, Parainfluenza, RSV) ET Aspirate gram stain and culture Glucose Management: Obtain Accucheck STAT upon arrival and every _____ hours CSF Studies: Tube Tube Tube Tube 1 – Culture and Gram Stain 2 Protein and Glucose 3 Hold for Further Studies 4 Cell Count and Differential Other CSF Studies: Herpes PCR to UCD Lab Other CSF Studies _________________________________________________________________________________ Physician Signature: ____________________________________________________ Physician # __________________________ Authorization for therapeutic substitution is given unless checked here Patient Identification Sutter Medical Center, Sacramento A Sutter Health Affiliate Severe Sepsis / Septic Shock Orders Pediatric 21950 (7/6/09) Pg 1 of 3 ORDERS SCANNED TO PHARMACY STAT MEDICATION Blood Gas: ABG VBG Every ______ hours x ______ hours A.M. Labs: CBC with Manual Differential CMP Blood Gas: Arterial Venous Lactate RP Other A.M. Labs: ___________________________________________________________________________________ Other Laboratory Tests: _____________________________________________________________________________ Radiology: Portable Chest X-ray NOW:________ Reason: __________________________________________________________ Portable Chest X-ray Every A.M. While Intubated x 3 days Portable Abdominal X-ray Reason: _________________________________________ Reason: ___________________________________________________________________ C.T. Site: _________________________________________________________________________________________ Reason: _________________________________________________________________________________________ With Contrast IV PO Without Contrast Other: ___________________________________________________________________________________________ Ventilation Settings / Oxygen Supplementation: Ventilator FiO2 ___________________________________________________________________________ Nasal Cannula_______________________ L/Minute See Ventilator Order Set Mode: _______________________________________ Simple Mask Tidal Volume: _________________________________ Non Re-Breaker Mask PIP: _________________________________________ Wean FiO2 as tolerated for saturations PEEP: _______________________________________ Greater than______________ PS: _________________________________________ Trach Collar Rate: ________________________________________ Insp.Time: ___________________________________ Other Respiratory Orders: ___________________________________________________________________________ ________________________________________________________________________________________________ Deep Vein Thrombosis Prophylaxis: (If greater than 50kg) Ted Socks Ted Hose SCD Physician Signature: _____________________________________________________ Date: ______________ Time: ___________ Authorization for therapeutic substitution is given unless checked here Patient Identification Sutter Medical Center, Sacramento A Sutter Health Affiliate Severe Sepsis / Septic Shock Orders Pediatric 21950 (7/6/09) Pg 2 of 3 ORDERS SCANNED TO PHARMACY STAT MEDICATION Medications: Weight:____________kg Allergies: ___________________________________________________________________ Fluid Bolus:_________________mLs IV over __________________________________________________________________ Maintenance Fluids:____________ with ____________ KCI/L at _____________mL/hour Dopamine __________ mcg/kg/minute Dobutamine __________mcg/kg/minute Milrinone __________mcg/kg/minute Epinephrine __________mcg/kg/minute Vasopressin __________milliunits/kg/hour Norepinephrine __________mcg/kg/minute Cefotaxime (Claforan) __________mg (50 mg/kg/dose. Max dose = 2 grams) IV every 6 hours Ceftriaxone (Rocephin) __________mg (50 mg/kg/dose. Max dose = 2 grams) IV every 12 hours *Not to be used with IV Calcium or in infants less than 2 months of age Cefepime (Maxipime) __________mg (50 mg/kg/dose. Max dose = 2 grams) IV every 12 hours Vancomycin (Vancocin) __________ mg (10 mg/kg/dose. Max dose = 2 grams) IV every 8 hours Check Vancomycin peak/trough levels after 3rd dose, pharmacy to adjust dosing Other Antibiotic ___________________________________________________________________________________________ Metronidazole (Flagyl) __________mg (7.5 mg/kg/dose. Max dose = 1 gram) IV every 6 hours Ranitidine Hydrochloride (Zantac) __________mg (1 mg/kg. Max dose 50 mg) IV every 8 hours (PUD prophylaxis) Pepcid __________mg (1 mg/kg. Max dose 20 mg) IV every 12 hours (PUD prophylaxis) Ibuprofen __________ mg (10 mg/kg/dose. Max dose 800 mg) PO every 6 hours as needed for temperature greater than __________ or pain Acetaminophen (Tylenol) __________ mg (15 mg/kg/dose. Max dose 1000 mg) PO/PR every 4 hours as needed for temperature greater than __________ or pain Lacrilube Ophthalmic Ointment, Both eyes Once per shift as needed ______________ Eye Care Arterial Line: 250 mL Normal Saline, Continuous IV Infusion __________ mL/hour ___________ Continuous Monitoring Central Venous Pressure Line (CVP): 250 mL Normal Saline, Continuous IV infusion __________ mL/hour ___________ Continuous Monitoring Physician Signature: ____________________________________________________ Physician # __________________________ Authorization for therapeutic substitution is given unless checked here Patient Identification Sutter Medical Center, Sacramento A Sutter Health Affiliate Severe Sepsis / Septic Shock Orders Pediatric 21950 (7/6/09) Pg 3 of 3 ORDERS ...
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