ADULT CRITICAL CARE ADMISSION ORDERS 1 of 4

Actual Estimated

Patient ID Area

Weight

kg

Actual Estimated

Height

cm

ALLERGIES:Allergies

Diagnosis: Admit to Critical Care Dr.: bkPhysician Pager: (I) Check, circle and/or fill in all orders to be implemented as appropriate. 1. ADVANCE DIRECTIVES: Full Support If New DNRrefer to forms KH00571KH00578 2. 3. 4. SEVERE SEPSIS: Refer to Adult Severe Sepsis Bundle Order Set (KH01226) VITAL SIGNS: Every 2 hours unless otherwise indicated INTAKE & OUTPUT: Every 8 hours Obtain weight on admission and then every 5. DIET: Nothing by mouth bkUnCheckedBoxBy mouth: bkUnCheckedBoxEnteral feeds: 6. ACTIVITY: Bedrest Other: 7. 8. POSITION OF BED: bkUnCheckedBoxHead of Bed 30 at all times OXYGEN: bkUnCheckedBoxNasal Cannula bkUnCheckedBoxFace Mask 9. MECHANICAL VENTILATION: bkUnCheckedBoxNoninvasive Positive Pressure Ventilation (BiPAP) bkUnCheckedBoxTitrate Oxygen Saturation to Ventilator Mode: % Pressure Control inspiration/ expiration liters/minute % Out of Bed to Chair at mL/hour post x-ray review of feeding tube day(s) Do Not Resuscitate (DNR) Additional Directives: Condition:

bkUnCheckedBoxSynchronized Intermittent Mandatory Ventilation (SIMV) Pressure-Regulated-Volume Controlled (PRVC) Volume Control Assist Control Pressure Support: bkUnCheckedBoxOther: mL Rate: /minute

Ventilator Settings:

Tidal Volume [6 mL/kg Ideal Body Weight (IBW)]: Fraction of inspired oxygen bkUnCheckedBox 2 bkUnCheckedBox(FiO ): %

Positive end expiratory pressure (PEEP): Date: 12/10/11 Time: 9:54 PM Physician/NP/PA Signature:
WHITE - CHART
KH00617 Rev. 08/04/09 ORDERS

CANARY - NURSING
Place STAT barcode sticker within this box only on form copy being scanned

ADULT CRITICAL CARE ADMISSION ORDERS 2 of 4

10. INDWELLING URINARY CATHETER: bkUnCheckedBoxPlace (indication): 11. NASOGASTRIC TUBE(NG) Intermittent Suction Clamped 12. LABS: ADMISSION LAB WORK Chemistries: -Basic Metabolic Panel (BMP) Magnesium Prealbumin Hematology/Coagulation: Phosphate

Patient ID Area

( ) Check, circle and/or fill in all orders to be implemented as appropriate.

-Complete Metabolic Panel (CMP) Ionized Calcium Lipase Amylase hour(s) if not receiving insulin

Fingerstick glucose every

bkUnCheckedBoxComplete Blood Count (CBC) with differential -Prothrombin Time (PT)/ Activated Partial Thromboplastin Time (aPTT) -Arterial Blood Gas (ABG)/saturation Venous Blood Gas

Oxygen/Perfusion Assessment: (VBG)/saturation

Serum lactate every CULTURES -Urine Sputum with STAT gram stain NEXT MORNING LABS BMP CBC CMP CBC with differential VBG/saturation bkUnCheckedBoxOther: 13. DIAGNOSTICS: bkUnCheckedBoxChest X-ray (indication): Electrocardiogram (EKG) Other (indication): Other (indication): Next AM Diagnostics (include indication): 14. CONSULTS: Service: Service: 15. REFERRALS (indication): Physical Therapy: Date: Time: -Speech and Language: Physician: Physician:

hour(s)

bkUnCheckedBoxUrinalysis with microscopic examination bkUnCheckedBoxBlood cultures x 2 (venipuncture)

bkUnCheckedBoxOther (please specify site and number): Magnesium PT/ PTT Phosphate

bkUnCheckedBoxABG/saturation

Indication: Indication:

Physician/NP/PA Signature:
WHITE - CHART CANARY - NURSING
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ORDERS

ADULT CRITICAL CARE ADMISSION ORDERS 3 of 4

16. MEDICATIONS

Patient ID Area

( ) Check, circle and/or fill in all orders to be implemented as appropriate.

A. DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS (Risk Assessment on back) REQUIRED to (I) check all that apply Heparin 5000 units subcutaneous every 8 hours Pneumatic Compression Device (PCD): Knee High Pump Pneumatic Compression Device (PCD): Foot Pump Other Orders: DVT Prophylaxis not indicated (Reason): DVT Prophylaxis contraindicated (Reason): B. EXISTING MEDICATIONS: COMPLETE MEDICATION RECONCILIATION FORM KH01116 (New Admissions) Complete Kaleida Transfer Profile (KTP) Form for Medication Orders (Transferred Patients) C. NEW MEDICATIONS: SEDATION Refer to Moderate Sedation Protocol Order for Mechanically Ventilated Patients (KH00425) GLUCOSE CONTROL not for management of Diabetic Ketoacidosis (DKA) Initiate when serum glucose is consistently greater than 180 mg/d Insulin Infusion Protocol (KH01051) OR Computerized Insulin Dosing Protocol (MDN-CGS Program) GASTROINTESTINAL PROPHYLAXIS (select 1 agent and route below) Famotidine 20 mg: bkUnCheckedBoxby mouth twice a day OR bkUnCheckedBoxdown nasogastric tube/dobhoff tube twice a day OR bkUnCheckedBoxintravenous every 12 hours (use only if unable to administer medication via enteral route) Pantoprazole 40 mg by mouth daily OR suspension down nasogastric tube/dobhoff tube daily OR intravenous daily (use only if unable to administer medication via enteral route) OTHER MEDICATION a. b. c. d. e. f. Date:
KH00617 Rev. 08/04/09 ORDERS

dose

route

interval

indication

Time:

Physician/NP/PA Signature:
WHITE - CHART CANARY - NURSING
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ADULT CRITICAL CARE ADMISSION ORDERS 4 of 4

Patient ID Area

DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS RISK ASSESSMENT

RISK FACTORS
AGE
greater than 60 years 41 - 60 years
points

IMMOBILITY
Coma Patient confined to bed greater than 72 hours Recent uninterrupted travel greater than 4 hours

points

SURGERY
Hip/Pelvic/Long Bone Fracture Multiple Trauma Laparoscopic/Pelvic Surgery Major Surgery greater than 45 minute duration

points

2 1

2 2 1

5 5 2 2

PRE-EXISTING/CURRENT MEDICAL CONDITIONS

points points

Ischemic Stroke/Paralysis Previous DVT or Pulmonary Embolism (PE) Hypercoagulation State* Cancer Central Venous Catheter greater than 1 week (excludes Renal Access) Infection (severe/sepsis) Chronic Obstructive Pulmonary Disease (COPD)/Respiratory Distress/Steroid or Oxygen Dependent Estrogen Use (oral contraceptives, hormone replacement therapy [HRT]) * Examples of Hypercoagulation State: Protein C or S deficiency

5 3 3 2 2 1 1 1

Current Heart Failure/ Myocardial Infarction Obesity (greater than 20% Ideal Body Weight [IBW]) Pregnancy/Postpartum less than 1 month Severe Dehydration Nephrotic syndrome Varicose Veins/Vein Surgery/Phlebitis Inflammatory Bowel Disease Chemotherapy Family Medical History unexplained DVT Lupus Anticoagulant Homocysteinemia

1 1 1 1 1 1 1 1 1

Antithrombin III deficiency

LOW RISK (Score of 1 or less)

No prophylaxis Ambulate

MODERATE TO HIGH RISK* (Score of 2 - 4)

Heparin 5000 units subcutaneous every 8 hours -ORPneumatic Compression Device (PCD)

HIGHEST RISK/MULTI MODAL* (Score of 5 or higher)

Heparin 5000 units subcutaneous every 8 hours -ANDPneumatic Compression Device (PCD)

*Recommendations apply to general medical and surgical patients. Please see below for additional recommendations for specific patient populations.

ALTERNATIVE RECOMMENDATIONS FOR SPECIFIC PATIENT POPULATIONS

High Risk Bleeding Neurosurgery Orthopaedic Surgery Trauma/ Coronary Artery Spinal Cord Injury Bypass Surgery Bariatric Surgery
(any population with moderate to high venous thromboembolism [VTE] risk)

History of Heparininduced Thrombocytopenia

Fondaparinux 2.5 mg subcutaneous daily
(Contraindicated if Creatinine Clearance [CrCl] less than 30 mL/minute)

Heparin 5000 units subcutaneous every 8 hours -ANDPneumatic Compression Device (PCD)

See form KH00202 Total Knee/Hip Arthroplasty Post-Operative Orders

Enoxaparin 30 mg subcutaneous every 12 hours -ANDPneumatic Compression Device (PCD)

Enoxaparin 40 mg subcutaneous daily

(Enoxaprin 30 mg subcutaneous daily if Creatinine Clearance [CrCl] less than 30 mL/minute)

Enoxaparin 40 mg subcutaneous every 12 hours

Pneumatic Compression Device (PCD)

Consider platelet monitoring for prolonged anticoagulation

References: Modified From: Motyke, GD, Zebal, LP and Caprini, et al. A Guide to Venous Thromboembolism Risk Factor Assessment. Journal of Thrombosis and Thrombolysis, 2000. Geerts W, Bergqvist D, Pineo G et al. Prevention of Venous Thromboembolism. Chest 2008; 133: 381S-453S

KH00617 Rev. 08/04/09