ICU Admission Order Set

ALL ORDERS MUST BE WRITTEN WITH A BALL POINT PEN AND INCLUDE DATE, TIME, AND PHYSICIAN’S SIGNATURE.
PHYSICIAN’S ORDER
(EXCLUDING IV Fluids and MEDICATIONS)
ICU Admission Orders—Page 1 of 5
DATE: _________________ TIME: _______________
Admitting MD: ____________________________
Diagnosis:_________________________________
__________________________________________
__________________________________________
Comorbidities/History
□ CAD □ PVD □ COPD □ Smoker
□ CA □ CVA □ Trauma □ HTN
□ CHF □ DM □ Sepsis □ CRF
□ ESRD
□ Hemodialysis
□ Trauma _______________
□ Cardiomyopathy □ Immunosuppressed
□ Poor Nutrition
□ Acute Coronary Syndrome
□ Other: ___________________________________
Activities
□ Bed rest
□ Other ___________________________________
Diet: _____________________________________
Consults:
□ Cardiology/ Dr. ___________________________
□ Renal/ Dr. _______________________________
□ Pulmonary/ Dr. ___________________________
□GI/Dr. ___________________________________
□ GU/ Dr. _________________________________
□ Neurologist/ Dr. ___________________________
□ Nuerosurgeon/ Dr. _________________________
□ Psychiatry/Dr. ____________________________
□ ID/Dr. ___________________________________
□ Surgical/ Dr. ______________________________
for □ Central Line □ Other: _________________
Continued on next page >>>>>>
Summary/Blanket orders are unacceptable.
Medication orders must be complete.
PRN medication orders must include an indication.
Write legibly.
Rewrite orders upon transfer and/or post-operatively.
Date, time, and sign verbal & telephone orders within 48 hours.
Physician’s Order Form (Page 1 of 5)
ICU Admission Order Set
GMHA #049063 Stock # 99049063
APPROVED DATE: Medicine Dept. 10/2010, MEC 07/2011, HIMC 03/2012
IVF and MEDICATION ORDERS ONLY IVF and MEDICATION ORDERS ONLY IVF and MEDICATION ORDERS ONLY IVF and MEDICATION ORDERS ONLY
DATE TIME INTRAVENOUS FLUID and MEDICATION
ORDERS
ALLERGY:
IV Fluids
□ 1000 mL 0.9% sodium chloride IV to run at _____
mL/hr x _____ liters.
□ 1000 mL: 5%dextrose IV to run at ____mL/hr x
__________ liters.
□ Add □ 20 mEq □ 40 meq Potassium chloride to
each liter of IV fluid.
□ Other IV fluids; ___________________________
Anticoagulation
□ Enoxaparin (Lovenox) - See attached order form.
□ Other: ___________________________________
________________________________________
DVT Prophylaxis
□ Tedhose/Pneumatic Stockings
□ Sequential Compression Device
□ Heparin – See attached order form.
□ Enoxaparin (Lovenox) - See attached order form.
□ Other: ___________________________________
_________________________________________
Stress Ulcer/GI Bleed Prophylaxis
□ Zantac 50 mg IV q 8 hours.
□ Pantoprazole (Protonix) 40 mg IV q 24 hours.
□ Sulcralfate (Carafate) 1 gram via NG/OG Tube
every 6 hours.
□ Other: ___________________________________
__________________________________________
__________________________________________
Continued on next page >>>>>>
DO NOT USE:
U
MS
IU MSO 4
Q.D. MgSO 4
Q.O.D. Trailing zero
Lack of leading zero
MD initials:
PATIENT ID LABEL

ALL ORDERS MUST BE WRITTEN WITH A BALL POINT PEN AND INCLUDE DATE, TIME, AND PHYSICIAN’S SIGNATURE.
PHYSICIAN’S ORDER
(EXCLUDING IV Fluids and MEDICATIONS)
ICU Admission Order Set – Page 2 of 5
□ Dietary
□ PT/OT
□ Social Service: ____________________________
□ Other: ___________________________________
Code Status:
□ Full ACLS
□ No Defibrillation
□ No Intubation
□ No Chest Compressions
□ No ACLS Interventions (Do Not Resuscitate):
continue care as ordered.
□ Other ___________________________________
_________________________________________
Treatments:
□ Vital Signs Routine per ICU/CCU Protocol
□ Pulse Oximetry
□ Nasal Canula 2 – 6 liters/hr as needed to
maintain oxygen saturation > 90%.
□ Foley Catheter to drainage bag.
Weights □ Every other day □ Daily
OG Tube □ Intermittent Suction □ Gravity
□ Clamp
□ Venous Thromboembolism Prophylaxis
□ Other: ___________________________________
_________________________________________
□ BiPap Settings: __________________________
__________________________________________
Continued on next page >>>>>>
IVF and MEDICATION ORDERS ONLY IVF and MEDICATION ORDERS ONLY IVF and MEDICATION ORDERS ONLY IVF and MEDICATION ORDERS ONLY
DATE TIME INTRAVENOUS FLUID and MEDICATION
ORDERS
ALLERGY:
Pain
□ Morphine Sulfate 1 – 4 mg IV every 1 hour PRN
for mild pain.
□ Morphine Sulfate 5 – 8 mg IV every 1 hour PRN
for moderate pain.
□ Morphine Sulfate 9 – 12 mg IV every 1 hour PRN
for severe pain.
□ Morphine Sulfate _____ mg IV every _____ hour
PRN for _________________________________
□ Other: ___________________________________
_________________________________________
Nausea
□ Ondansetron (Zofran) 4 mg IV every 8 hours PRN
for nausea.
□ Promethazine (Phenergan) 25 – 50 mg IV every 4
hours PRN for nausea.
□ Properidol (Inapsine) 0.625 mg IV every 4 hours
PRN for nausea.
□ Other: __________________________________
________________________________________
Other Medications
( ) _______________________________________
_______________________________________
( ) _______________________________________
_______________________________________
( ) _______________________________________
_______________________________________
Continued on next page >>>>>>
Summary/Blanket orders are unacceptable.
Medication orders must be complete.
PRN medication orders must include an indication.
Write legibly.
Rewrite orders upon transfer and/or post-operatively.
Date, time, and sign verbal & telephone orders within 48 hours.
Physician’s Order Form (Page 2 of 5)
ICU Admission Order Set
GMHA #049063 Stock # 99049063
APPROVED DATE: Medicine Dept. 10/2010, MEC 07/2011, HIMC 03/2012
DO NOT USE:
U
MS
IU MSO 4
Q.D. MgSO 4
Q.O.D. Trailing zero
Lack of leading zero
MD initials:
PATIENT ID LABEL

ALL ORDERS MUST BE WRITTEN WITH A BALL POINT PEN AND INCLUDE DATE, TIME, AND PHYSICIAN’S SIGNATURE.
PHYSICIAN’S ORDER
(EXCLUDING IV Fluids and MEDICATIONS)
ICU Admission Order Set – Page 3 of 5
DATE TIME INTRAVENOUS FLUID and MEDICATION
ORDERS
ALLERGY:
□ Ventilator Settings:
FiO2 _______________ TV _______________
PEEP _____________ AC _______________
PS _____________ Rate _______________
□Ventilator Bundle (for all ventilator patients):
HOB 30 degrees.
Daily “sedation wakeup”.
Daily assessment for weaning from ventilator.
Oral Care every 2 hours (with antiseptic
solution).
ABG every morning
Additional Pulmonary Orders:
( ) _______________________________________
_______________________________________
( ) _______________________________________
_______________________________________
( ) _______________________________________
_______________________________________
STAT Labs and Diagnostics:
□ CBC (auto diff) □ Liver Panel
□ CBC (manual diff) □ UA
□ PT/PTT
□ D-Dimer
□ Finger Stick for BS □ Lactate
□ ABG
□ BNP
□ CHEM 7
□ Magnesium
□ Phosphorus
□ Amonia
□ Calcium
□ LDH
Continued on next page >>>>>>
Summary/Blanket orders are unacceptable.
Medication orders must be complete.
PRN medication orders must include an indication.
Write legibly.
Rewrite orders upon transfer and/or post-operatively.
Date, time, and sign verbal & telephone orders within 48 hours.
Physician’s Order Form (Page 3 of 5)
ICU Admission Order Set
GMHA #049063 Stock # 99049063
APPROVED DATE: Medicine Dept. 10/2010, MEC 07/2011, HIMC 03/2012
IVF and MEDICATION ORDERS ONLY IVF and MEDICATION ORDERS ONLY IVF and MEDICATION ORDERS ONLY IVF and MEDICATION ORDERS ONLY
□ POTASSIUM REPLACEMENT PROTOCOL
(NOT for use with Renal Patients)
Check potassium level.
Discontinue potassium protocol if serum
creatinine is greater than 3 mg/dL and call
physician for orders.
Once potassium is WNL, ask physician for oral
potassium order.
□ If potassium level LESS THAN 3.5 mg/dL:
Central Line: Infuse Potassium Chloride 40
mEq IV in 100 mL NSS over 2 hours.
Peripheral Line: Infuse Potassium Chloride 20
mEq IV in 100 mL NSS x 2 doses over 4 hours
of total dose of 40 mEq. Infuse at 50 mL/hr.
Repeat Potassium Level 3 hours after infusion
complete.
□ If potassium level 3.5 mg/dL – 3.9 mEq/L:
Central Line: Infuse Potassium Chloride 20
mEq in 100 mL NSS over 1 hour.
Peripheral Line: Infuse Potassium Chloride 20
mEq in 100 mL NSS over 2 hours. Repeat
Potassium Level 3 hours after infusion complete.
□ If potassium level GREATER THAN 5.5
mEq/L:
STOP ALL ORAL AND IV POTASSIUM AND
NOTIFY PHYSICIAN.
Continued on next page >>>>>>
DO NOT USE:
U
MS
IU MSO 4
Q.D. MgSO 4
Q.O.D. Trailing zero
Lack of leading zero
MD initials:
PATIENT ID LABEL

ALL ORDERS MUST BE WRITTEN WITH A BALL POINT PEN AND INCLUDE DATE, TIME, AND PHYSICIAN’S SIGNATURE.
PHYSICIAN’S ORDER
(EXCLUDING IV Fluids and MEDICATIONS)
ICU Admission Order Set – Page 4 of 5
DATE TIME INTRAVENOUS FLUID and MEDICATION
ORDERS
ALLERGY:
STAT Labs and Diagnostics continued:
□ CPK, MB, Troponin □ Chem 20
□ Culture
□ Urine
□ Sputum
□ Stool
□ Blood x ____
□ Other: ___________________________________
□ CT Scan of: ______________________________
□ With Contrast: □ IV □ Oral □ NGT
□ OGT □ PEG □ Rectal
□ WithOUT Contrast
□ Portable CXR
□ Ultrasound of _____________________________
________________________________________
□ Echocardiogram ___________________________
to interpret study.
□ EKG
AM Labs and Diagnostics:
□ CBC (auto diff) □ Liver Panel
□ CBC (manual diff) □ UA
□ PT/PTT
□ D-Dimer
□ Lactate
□ ABG
□ BNP □ CHEM 7
□ Magnesium
□ Phosphorus
□ Ammonia
□ Calcium
□ LDH
□ CPK, MB, Troponin
□ Accucheck Every _____
□ Culture □ Urine □ Sputum □ Urine
□ Stool □ Other: ________________
□ CT Scan of: ______________________________
□ With Contrast: □ IV □ Oral
□ WithOUT Contrast
Continued on next page >>>>>>
IVF and MEDICATION ORDERS ONLY IVF and MEDICATION ORDERS ONLY IVF and MEDICATION ORDERS ONLY IVF and MEDICATION ORDERS ONLY
□ MAGNESIUM REPLACEMENT PROTOCOL
(NOT for use with Renal Patients)
Check Magnesium Level.
□ If magnesium level 1.6 – 1.7 mg/dL:
Infuse 2 gram Magnesium Sulfate in 250 mL
NSS IV over 8 hours.
Repeat serum Magnesium Level 8 hours after
completion of infusion.
□ If magnesium level 1.4 – 1.5 mg/dL:
Infuse 4 grams Magnesium Sulfate in 250 mL
NSS IV over 8 hours.
Repeat serum Magnesium Level 8 hours after
completion of infusion.
□ If magnesium level 1.2 – 1.3 mg/dL:
Infuse 6 grams Magnesium Sulfate in 250 mL
NSS IV over 8 hours.
Repeat serum Magnesium Level 8 hours after
completion.
□ If magnesium level LESS THAN 1.2 mg/dL
WITH Seizures:
Infuse 4 grams Magnesium Sulfate in 250 mL
D5W at a maximum rate of 3 mL/min.
Continued on next page >>>>>>
Summary/Blanket orders are unacceptable.
Medication orders must be complete.
PRN medication orders must include an indication.
Write legibly.
Rewrite orders upon transfer and/or post-operatively.
Date, time, and sign verbal & telephone orders within 48 hours.
Physician’s Order Form (Page 4 of 5)
ICU Admission Order Set
GMHA #049063 Stock # 99049063
APPROVED DATE: Medicine Dept. 10/2010, MEC 07/2011, HIMC 03/2012
DO NOT USE:
U
MS
IU MSO 4
Q.D. MgSO 4
Q.O.D. Trailing zero
Lack of leading zero
MD initials:
PATIENT ID LABEL

ALL ORDERS MUST BE WRITTEN WITH A BALL POINT PEN AND INCLUDE DATE, TIME, AND PHYSICIAN’S SIGNATURE.
DATE TIME PHYSICIAN’S ORDER
(EXCLUDING IV Fluids and MEDICATIONS)
ICU Admission Order Set – Page 5 of 5
DATE TIME INTRAVENOUS FLUID and MEDICATION
ORDERS
ALLERGY:
AM Labs and Diagnostics continued:
□ Portable CXR
□ Ultrasound of _____________________________
________________________________________
□ Echocardiogram ___________________________
to interpret study.
□ EKG
TORB: ____________________________________
MD Signature: ______________________________
IVF and MEDICATION ORDERS ONLY IVF and MEDICATION ORDERS ONLY IVF and MEDICATION ORDERS ONLY IVF and MEDICATION ORDERS ONLY
□ For Torsades de Pointes:
Bolus 1 gram magnesium Sulfate in 50 mL D5W
over 5 to 60 minutes.
Follow with 0.5 mg to 1 gram per hour—titrated
to control Torsades.
Discontinue after level is normal.
Repeat Serum Magnesium 8 hours after
completion of infusion.
□ Vaccine Order
□ Pneumonia Vaccine
□ Influenza Vaccine
□ Wound Care Bundle
MD Signature: ______________________________
Summary/Blanket orders are unacceptable.
Medication orders must be complete.
PRN medication orders must include an indication.
Write legibly.
Rewrite orders upon transfer and/or post-operatively.
Date, time, and sign verbal & telephone orders within 48 hours.
Physician’s Order Form (Page 5 of 5)
ICU Admission Order Set
GMHA #049063 Stock # 99049063
APPROVED DATE: Medicine Dept. 10/2010, MEC 07/2011, HIMC 03/2012
DO NOT USE:
U
MS
IU MSO 4
Q.D. MgSO 4
Q.O.D. Trailing zero
Lack of leading zero
PATIENT ID LABEL