Pre-Printed Orders - Critical Care: Medical/Surgical Admission

Page 1 of 4
Weight: _________________(kg)
REFER TO THE ALLERGY SCREEN IN MEDITECH FOR ALLERGY INFORMATION
To complete the order form, check the appropriate boxes and/or fill in the required blanks.
To delete orders, draw one line through the item and initial.
MRP:__________________________ Admission Diagnosis:____________________________________________
Consult(s):
Registered Dietitian consult
Physiotherapy consult
Other:______________________ (Date and time consult(s) notified:_______/_______/_____________ Initial: ________)
Other:______________________ (Date and time consult(s) notified:_______/_______/_____________ Initial: ________)
Assessment:
Continuous cardiac monitoring, record strip q12h and prn
Vital Signs: q__________h and prn
Neuro Vitals: q__________h and prn
______________ Restraints to prevent injury x 24 h (obtain consent)
Mouth Care q2 - 4h as per policy
Respiratory:
Titrate O2 to keep SpO2 greater than or equal to 90% or _____________
BiPAP as per medical directive
Ventilation/Weaning as per medical directive
Labwork: (Upon admission, obtain sample only if not already done within previous 24 hours)
CBC, lytes, urea, creatinine, glucose, albumin, liver tests (includes gamma GT, Tbili, corrected calcium, ALT, AST, ALP),
magnesium, phosphorus, CK, troponin I, PTT, PT, INR on admission.
CBC, lytes, urea, creatinine, glucose, corrected calcium, albumin, magnesium, phosphorus q _____________________
PTT, PT, INR q_________________
CK, troponin I q _______________ x __________________
Liver tests (includes Gamma GT, Tbili, corrected calcium, ALT, AST, ALP) q ________________ x ________________
Lipase, amylase now and _______________
Lactate now and ________________
TSH with next bloodwork
Group and reserve (obtain consent)
Blood cultures x 2:
Now for temperature greater than 38.5 degrees Celsius
Urine for:
R&M C&S
Sputum for:
Culture Other ______________________________
Tests:
ECG now, repeat ECG _______________________
Portable Chest x-ray daily while intubated
Portable Chest x-ray____________________________________
Activity & Nutrition:
Head of bed up 30 degrees
NPO
PRE-PRINTED ORDERS
CRITICAL CARE: MEDICAL/SURGICAL
ADMISSION ORDERS (Adult)
Capillary blood glucose testing _____________________
OR ________________________________
Date: Time:
Bed Rest Up to Chair AAT
OR ___________________________
Complete additional orders on page 3
MD SIGNATURE
THIS PPO MUST BE FAXED TO PHARMACY PHYSICIAN'S ORDERS - CRITICAL CARE:
MEDICAL/SURGICAL ADMISSION ORDERS (Adult)
60009 D HR (March/2012) Page 1 of 4

K+
(mmol/L)
Result
Greater
than or
equal to 5.5
PRE-PRINTED ORDERS - CRITICAL CARE ADMISSION
IV DOSAGE
(if NOT given as a
po/OG/NG dose)
NO supplemental potassium
to be given via IV or po/OG/NG
NOTIFY MD
4 - 5.4 NO supplemental potassium
to be given via IV or po/OG/NG
3.5 - 3.9 Give 20 mEq KCl IV in 100 mL
sterile water* over one hour
Must be given via central line
POTASSIUM NOMOGRAM
Critical Care RN
PO/OG/NG route is preferred.
ONLY to utilize nomogram. Critical Care RN to choose
ONE
3 - 3.4 Give 40 mEq KCl IV in 100 mL
sterile water* over one hour
Must be given via central line
2.5 - 2.9 Give 40 mEq KCl IV in 100 mL
sterile water* over one hour.
Must be given via central line
Less than
2.5
* ONLY USE commercially prepared
Critical Care RN ONLY to utilize nomogram.
Magnesium (mmol/L)
Result
Greater than or equal to 0.8
0.6 - 0.79
0.5 - 0.59
0.3 - 0.49
Less than 0.3
NO
po/OG/NG DOSAGE
(if NOT given via IV)
CALL MD CALL MD
PREMIXED bag available in OMNICELL (Sure-Med).
MAGNESIUM NOMOGRAM
Give 1 g magnesium sulphate IV in 100 mL NS over one hour
Give 2 g magnesium sulphate IV in 100 mL NS over one hour
Give 3 g magnesium sulphate IV in 100 mL NS over one hour
PHOSPHATE REPLACEMENT
supplemental potassium to be given In 12 hours
via IV or po/OG/NG
NOTIFY MD
REPEAT BLOOD
ELECTROLYTES
NO supplemental potassium to be given
In 24 hours
via IV or po/OG/NG
Give 20 mEq KCI elixir OG/NG/po In 24 hours
OR
Give 2 tablets of KCI 600mg slow release po
Give 40 mEq KCI elixir OG/NG/po
OR
Give 4 tablets of KCI 600mg slow release po
Give 40 mEq KCI elixir OG/NG/po
OR
Give 4 tablets of KCI 600mg slow release po
NO
In 12 hours
In 6 hours
In 6 hours
DOSAGE REPEAT MAGNESIUM
LEVEL
magnesium
In 24 hours
CALL MD
route of KCI administration.
Critical Care RN ONLY to utilize nomogram. Critical Care RN to choose ONE route of Phosphate administration.
Oral/OG/NG route is preferred.
Phosphate
(mmol/L) Result
If serum phosphate is
less than 0.8 mmol/L
IV DOSAGE
(if NOT given as a po/OG/NG dose)
Infuse premixed IV bag containing:
sodium 20 mmol and phosphate
15 mmol per 250 mL NS IV over 4-6 h
po/OG/NG DOSAGE
(if NOT given via IV)
Give 2 tablets of phosphate
500 mg po/OG/NG (Must dissolve
in water for administration)
PRE-PRINTED ORDERS - CRITICAL CARE:
MEDICAL/SURGICAL ADMISSION ORDERS (Adult)
Page 2 of 4
In 24 hours
In 12 hours
In 6 hours
REPEAT BLOOD
ELECTROLYTES
In 24 hours
60009 D HR (March/2012) Page 2 of 4

Page 3 of 4
PRE-PRINTED ORDERS
CRITICAL CARE: MEDICAL/SURGICAL
ADMISSION ORDERS (Adult)
Weight: _________________(kg)
REFER TO THE ALLERGY SCREEN IN MEDITECH FOR ALLERGY INFORMATION
To complete the order form, check the appropriate boxes and/or fill in the required blanks.
To delete orders, draw one line through the item and initial.
Lines/Tubes/Drains:
IV #1 _______________ at _______________ mL/h IV #2 _______________ at _______________ mL/h
IV Saline Lock, flush q12 hours
Titrate IV solution: __________________________________ to:
CVP PAWP VALUE GIVE IV BOLUS IV RATE
0 - 5 mm Hg mL/h
5 - 10 mm Hg
mL/h
10 - 15 mm Hg
mL/h
Greater than 15 mm Hg
mL/h
If central line in situ, obtain CVP q ________ h and prn
If PA line in situ, obtain CO q __________ h, PAWP q __________ h
Orogastric tube (intubated patients)/Nasogastric tube (extubated patients) to:
low intermittent suction
Small Bore Feeding Tube
Foley catheter
OR straight drainage OR clamped
Medications:
If NPO, may take po meds
Ranitidine 150 mg po/NG bid
Heparin 5,000 units SC q8h
Intermittent Pneumatic Compression Devices
WARNING: - Nomograms are to be discontinued on discharge to units
Critical Care RN to administer
Critical Care RN to administer
Critical Care RN to administer
OR
OR
potassium
magnesium
phosphate
Date: Time:
Ranitidine 50 mg IV q8h
Dalteparin 5,000 units SC daily
Metoclopromide 10 mg IV (for small bore feeding tube insertion ONLY)
Dimenhydrinate 25-50 mg po/IV q4h prn for nausea
Acetaminophen 325-650 mg po/NG/pr q4h prn for headache or fever greater than 38.3 degrees Celsius
(Maximum dose of 4 g/24 h)
For Intubated Patients: Salbutamol 8 puffs q1h PRN
For Intubated Patients: Chlorhexidine gluconate 0.12% 15 mL BID (as per Oral Care for Intubated Patients policy)
Midazolam
Midazolam
Fentanyl
Fentanyl
62.5 mg in 62.5 mL NS (1mg/mL) IV _____________ mg/h
________ mg IV q 20 minutes prn
1,000 mcg in 100 mL NS (10 mcg/mL) IV ______________mcg/h
_________mcg IV q 20 minutes prn
Others (antibiotics, vasoactive and inotropic medications):
THIS PPO MUST BE FAXED TO PHARMACY
OR ________________________________
OR ___________________________
replacement based on lab results (refer to nomogram on back of page)
replacement based on lab results (refer to nomogram on back of page)
replacement based on lab results (refer to back page)
MD SIGNATURE
PRE-PRINTED ORDERS - CRITICAL CARE:
MEDICAL/SURGICAL ADMISSION ORDERS (Adult)
60009 D HR (March/2012) Page 3 of 4

K+
(mmol/L)
Result
Greater
than or
equal to 5.5
PRE-PRINTED ORDERS - CRITICAL CARE ADMISSION
IV DOSAGE
(if NOT given as a
po/OG/NG dose)
NO supplemental potassium
to be given via IV or po/OG/NG
NOTIFY MD
4 - 5.4 NO supplemental potassium
to be given via IV or po/OG/NG
3.5 - 3.9 Give 20 mEq KCl IV in 100 mL
sterile water* over one hour
Must be given via central line
POTASSIUM NOMOGRAM
Critical Care RN ONLY to utilize nomogram. Critical Care RN to choose ONE route of KCI administration.
PO/OG/NG route is preferred.
3 - 3.4 Give 40 mEq KCl IV in 100 mL
sterile water* over one hour
Must be given via central line
2.5 - 2.9 Give 40 mEq KCl IV in 100 mL
sterile water* over one hour.
Must be given via central line
Less than
2.5
* ONLY USE commercially prepared
Critical Care RN ONLY to utilize nomogram.
Magnesium (mmol/L)
Result
Greater than or equal to 0.8
0.6 - 0.79
0.5 - 0.59
0.3 - 0.49
Less than 0.3
NO
po/OG/NG DOSAGE
(if NOT given via IV)
CALL MD CALL MD
PREMIXED bag available in OMNICELL (Sure-Med).
MAGNESIUM NOMOGRAM
Give 1 g magnesium sulphate IV in 100 mL NS over one hour
Give 2 g magnesium sulphate IV in 100 mL NS over one hour
Give 3 g magnesium sulphate IV in 100 mL NS over one hour
PHOSPHATE REPLACEMENT
supplemental potassium to be given In 12 hours
via IV or po/OG/NG
NOTIFY MD
REPEAT BLOOD
ELECTROLYTES
NO supplemental potassium to be given
In 24 hours
via IV or po/OG/NG
Give 20 mEq KCI elixir OG/NG/po In 24 hours
OR
Give 2 tablets of KCI 600mg slow release po
Give 40 mEq KCI elixir OG/NG/po
OR
Give 4 tablets of KCI 600mg slow release po
Give 40 mEq KCI elixir OG/NG/po
OR
Give 4 tablets of KCI 600mg slow release po
NO
In 12 hours
In 6 hours
In 6 hours
DOSAGE REPEAT MAGNESIUM
LEVEL
magnesium
In 24 hours
Critical Care RN ONLY to utilize nomogram. Critical Care RN to choose. ONE route of Phosphate administration.
Oral/OG/NG route is preferred.
Phosphate
(mmol/L) Result
If serum phosphate is
less than 0.8 mmol/L
IV DOSAGE
(if NOT given as a po/OG/NG dose)
Infuse premixed IV bag containing:
sodium 20 mmol and phosphate
15 mmol per 250 mL NS IV over 4-6 h
CALL MD
po/OG/NG DOSAGE
(if NOT given via IV)
Give 2 tablets of phosphate
500 mg po/OG/NG (Must dissolve
in water for administration)
PRE-PRINTED ORDERS - CRITICAL CARE:
MEDICAL/SURGICAL ADMISSION ORDERS (Adult)
Page 4 of 4
In 24 hours
In 12 hours
In 6 hours
REPEAT BLOOD
ELECTROLYTES
In 24 hours
60009 D HR (March/2012) Page 4 of 4