<p> PLACE LABEL HERE TRAUMA SERVICE ICU ADMISSION ORDERS</p><p>The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked. Initial all handwritten order modifications and the bottom of each page when indicated (multipage). </p><p>1. Do you expect that the patient’s condition will require a hospital stay that will cross two midnights (includes the time spent in outpatient- ED, surgery, OBS) and the patient has medical necessity for an inpatient admission?  Yes, admit as inpatient, proceed to # 2  No, place in observation 2. If admitted as inpatient, Inpatient Physician Certification: Diagnosis: ______Level of Care:  Critical  Intermediate  Acute Care Location/Specialty Unit Preference: ICU</p><p>3.  Telemetry: If patient Medical/Surgical, must complete form # 36084 4.  Isolation:  Contact  Droplet  Airborne For: ______5. Consult: ______Reason: ______Consult: ______Reason: ______6. Diagnostics:  STAT On admission: ______In AM: CBC, Chem 7, Ionized Calcium, Magnesium, Phosphorous, Lactic Acid, PT, PTT, ABG Portable CXR Reason: Traumatic Injury 7. Follow Spinal Clearance (form # 33586) and Spinal Treatment Orders (form # 33585) 8. Vital signs q 1 hr 9. Neuro checks q  1 hr  2 hr  4 hr 10. Intake and Output q  1 hr  2 hr</p><p>11. O2 Protocol (form # 34431) 12. Notify admitting physician if: Heart rate < 50 or > 120 Systolic BP < 90 or > 180 Diastolic BP > 110 Urine output < 30 ml/hr x 2 hrs Temperature > 102°F AND a change in vital signs or clinical status Hemoglobin is < 8.5 g/dl or drops more than 2 g/dl for 48 hrs post admit 13.  Central line in place: Port Use: Proximal- IVFs, IVPBs; Medial- TPN, Lipids, IVFs; Distal- Blood, blood sampls, IVFs, Transducer Sterile dressing change q 7 days and prn Port cap change q 7 days Normal Saline Port Flushes: 5 ml prior to blood sampling; 10 ml or more before and after meds and fluids, including incompatible meds and fluids; 20 ml or more after viscous solutions or blood sampling and administration; 10 ml q shift when port not in use Record CVP q ______hr(s) 14. Foley to BSB with urometer 15.  Chest tubes: -20 cm continuous wall suction 16. If temperature < 36.5ºC (97.7ºF) institute warming measures 17.  NGT/OGT to low intermittent suction. Notify physician if NG/OG tube is inadvertently removed. 18. Diet:  NPO  NPO, may have sips with meds Clear liquids 19. Wound Care: ______20. Activity:  Bedrest  Position or activity restrictions: ______ OOB, no limitations  Other: ______Copy to pharmacy Order writer’s initials ______</p><p>*3-16298* FORM 3-16298 REV. 11/2016 Page 1 of 2 PLACE LABEL HERE TRAUMA SERVICE ICU ADMISSION ORDERS</p><p>Copy to pharmacy Order writer’s initials ______</p><p>*3-16298* FORM 3-16298 REV. 11/2016 Page 2 of 2 PLACE LABEL HERE TRAUMA SERVICE ICU ADMISSION ORDERS</p><p>The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked. Initial all handwritten order modifications and the bottom of each page when indicated (multipage). SCHEDULED MEDICATIONS 21. VTE prophylaxis, Initiate Venous Thromboembolism (VTE) Prophylaxis Orders (form # 33058)  Low risk: No pharmacologic or mechanical prophylaxis, ambulate 3 times daily  Heparin 5,000 units SQ q 8 hrs (q 12 hrs if wt < 50 kg or age > 75) begin in AM on POD # 1 or  Lovenox (enoxaparin) 40 mg SQ daily (30 mg if CrCl < 30 ml/min) begin in AM on POD # 1 and/or  Mechanical devices: SCDs  Contraindication to pharmacologic:  Coagulopathy  Thrombocytopenia  Active/Risk of Bleeding  Hemorrhage  Other______ Contraindication to mechanical:  BLE Trauma  BLE Amputee  BLE Arterial Insuffiiciency  Other: ______22. IVF: ______IV at ______ml/hr 23. Antibiotics:  Ancef (cefazolin) 1 gm IV q 8 hrs (pharmacy to renal dose if CrCl < 30)  Other: ______or Beta-lactam (penicillin and cephalosporin) allergy or history of MRSA only:  Vancomycin, pharmacy to dose 24. Ulcer Prophylaxis: Pepcid (famotidine) 20 mg IV q 12 hrs </p><p>PRN MEDICATIONS See policy 520-06 for range orders and pain intensity guidelines. 25. Ionized Ca < 1.12:  Calcium Gluconate 1 gm in NS 50 ml IV q 1 hr prn infuse over 20 min Recheck ionized Ca after infusion and repeat prn if ionized Ca < 1.12 26. Sedation:  Versed (midazolam) ______mg IV q _____ hr(s) prn. Begin at lowest dose 27. Severe pain:  Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation. 28. Mild pain/HA/ temp >100.5F/HA:  Tylenol (acetaminophen) 650 mg  po or  NG  per rectum q 4 hrs prn  Motrin (ibuprofen) 400 mg  po or  NG q 6 hrs prn 29. Nausea/Vomiting:  Zofran (ondansetron) 4 mg IV q 6 hrs prn  If N/V persists, add Reglan (metoclopramide) 10 mg IV or po q 6 hrs prn (5 mg if > 65 y/o) 30. Sleep:  Melatonin 5 mg po q HS prn or  Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn 31. Stool softener:  Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement 32. Constipation:  Milk of Magnesia (MOM) 30 ml  po or  NG daily prn 33. Cough:  Robitussin (guaifenesin) 15 ml po q 4 hrs prn 34. CVC occlusion: Cathflo (activase, 2 mg/2 ml) IV prn x 2 doses. Instill 2 mg into occluded catheter per Lippincott procedure: Central Venous Access Device, Declotting . If declotting unsuccessful after 120 minutes, may repeat procedure with a second dose of Cathflo 2 mg /2 ml. Notify physician if catheter remains occluded 120 minutes after second dose.</p><p>ADDITIONAL ORDERS: ______</p><p>______Date Time Physician Signature PID Number</p><p>Copy to pharmacy</p><p>FORM 3-16298 REV. 11/2016 Page 3 of 2</p>