<p> PLACE LABEL HERE NEONATOLOGY SERVICE TRANSPORT 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>Diagnosis & Status: Admit as Inpatient ______(reason for admission)</p><p>Current weight: ______grams Gestational age: ______weeks Date: ______Time: ______1. Obtain and record maternal and infant’s history including lab work previously drawn </p><p>2. Obtain and record a complete physical assessment</p><p>3. Call physician to report infant status and obtain orders</p><p>4. Place infant on cardiopulmonary monitor and pulse oximeter (set HR alarm at 100-200 bpm and apnea alarm at 20 seconds)</p><p>5. Place peripheral IV or superficial UVC – notify physician if peripheral IV access takes longer than 10 min to obtain</p><p>6. Make NPO and place appropriate NG/OG tube if indicated</p><p>7. Obtain vital signs q 15 min and call physician with any significant change in clinical status</p><p>IV Fluids: D10W at 80 ml/kg/day for birth weight greater than 1.5 kg D10W at 100 ml/kg/day for birth weight 1 kg – 1.5 kg D10W at 110 ml/kg/day for birth weight 750 grams – 1 kg D10W at 120 ml/kg/day for birth weight less than 750 grams UAC fluid: NS 0.45 with heparin 1 unit/ml at 1 ml/hr, or run at 0.5 ml/hr if less than or equal to 1,000 grams UVC fluid: add heparin 1 unit/ml to ______, run at ___ml/hr to maintain total intake at ______ml/kg/day PAL fluid: NS 0.45 plus 2% lidocaine 2ml /100ml plus sodium bicarbonate 0.25 mEq /100ml plus heparin 2 units/ml at 1 ml/hr, or run at 0.5 ml/hr if less than or equal to 1,000 grams </p><p>Medications: Give D10W 2ml/kg IV for blood glucose screen less than 40 mg/dL Repeat screen 30 min after bolus Repeat D10W bolus if follow up glucose screen less than 40 mg/dL Call physician if more than two consecutive D10W boluses are needed, or if glucose screen greater than 200 mg/dL on more than two consecutive screens NS 0.9% 15 ml/kg IV over 20 min Ampicillin 100 mg/kg IV times one dose Gentamicin 5 mg/kg IV q 48 hrs for infants less than 30 weeks Gentamicin 4.5 mg/kg IV q 36 hrs for infants 30 – 34 weeks (inclusive) Gentamicin 4 mg/kg IV q 24 hrs for all infants greater than 34 weeks ______ Surfactant 2.5 ml/kg per ETT times one dose Fentanyl 2-4 micrograms/kg/dose IV q 2-4 hrs prn Norcuron 0.1 – 0.2 mg/kg q 1-2 hrs IV Phenobarbital 20 mg/kg IV times one dose</p><p>Send copy to pharmacy Order writer’s initials ______</p><p>*3-17242* FORM 3-17242 REV. 07/2012 Page 1 of 2 PLACE LABEL HERE NEONATOLOGY SERVICE TRANSPORT 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>Laboratory:</p><p> Blood gas (ABG, CBG, VBG) X-ray (CXR, KUB, Other______) Blood glucose monitoring on arrival at referral hospital then q hr while on transport</p><p>Other:</p><p> ______ ______ ______</p><p>8. Call physician with most recent vital signs, updated history, clinical condition of patient, available lab results and ventilator settings before final departure from referring hospital</p><p>9. Make telephone contact with physician for any significant changes in clinical status while in ambulance or if transport time to GWP exceeds 1 hour</p><p>______Date Time Physician Signature PID Number</p><p>Send copy to pharmacy </p><p>FORM 3-17242 REV. 07/2012 Page 2 of 2</p>
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