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UMC Health System Patient Label Here
Admit Sepsis Plan - Begin Immediately
PHYSICIAN ORDERS
Weight ____________________________________________ Allergies ________________________________________________________
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
Admit/Discharge/Transfer
Request Patient Bed Requested Location: MICU, Pt Status: Inpatient (LOS > 2 midnights) Requested Location: SICU, Pt Status: Inpatient (LOS > 2 midnights) Requested Location: Floor, Pt Status: Inpatient (LOS > 2 midnights)
Patient Condition Acuity Level Intermediate Acuity Level Critical
Acuity Level Floor Status
Communication
Code Status Code Status: Full Code Code Status: DNR - Do Not Resuscitate Code Status: DNI - Do Not Intubate Code Status: DNR/DNI - Do Not Resuscitate or Intubate Code Status: Partial Resuscitative Effort
Notify Provider/Primary Team of Pt Admit In AM Upon Arrival to Unit Now
MedicationsMedication sentences are per dose. You will need to calculate a total daily dose if needed.
SIRS: Meets two or more of the following criteria: - HR greater than 90 bpm -Temperature greater than 100.4 F (38 C) or less than 96.8 F (36 C) - WBC greater than 12.000 or less than 4000 -RR greater than 20 per min or PaCO2 less than 32 mmhg
Sepsis: SIRS + Infection Confirmed Infection or Suspected Infection
Initiate antibiotics within three hours of an EC Admission or one hour of an ICU Transfer.
Follow up with cultures and sensitivity results and adjust antibiotics accordingly.
ANTIBIOTICS AS FOLLOWS: (Consult pharmacy for appropriate dosing based on age, weight, and renal function.
Consult Pharmacy Reason: Dose Medication
Antibiotics
Sepsis Antibiotics Reference ***See Reference Text***
TO Read Back Scanned Powerchart Scanned PharmScan
Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Page: 1 of 17 Admit Sepsis Plan Version: 6 Effective on: 08/12/15
1201
Dx ________________________________________________
UMC Health System Patient Label Here
Admit Sepsis Plan - When Pt. Arrives to Room
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
Patient Care
Vital Signs Per Unit Standards
Patient Activity Bedrest Bedrest | Bathroom Privileges
Bedrest | Up to Bedside Commode Only Up Ad Lib/Activity as Tolerated | Assist as Needed
ICU Progressive Mobility Protocol ***See Reference Text***
Set Up for Central Line Placement
Obtain Consent Consent for: Central Line Insertion
Set Up for Arterial Line Placement
Obtain Consent Consent for: Arterial Line Insertion
Insert Urinary Catheter Criticore, To: Dependent Drainage Bag Foley, To: Dependent Drainage Bag
Urinary Catheter Care
Central Venous Pressure Monitoring (CVP Monitoring) Per Unit Standards Per Unit Standards with ScvO2
Apply Minimally Invasive Hemodynamic Mon (Apply Minimally Invasive Hemodynamic Monitoring Device)
Strict Intake and Output
Sepsis PCT Algorithm ***See Reference Text***
Communication
Notify Provider of VS Parameters Temp Greater Than 100.4, Temp Less Than 96.8, RR Greater Than 20, MAP Less Than 65, ScvO2 less than 70%
Notify Provider (Misc) (Notify Provider of Results) Reason: WBC greater than 12,000 or less than 4,000.
Notify Provider (Misc) (Notify Provider of Results) Reason: PaCO2 less than 32 mmhg
Notify Provider (Misc) Reason: Urine Output less than 0.5 mL/kg/hr
SIRS: Meets two or more of the following criteria: - HR greater than 90 bpm -Temperature greater than 100.4 F (38 C) or less than 96.8 F (36 C) - WBC greater than 12.000 or less than 4000 -RR greater than 20 per min or PaCO2 less than 32 mmhg
Sepsis: SIRS + Infection Confirmed Infection or Suspected Infection
Dietary
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Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Page: 2 of 17 Admit Sepsis Plan Version: 6 Effective on: 08/12/15
1201
UMC Health System Patient Label Here
Admit Sepsis Plan - When Pt. Arrives to Room
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
Oral Diet Regular Diet Full Liquid Diet Clear Liquid Diet Mechanically Altered Diet Renal Diet AHA Diet
ADA Diet 1800 Calories, AHA 1600 Calories, AHA 1800 Calories 1600 Calories
NPO Diet NPO NPO, Except Meds
NPO, Except Ice Chips NPO, Except Meds, Except Ice Chips
IV Solutions
NS (NS bolus) 20 mL/kg, IVPB, iv soln, ONE TIME, Infuse over 30 min
NS IV, mL/hr IV, 200 mL/hr IV, 150 mL/hr IV, 125 mL/hr IV, 75 mL/hr
MedicationsMedication sentences are per dose. You will need to calculate a total daily dose if needed.
Initiate antibiotics within three hours of an EC Admission or one hour of an ICU Transfer.
Notify Provider (Misc) Reason: Patient has arrived to unit
Follow up with cultures and sensitivity results and adjust antibiotics accordingly.
ANTIBIOTICS AS FOLLOWS: (Consult pharmacy for appropriate dosing based on age, weight, and renal function.
Consult Pharmacy Reason: Dose Medication
GI Prophylaxis
pantoprazole 40 mg, PO, tab ec, Daily Do not crush or chew. 40 mg, per tube, liq, Daily **Follow Administration Instructions Carefully**
With a nasogastric (NG) tube or gastrostomy tube in place: Remove the plunger from the barrel of a 60 mL catheter-tip syringe. Throw away the plunger.
Connect the catheter tip of the syringe to a 16 French (or larger) tube. Hold the syringe attached to the tubing as high as possible
while giving PROTONIX oral suspension to prevent any bending of the tubing. Empty the contents of the packet into the barrel of the syringe.
Add 10 mL of apple juice and gently tap or shake the barrel of the syringe to help empty the syringe. Do this again at least two more times using the same amount of apple juice (10 mL) each time. No granules should be left in the syringe. 40 mg, IVPush, inj, Daily
IVP over 2 min. Reconstitute with 10mL NS. Stable for 2 hrs at room temp after reconstitution.
Blood Pressure Management
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Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Page: 3 of 17 Admit Sepsis Plan Version: 6 Effective on: 08/12/15
1201
UMC Health System Patient Label Here
Admit Sepsis Plan - When Pt. Arrives to Room
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
norepinephrine 4 mg/250 mL D5W Start at rate:______________mcg/min IV
Notify Nurse (DO NOT USE FOR MEDS) Notify provider if needing to add another vasopressor.
Laboratory
CBC with Differential
Prothrombin Time with INR
PTT
Comprehensive Metabolic Panel
Lactic Acid Level Routine q6h for 24 hr
Magnesium Level
Phosphorus Level
CKMB
CK
Troponin T
Cortisol Random
Microbiology/Virology
Notify Nurse (DO NOT USE FOR MEDS) Obtain all cultures prior to starting antibiotics.
Culture Blood
Culture Blood
Culture Sputum with Gram Stain
Culture Urine
Culture Wound with Gram Stain
Diagnostic Tests
DX Chest Portable
EKG-12 Lead
Respiratory
Respiratory Care Plan Guidelines
Arterial Blood Gas Additional Tests: Lactate
Physical Medicine and Rehab
Consult Occ Therapy for Eval & Treat
Consult PT Mobility for Eval & Treat
...Additional Orders
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Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Page: 4 of 17 Admit Sepsis Plan Version: 6 Effective on: 08/12/15
1201
UMC Health System Patient Label Here
Admit Sepsis Plan - When Pt. Arrives to Room - Type and Screen Plan
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
Laboratory
BB Blood Type (ABO/Rh)
BB Antibody Screen
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Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Page: 5 of 17 Admit Sepsis Plan Version: 6 Effective on: 08/12/15
1201
UMC Health System Patient Label Here
Admit Sepsis Plan - When Pt. Arrives to Room - VTE Prophylaxis Plan
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
Patient Care
VTE Guidelines See Reference Text for Guidelines
***If VTE Pharmacologic Prophylaxis not given, choose the Contraindications for VTE below and complete reason contraindi cated***
Contraindications VTE Patient low risk for VTE Patient is ambulatory Patient Refusal Family/Caregiver Refusal
Cont IV heparin day of/after admission Anticoag therapy not warfarin for Afib Warfarin prior to admit; on hold r/t INR Risk of Bleeding Thrombocytopenia Active Bleeding Alteplase Administered w/in 24 hrs IV Heparin w/in 24 hrs of Surgery
Apply Elastic Stockings Apply to: Bilateral Lower Extremities, Length: Knee High Apply to: Left Lower Extremity (LLE), Length: Knee High Apply to: Right Lower Extremity (RLE), Length: Knee High Apply to: Bilateral Lower Extremities, Length: Thigh High
Apply to: Left Lower Extremity (LLE), Length: Thigh High Apply to: Right Lower Extremity (RLE), Length: Thigh High
Apply Sequential Compression Device Apply to Bilateral Lower Extremities Apply to Left Lower Extremity (LLE) Apply to Right Lower Extremity (RLE)
Apply Pedal Pump Apply to Bilateral Feet Apply to Left Foot Apply to Right Foot
MedicationsMedication sentences are per dose. You will need to calculate a total daily dose if needed.
***Recommended Trauma Dose = 30 mg, subcut, q12h*** ***Recommended Dose for Morbidly Obese Patients = 40 mg, subcut, q12h***
enoxaparin 40 mg, subcut, syringe, q24h 30 mg, subcut, syringe, q12h 30 mg, subcut, syringe, q24h, For CrCl less than 30 mL/hr 40 mg, subcut, syringe, q12h, For BMI greater than 39
heparin 5,000 units, subcut, inj, q12h 5,000 units, subcut, inj, q8h
fondaparinux 2.5 mg, subcut, syringe, q24h
***If you order RIVAROXABAN for your patient, please indicate the reason below***
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Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Page: 6 of 17 Admit Sepsis Plan Version: 6 Effective on: 08/12/15
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UMC Health System Patient Label Here
Admit Sepsis Plan - When Pt. Arrives to Room - VTE Prophylaxis Plan
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
Reason for Oral Factor Xa Inhibitor Reason: Atrial fibrillation Reason: Persistent atrial fibrillation Reason: Paroxysmal atrial fibrillation Reason: Atrial flutter
Reason: Hx Afib/flutter - NA w/in 8wks post CABG Reason: Partial hip arthroplasty Reason: Total hip arthroplasty Reason: Total hip replacement Reason: Total knee arthroplasty Reason: Total knee replacement
rivaroxaban 10 mg, PO, tab, In PM 20 mg, PO, tab, In PM, for A-fib/Secondary Prevention for DVT
warfarin 5 mg, PO, tab, QPM
aspirin 81 mg, PO, tab chew, Daily 325 mg, PO, tab, Daily
TO Read Back Scanned Powerchart Scanned PharmScan
Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Page: 7 of 17 Admit Sepsis Plan Version: 6 Effective on: 08/12/15
1201
UMC Health System
Admit Sepsis Plan - When Pt. Arrives to Room-
SLIDING SCALE INSULIN PROTOCOL PLAN
PHYSICIAN ORDERS
Weight ____________________________________________ Allergies ________________________________________________________
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
Patient Care
POC Blood Sugar Check Per Sliding Scale Insulin Frequency AC & HS AC & HS 3 days TID BID q12h q6h q6h 24 hr q4h q2h
Sliding Scale Insulin Protocol Follow SSI Reference Text
MedicationsMedication sentences are per dose. You will need to calculate a total daily dose if needed.
insulin regular (Low Dose Insulin Sliding Scale) 0-10 units, subcut, inj, AC & nightly, PRN glucose levels - see parameters
Low Dose Insulin Sliding Scale Blood glucose is less than 70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician
70-110 - 0 units; 111-150 - 0 units; 151-200 - 2 units subQ; 201-250 - 3 units subQ; 251-300 - 4 units subQ; 301-350 - 6 units subQ; 351-400 - 8 units subQ;
Greater than 400 - 10 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician. 0-10 units, subcut, inj, q6h, PRN glucose levels - see parameters
Low Dose Insulin Sliding Scale Blood glucose is less than 70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician
70-110 - 0 units; 111-150 - 0 units; 151-200 - 2 units subQ; 201-250 - 3 units subQ; 251-300 - 4 units subQ; 301-350 - 6 units subQ; 351-400 - 8 units subQ;
Greater than 400 - 10 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician. 0-10 units, subcut, inj, q4h, PRN glucose levels - see parameters
Low Dose Insulin Sliding Scale Blood glucose is less than 70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician 70-110 - 0 units; 111-150 - 0 units; 151-200 - 2 units subQ; 201-250 - 3 units subQ; 251-300 - 4 units subQ; 301-350 - 6 units subQ; 351-400 - 8 units subQ;Greater than 400 - 10 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician.
Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Page: 8 of 17 Admit Sepsis Plan Version: 6 Effective on: 08/12/15 1201
Patient Label Here
Dx _____________________________________________________
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Continued on next page...
Patient Label Here UMC Health System
Admit Sepsis Plan - When Pt. Arrives to Room-
SLIDING SCALE INSULIN PROTOCOL PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
0-10 units, subcut, inj, q2h, PRN glucose levels - see parameters Low Dose Insulin Sliding Scale Blood glucose is less than 70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician
70-110 - 0 units; 111-150 - 0 units; 151-200 - 2 units subQ; 201-250 - 3 units subQ; 251-300 - 4 units subQ; 301-350 - 6 units subQ; 351-400 - 8 units subQ;
Greater than 400 - 10 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician. 0-10 units, subcut, inj, TID, PRN glucose levels - see parameters Low Dose Insulin Sliding Scale Blood glucose is less than 70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician
70-110 - 0 units; 111-150 - 0 units; 151-200 - 2 units subQ; 201-250 - 3 units subQ; 251-300 - 4 units subQ; 301-350 - 6 units subQ; 351-400 - 8 units subQ;
Greater than 400 - 10 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician. 0-10 units, subcut, inj, BID, PRN glucose levels - see parameters Low Dose Insulin Sliding Scale Blood glucose is less than 70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician
70-110 - 0 units; 111-150 - 0 units; 151-200 - 2 units subQ; 201-250 - 3 units subQ; 251-300 - 4 units subQ; 301-350 - 6 units subQ; 351-400 - 8 units subQ;
Greater than 400 - 10 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician.
TO Read Back Scanned Powerchart Scanned PharmScan
Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Page: 9 of 17 Admit Sepsis Plan Version: 6 Effective on: 08/12/15 1201
UMC Health System
Admit Sepsis Plan - When Pt. Arrives to Room-
SLIDING SCALE INSULIN PROTOCOL PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
insulin regular (Moderate Dose Insulin Sliding Scale) 0-12 units, subcut, inj, AC & nightly, PRN glucose levels - see parameters Moderate Dose Insulin Sliding Scale
Blood glucose is less than 70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician
70-110 - 0 units; 111-150 - 2 units subQ; 151-200 - 3 units subQ; 201-250 - 4 units subQ; 251-300 - 6 units subQ; 301-350 - 8 units subQ;
351-400 - 10 units subQ; Greater than 400 - 12 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300; then resume normal accucheck and sliding scale routine. Call physician. 0-12 units, subcut, inj, q6h, PRN glucose levels - see parameters Moderate Dose Insulin Sliding Scale
Blood glucose is less than 70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician
70-110 - 0 units; 111-150 - 2 units subQ; 151-200 - 3 units subQ; 201-250 - 4 units subQ; 251-300 - 6 units subQ; 301-350 - 8 units subQ;
351-400 - 10 units subQ; Greater than 400 - 12 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300; then resume normal accucheck and sliding scale routine. Call physician. 0-12 units, subcut, inj, q4h, PRN glucose levels - see parameters Moderate Dose Insulin Sliding Scale
Blood glucose is less than 70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician
70-110 - 0 units; 111-150 - 2 units subQ; 151-200 - 3 units subQ; 201-250 - 4 units subQ; 251-300 - 6 units subQ; 301-350 - 8 units subQ;
351-400 - 10 units subQ; Greater than 400 - 12 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300; then resume normal accucheck and sliding scale routine. Call physician. 0-12 units, subcut, inj, q2h, PRN glucose levels - see parameters Moderate Dose Insulin Sliding Scale
Blood glucose is less than 70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician
70-110 - 0 units; 111-150 - 2 units subQ; 151-200 - 3 units subQ; 201-250 - 4 units subQ; 251-300 - 6 units subQ; 301-350 - 8 units subQ;
351-400 - 10 units subQ;
Continued on next page....
.
Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Page: 10 of 17 Admit Sepsis Plan Version: 6 Effective on: 08/12/15 1201
Patient Label Here
Greater than 400 - 12 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician.
TO Read Back Scanned Powerchart Scanned PharmScan
Patient Label Here UMC Health System
Admit Sepsis Plan - When Pt. Arrives to Room-
SLIDING SCALE INSULIN PROTOCOL PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
0-12 units, subcut, inj, TID, PRN glucose levels - see parameters Moderate Dose Insulin Sliding Scale
Blood glucose is less than 70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician
70-110 - 0 units; 111-150 - 2 units subQ; 151-200 - 3 units subQ; 201-250 - 4 units subQ; 251-300 - 6 units subQ; 301-350 - 8 units subQ;
351-400 - 10 units subQ; Greater than 400 - 12 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300; then resume normal accucheck and sliding scale routine. Call physician. 0-12 units, subcut, inj, BID, PRN glucose levels - see parameters Moderate Dose Insulin Sliding Scale
Blood glucose is less than 70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician
70-110 - 0 units; 111-150 - 2 units subQ; 151-200 - 3 units subQ; 201-250 - 4 units subQ; 251-300 - 6 units subQ; 301-350 - 8 units subQ;
351-400 - 10 units subQ; Greater than 400 - 12 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300; then resume normal accucheck and sliding scale routine. Call physician.
insulin regular (High Dose Insulin Sliding Scale) 0-14 units, subcut, inj, AC & nightly, PRN glucose levels - see parameters High Dose Insulin Sliding Scale
Blood glucose is less than 70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician
70-110 - 0 units; 111-150 - 3 units subQ; 151-200 - 4 units subQ; 201-250 - 6 units subQ; 251-300 - 8 units subQ;
301-350 - 10 units subQ; 351-400 - 12 units subQ; Greater than 400 - 14 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician 0-14 units, subcut, inj, q6h, PRN glucose levels - see parameters High Dose Insulin Sliding Scale
Blood glucose is less than 70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician; 70-110 - 0 units; 111-150 - 3 units subQ; 151-200 - 4 units subQ; 201-250 - 6 units subQ; 251-300 - 8 units subQ;
301-350 - 10 units subQ; 351-400 - 12 units subQ;
Order Take By Signature: __________________________________________________________________________ Date ____________________________ Time____________________________
Physician Signature: ____________________________________________________________________________ Date ____________________________ Time ____________________________
Page: 11 of 17 Admit Sepsis Plan Version: 6 Effective on: 08/12/15 1201
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Continued on next page...
Greater than 400 - 14 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician.
Patient Label Here UMC Health System
Admit Sepsis Plan - When Pt. Arrives to Room-
SLIDING SCALE INSULIN PROTOCOL PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
0-14 units, subcut, inj, q4h, PRN glucose levels - see parameters High Dose Insulin Sliding Scale
Blood glucose is less than 70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician;
70-110 - 0 units; 111-150 - 3 units subQ; 151-200 - 4 units subQ; 201-250 - 6 units subQ; 251-300 - 8 units subQ;
301-350 - 10 units subQ; 351-400 - 12 units subQ; Greater than 400 - 14 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician 0-14 units, subcut, inj, q2h, PRN glucose levels - see parameters High Dose Insulin Sliding Scale
Blood glucose is less than 70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician;
70-110 - 0 units; 111-150 - 3 units subQ; 151-200 - 4 units subQ; 201-250 - 6 units subQ; 251-300 - 8 units subQ;
301-350 - 10 units subQ; 351-400 - 12 units subQ; Greater than 400 - 14 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician 0-14 units, subcut, inj, TID, PRN glucose levels - see parameters High Dose Insulin Sliding Scale
Blood glucose is less than 70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician;
70-110 - 0 units; 111-150 - 3 units subQ; 151-200 - 4 units subQ; 201-250 - 6 units subQ; 251-300 - 8 units subQ; 301-350 - 10 units subQ; 351-400 - 12 units subQ; Greater than 400 - 14 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician 0-14 units, subcut, inj, BID, PRN glucose levels - see parameters
High Dose Insulin Sliding Scale Blood glucose is less than 70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician.
70-110 - 0 units; 111-150 - 3 units subQ;
151-200 - 4 units subQ; 201-250 - 6 units subQ; 251-300 - 8 units subQ; 301-350 - 10 units subQ; 351-400 - 12 units subQ; Greater than 400 - 14 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician.
TO Scanned Powerchart Scanned PharmScan
Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Page: 12 of 17 Admit Sepsis Plan Version: 6 Effective on: 08/12/15 1201
Read BackContinued on next page...
Patient Label Here UMC Health System
Admit Sepsis Plan - When Pt. Arrives to Room-
SLIDING SCALE INSULIN PROTOCOL PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
insulin regular (Blank Insulin Sliding Scale) See Comments, subcut, inj, PRN glucose levels - see parameters Blood glucose is less than ___; Initiate hypoglycemic protocol and Call physician; 70-110 - __ units;
111-150 - __ units subQ; 151-200 - __ units subQ; 201-250 - __ units subQ; 251-300 - __ units subQ; 301-350 - __ units subQ; 351-400 - __ units subQ; Greater than 400 - __ units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG less than ___, then resume normal accucheck and sliding scale routine. Call physician
HYPOglycemia Protocol
HYPOglycemia Protocol If BS is less than 70 mg/dL, and patient SYMPTOMATIC, give 6 oz. of juice PO (if applicable) and/or follow HYPOglycemia Protocol meds.
glucose (D50) 25 g, IVP, syringe, as needed, PRN glucose levels - see parameters Patient unable to swallow / NPO WITH IV access. Dextrose 50% 50 mL IV.
Recheck BG in 15 -20 minutes. Repeat treatment until blood glucose greater than 100 mg/dL. If not NPO provide additional snack once able to swallow.
glucose 15 g, PO, gel, as needed, PRN glucose levels - see parameters
glucagon 1 mg, IM, inj, as needed, PRN glucose levels - see parameters
Patient UNABLE to swallow / NPO WITHOUT IV access. Administer Glucagon 1 mg IM or SubQ. Contact physician for further orders. Establish IV access with saline lock. Recheck BG every 15 to 20 minutes. Use aspiration precautions as glucagon may cause nausea and vomiting.
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Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Page: 13 of 17 Admit Sepsis Plan Version: 6 Effective on: 08/12/15 1201
UMC Health System Patient Label Here
Admit Sepsis Plan - When Pt. Arrives to Room - Discomfort Med Plan
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
Patient Care
Perform Bladder Scan Scan PRN, If more than 250, Then: Call MD, Perform as needed for patients complaining of urinary discomfort and/or bladder distention present OR 6 hrs post Foley removal and patient has not voided.
MedicationsMedication sentences are per dose. You will need to calculate a total daily dose if needed.
phenol-menthol topical (phenol-menthol 2.9%-0.12% (Cepastat) lozenge) 1 lozenge, PO, lozenge, q4h, PRN sore throat
Do not exceed 6 lozenges in 24 hours
dextromethorphan-guaiFENesin (dextromethorphan-guaiFENesin 20 mg-200 mg/10 mL oral liquid) 10 mL, PO, liq, q4h, PRN cough
dexamethasone-diphenhydrAMIN-nystatin-NS (Fred’s Brew) 15 mL, swish & spit, liq, q2h, PRN mucositis While awake
lidocaine topical (Lidocaine Viscous 2% mucous membrane solution) 15 mL, swish & spit, liq, q4h, PRN mucositis
Analgesics
acetaminophen 500 mg, PO, tab, q6h, PRN pain-mild (scale 1-3)
***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF acetaminophen ineffective/contraindicated, USE ibuprofen if ordered:*****
1,000 mg, PO, tab, q4h, PRN pain-mild (scale 1-3) ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF acetaminophen ineffective/contraindicated, USE ibuprofen if ordered:*****
acetaminophen 650 mg, rectally, supp, q4h, PRN pain-mild (scale 1-3) ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****If acetaminophen ineffective/contraindicated, USE ibuprofen if ordered:*****
ibuprofen 400 mg, PO, tab, q6h, PRN pain-mild (scale 1-3) ***Do not exceed 3,200 mg of ibuprofen from all sources in 24 hours*** Give with food.
Use if acetaminophen ineffective or contraindicated.
HYDROcodone-acetaminophen (HYDROcodone-acetaminophen 5 mg-325 mg oral tablet) 1 tab, PO, tab, q4h, PRN pain-moderate (scale 4-7)
***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF HYDROcodone-acetaminophen ineffective/contraindicated or NPO, USE ketorolac if ordered***** 2 tab, PO, tab, q4h, PRN pain-moderate (scale 4-7)
***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF HYDROcodone-acetaminophen ineffective/contraindicated or NPO, USE ketorolac if ordered*****
TO Read Back Scanned Powerchart Scanned PharmScan
Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
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UMC Health System Patient Label Here
Admit Sepsis Plan - When Pt. Arrives to Room - Discomfort Med Plan
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
acetaminophen-codeine (acetaminophen-codeine #3) 1 tab, PO, q4h, PRN pain-moderate (scale 4-7)
***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF acetaminophen-codeine #3 ineffective/contraindicated or NPO, USE ketorolac if ordered***** 2 tab, PO, q4h, PRN pain-moderate (scale 4-7)
***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF acetaminophen-codeine #3 ineffective/contraindicated or NPO, USE ketorolac if ordered*****
ketorolac 15 mg, IVPush, inj, q6h, PRN pain-moderate (scale 4-7), x 48 hr ***May give IM if no IV access*** Use if HYDROcodone-acetaminophen ineffective or contraindicated. 30 mg, IVPush, inj, q6h, PRN pain-moderate (scale 4-7), x 48 hr ***May give IM if no IV access*** Use if HYDROcodone-acetaminophen ineffective or contraindicated.
morphine 2 mg, IVPush, inj, q4h, PRN pain-severe (scale 8-10) ***Slow IV Push*** *****IF morphine is ineffective/contraindicated, USE HYDROmorphone if ordered***** 4 mg, IVPush, inj, q4h, PRN pain-severe (scale 8-10) ***Slow IV Push*** *****IF morphine is ineffective/contraindicated, USE HYDROmorphone if ordered*****
HYDROmorphone 1 mg, IVPush, inj, q4h, PRN pain-severe (scale 8-10) ***Slow IV Push***
Use if morphine ineffective or contraindicated.
Antiemetics
promethazine 25 mg, PO, tab, q4h, PRN nausea/vomiting
*****IF promethazine is ineffective/contraindicated or patient is NPO, USE ondansetron if ordered*****
ondansetron 4 mg, IVPush, soln, q8h, PRN nausea/vomiting
Use if promethazine ineffective or contraindicated.
Gastrointestinal Agents
docusate 100 mg, PO, cap, Nightly, PRN constipation *****IF docusate is contraindicated or ineffective after 12 hours, USE bisacodyl if ordered*****
bisacodyl 10 mg, rectally, supp, Daily, PRN constipation *****IF bisacodyl is contraindicated or ineffective after 6 hours, USE Fleet Enema if ordered*****
TO Read Back Scanned Powerchart Scanned PharmScan
Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Page: 15 of 17 Admit Sepsis Plan Version: 6 Effective on: 08/12/15
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UMC Health System Patient Label Here
Admit Sepsis Plan - When Pt. Arrives to Room - Discomfort Med Plan
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
sodium biphosphate-sodium phosphate (Fleet Enema) 132 mL, rectally, enema, Daily, PRN constipation
loperamide 4 mg, PO, cap, ONE TIME, PRN diarrhea Initial dose after first loose stool 4 mg, PO, liq, ONE TIME, PRN diarrhea Initial dose after first loose stool
loperamide 2 mg, PO, cap, as needed, PRN diarrhea
2 mg after each loose stool, up to 16 mg per day 2 mg, PO, liq, as needed, PRN diarrhea
2 mg after each loose stool, up to 16 mg per day
Antacids
Al hydroxide-Mg hydroxide-simethicone (aluminum hydroxide-magnesium hydroxide-simethicone 200 mg-200 mg-20 mg/5 mL oral suspension)
30 mL, PO, susp, q4h, PRN indigestion Administer 1 hour before meals and nightly.
simethicone 80 mg, PO, tab chew, q4h, PRN gas 160 mg, PO, tab chew, q4h, PRN gas
Sedatives
ALPRAZolam 0.25 mg, PO, tab, TID, PRN anxiety *****IF ALPRAZolam is ineffective/contraindicated or patient is NPO, USE LORazepam if ordered*****
LORazepam 1 mg, IVPush, inj, q6h, PRN anxiety 0.5 mg, IVPush, inj, q6h, PRN anxiety
zolpidem 5 mg, PO, tab, Nightly, PRN insomnia
may repeat x1 in one hour if ineffective
Antihistamines
diphenhydrAMINE 25 mg, PO, cap, q4h, PRN itching *****IF diphenhydrAMINE PO is ineffective or patient is NPO, USE diphenhydrAMINE inj if ordered*****
diphenhydrAMINE 25 mg, IVPush, inj, q4h, PRN itching
Use if oral dose is ineffective or patient is NPO
Anti-pyretics
TO Read Back Scanned Powerchart Scanned PharmScan
Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Page: 16 of 17 Admit Sepsis Plan Version: 6 Effective on: 08/12/15
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UMC Health System Patient Label Here
Admit Sepsis Plan - When Pt. Arrives to Room - Discomfort Med Plan
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
acetaminophen 500 mg, PO, tab, q4h, PRN fever
***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF acetaminophen is ineffective/contraindicated, USE ibuprofen if ordered***** 1,000 mg, PO, tab, q4h, PRN fever
***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF acetaminophen is ineffective/contraindicated, USE ibuprofen if ordered*****
ibuprofen 200 mg, PO, tab, q4h, PRN fever
Do not exceed 3,200 mg in 24 hours. Give with food. Use if acetaminophen is ineffective or contraindicated. 400 mg, PO, tab, q4h, PRN fever
Do not exceed 3,200 mg in 24 hours. Give with food. Use if acetaminophen is ineffective or contraindicated.
Anorectal Preparations
witch hazel-glycerin topical (witch hazel-glycerin 50% topical pad) 1 app, topical, pad, as needed, PRN hemorrhoid care Wipe affected area
*****IF witch hazel-glycerin or phenylephrine ointment ineffective/contraindicated, USE hydrocortisone-pramoxine foam if ordered*****
phenylephrine topical (phenylephrine 0.25%-3% rectal ointment) 1 app, rectally, oint, q6h, PRN hemorrhoid care Apply to affected area
*****IF witch hazel-glycerin or phenylephrine ointment ineffective/contraindicated, USE hydrocortisone-pramoxine foam if ordered*****
hydrocortisone-pramoxine topical (hydrocortisone-pramoxine 1%-1% rectal foam) 1 app, rectally, foam, q8h, PRN hemorrhoid care apply to affected area
TO Read Back Scanned Powerchart Scanned PharmScan
Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Page: 17 of 17 Admit Sepsis Plan Version: 6 Effective on: 08/12/15
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