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PHYSICIAN’S ORDERS
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Date: ________________ Time: ____________ Weight: ______ Kg Actual Estimate Admission Diagnosis:_____________________________________
Admitting Physician:______________________________________

Code status:____________________________________________

MD to Notify Family Physician of ICU Admission Date Notified: ___________________________
IV Solution(s)
___________________________________ Rate: ___________________________ mL/h
___________________________________ Rate: ___________________________ mL/h

Mechanical Ventilation
b) Tidal volume ______ (mL) OR pressure limit at _______(cm H20) as applicable
c) PEEP _________ cm H20
d) Adjust
e) _________________________________ f) _________________________________
Patient Positioning and Precautions
No spinal precautions necessary, maintain HOB greater than 30° Cervical, thoracic and lumbar spine precautions: • Apply stiff-neck cervical collar • Maintain bed in 30° Reverse Trendelenberg Activity (Reassess Daily)
Bed rest AAT Specify if restrictions required _________________________ Gastrointestinal Access
Insert nasal #18 French Salem Sump *OR*
Insert oral #18 French Salem Sump
Esophagectomy patient, do not change or adjust OG/NG tube position; leave air vent open
(i.e. do not place anti-reflux valve on air vent). Nutrition Support
NPO; NG/OG tube to low intermittent suction Initiate and titrate feeds as per ICU Feeding Protocol Enteral feeding formula:_______________ (refer to ICU Enteral Products Formulary) Start rate: _______ mL/h (if different from 25 mL/h) Goal rate: _______ mL /h (refer to Goal Feed Rate Resource) ___________________________ ______________________________ _____________ PHYSICIAN’S ORDERS
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Medications
DISCONTINUE ALL PREVIOUS MEDICATION ORDERS

Monitoring for Analgesia, Agitation/Delirium and Anxiety
Interaction level 1: Patient should be able to communicate presence of pain or anxiety.

Document:
•
VICS score Q4H and pre and post interventions to treat: agitation/delirium, pain and anxiety Pain intensity with Numeric Rating Scale (0-10) pre and post interventions to relieve pain (target 3/10 or as patient directs)
Analgesia
Administer prior to procedures that may cause pain To relieve pain in patients who communicate need for intervention To treat signs of pain in patients who cannot communicate, but pain is suspected given clinical
situation. Review signs of inferred pain with MD Q4H.
Morphine 0.5 mg to 6 mg IV Q5MIN as per protocol PRN. Call MD if infusion considered necessary after 6 hours of bolus therapy.
Peri-procedural Sedation
Midazolam 0.5 mg to 6 mg IV Q3MIN PRN – administer prior to procedure as per protocol Delirium

If patient is agitated, but is unable to communicate presence of pain or anxiety
call MD to assess patient for delirium. Use separate orders for delirium.
Lorazepam 0.5 mg to 1 mg sublingual / IV Q4H PRN x 24h to relieve patient confirmed anxiety Sedation Needed for Other Indication

See separate orders for patients who require: sedation for physiologic goals ___________________________ ______________________________ _____________ PHYSICIAN’S ORDERS
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Inhaled Bronchodilators
Ventilated patients
salBUTamol 800 to 1,200 micrograms (8-12 puffs) by MDI Q1H PRN salBUTamol 800 to 1,200 micrograms (8-12 puffs) by MDI Q4H x 7 days
ipratropium 160 to 240 micrograms (8-12 puffs) by MDI Q4H x 7days (For patients with COPD)
Non-ventilated Patients
salBUTamol 2.5 to 5 mg nebulized Q1H PRN salBUTamol 2.5 to 5 mg nebulized Q4H x 7 days
ipratropium 0.25 to 0.5 mg nebulized Q6H x 7 days (For patients with COPD)

Vasopressors/Inotropes
Maintain mean arterial pressure at or above _________mm Hg. Contact physician to reassess if dose increase is required above maximum NORrepinephrine 0 to_____ mcg/MIN IV (maximum dose 10 mcg/MIN) DOPamine 0 to _____ mcg/kg/MIN IV (maximum dose 5 mcg/kg/MIN) 0 to _____ mcg/kg/MIN IV *OR* at ___________ mcg/kg/MIN IV
___________________________________________
Antibiotics:

_____________________________________ Indication:____________
_____________________________________ Indication:____________
_____________________________________ Indication:____________

Micronutrients
Multivitamins 10 mL IV daily x 3 days Folic acid 5 mg IV daily x 3 days Thiamine 100 mg IV daily x 3 days Glycemic Control
Glucometer Q______ Regular Insulin IV infusion as per “ICU Protocol to control blood glucose 7 to 10 mmol/L” Stress Ulcer Prophylaxis (See ICU protocol for indications)
Ranitidine 50 mg IV Q8H *OR*
Ranitidine 150 mg NG/OG Q12H
___________________________ ______________________________ _____________ PHYSICIAN’S ORDERS
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Bowel Protocol
If spine injury, physician to complete “ICU Bowel Protocol for Spine Injured Patient” ICU Bowel Protocol for Non-Spine Injured patients • Docusate 200 mg NG daily at 1000h, and continue after bowel movement • If no bowel movement in last 24 hours give: • Milk of Magnesia 30 mL NG daily at 1000h and Cascara 15 mL NG daily at 1000h
• Continue Milk of Magnesia and Cascara until bowel movement
• If no bowel movement within 24 hours in response to above give:
• One (130 mL) sodium phosphates enema (FLEET phosphate enema) PR at 1000h • If no bowel movement within 24 hours in response to above discuss with MD
Thromboprophylaxis
See ICU protocol for indications and contra-indications
Precautions:
• No IM injections If patient is receiving enoxaparin • If possible, avoid ASA and NSAIDS if patient is receiving enoxaparin • If receiving continuous epidural analgesia and enoxaparin: • Avoid concomitant antiplatelet agents (ASA, NSAIDS, ticlopidine, or clopidogrel) or other anticoagulants (heparin, warfarin, or dextran). • Removal of epidural catheters should occur at least 12 hours after the previous enoxaparin dose, and the subsequent enoxaparin dose should not be given for at least 2 hours after catheter removal. Enoxaparin 30 mg subcutaneous BID (For major orthopaedic trauma or spinal cord injury) *OR*
Heparin 5,000 units subcutaneous Q12H (If patient is 100 kg or less) *OR*
Heparin 5,000 units subcutaneous Q8H (If patient is greater than 100 kg)
Intermittent pneumatic compression device (For patients with significant bleeding risk)
___________________________ ______________________________ _____________ PHYSICIAN’S ORDERS
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Electrolyte Replacement Protocol
CAUTION USE ELECTROLYTE REPLACEMENT PROTOCOLS ONLY IF THE FOLLOWING CRITERIA ARE MET (Review daily) SCr is less than 150 mmol/L or normal renal function Urine output is greater than 0.5 mL/kg/h x 2 consecutive hours Potassium Replacement Protocol
If serum K is 3.1 to 4.0 mmol/L:
Give potassium chloride 20 mmol IV over 1 hour
If serum K is 2.5 to 3.0 mmol/L:
NOTIFY MD and give potassium chloride 20 mmol IV over 1 hour; repeat x 1
If serum K is less than 2.5 mmol/L: NOTIFY MD and give potassium chloride 20 mmol IV over 1 hour; repeat x 2

Check serum potassium 2 hours after the end of the final replacement dose Phosphate Replacement Protocol
If serum PO4 is less than 0.8 mmol/L AND serum K is less than 4.0 mmol/L:
Give POTASSIUM Phosphate 15 mmol IV over 4 hours Q8H x 3 doses
Check serum potassium, PO4 and ionized calcium 6 hours after end of final dose
If serum PO4 is less than 0.8 mmol/L AND serum K is 4.0 mmol/L or above:
Give SODIUM phosphate 15 mmol IV over 4 hours Q8H x 3 doses
•
Check serum PO4 and ionized calcium 6 hours after end of final dose Magnesium Replacement Protocol
If serum Mg is less than 0.7 mmol/L:
Give magnesium sulphate 5 g IV over 4 hours Q8H x 3 doses
Check serum magnesium 6 hours after end of final dose ___________________________ ______________________________ _____________

Source: http://www.bcsccm.ca/img/ICU%20ADMISSION%20orders.pdf