Microsoft word - preterm care order set revised.docx

Preterm Care: ORDER SET Addressograph/label:
Diagnosis:______________________________ EGA:______weeks Allergies(include reactions):_________________________________________ Prenatal Care Provider:______________________________ 1. □ Continuous Fetal Monitoring/Tocodynamometry
i. □ Other:_______________________________
2. □ Activity:
i. □ bedrest
□ bedrest w/ BRP’s □Other____________________
3. Diet: □ NPO
□ Ice Chips only □ Clear liquids □ Other_____________ 3. Vital Signs: □ Per protocol for _____________________________
4. IV therapy: peripheral IV (18 gauge preferred)
□Normal Saline Solution (NSS) 1000ml at (rate) _______ml/hour □ Other_______________ at (rate)________ml/hour □ Total IV fluids at _______ml/hour 5. Laboratory tests: Place a √ in the desired box(s)
□ CBC with platelets □ Type & Screen □ DIC screen □ Other_______________________________ □ Liver function tests: □ LDH □ ALT □ AST □ Metabolic profile: □ Chem 12 □ BMP □ SMA6 □ SMA 12(institution will modify)
□ Cultures: □GC □ Chlamydia □ GBS □ Other___________________ □ Urinalysis □ Urine culture & sensitivity/gram stain □ Other_______________ □ Straight Cath specimen □ 24 hour urine collection for total protein, creatnine, creatnine clearance 6. □ Foley catheter to straight drainage
7. □ Intake and Output
8. □ Pneumatic Compression boots
9.. Medications:
i. □ Steroid therapy for fetal lung maturity enhancement (EGA 24-34 wks; for
PPROM 24-34 wks. EGA)□ Betamethasone (e.g. celestone®) 12mg IM NOW and
repeat in 24 hours or,
ii. □ Dexamethasone (e.g. decadron®) 6mg IM NOW and every 12 hours for 4 doses
b. □ Antibiotic regimen for Group B prophylaxis or Treatment:
i. □ Penicillin G 5 million units IV NOW, then Penicillin G 2.5 million units every 4 hours
ii. □ IF Penicillin allergic: Clindamycin (e.g. Cleocin®) 900mg IV NOW and every 8 hours,
c. □ IF PPROM:
i. □ Ampicillin (e.g. marcillin®) 2 grams IV every 6 hours IF Penicillin allergic :
: □ Clindamycin (e.g. Cleocin®) 900mg IV NOW and every 8 hours
AND □ Azithromycin 500 mg IV daily
* If GBS status is unknown and patient is <37 weeks EGA – BEGIN TREATMENT/Prophylaxis!
d. Magnesium Sulfate Therapy: (Patient may receive Magnesium sulfate for Neuroprotection
OR seizure prophylaxis; NOT BOTH. NOTE: different loading doses for each, but same maintenance
rate). If patient with renal failure, dose may need to be adjusted.
i. Neuroprotection (23w/0days to 31w/6days)
i. □ Magnesium sulfate in water, 40 gram/1000ml premix - 6 gram/150 ml loading dose followed by: 2 grams/hour maintenance infusion until delivery or 12 hours have elapsed . Seizure Prophylaxis for Preeclampsia:
□ Magnesium sulfate in water, 40 gram/1000ml premix- 4-6 gram/100ml loading dose followed by: e. Tocolysis:
i. □ Indomethacin: (Not indicated > 32 weeks EGA) 50 mg p.o. NOW, then:
□ 25mg p.o. or PR every 6 hours for 48 hours
□ 50 mg p.o. or PR every 6 hours for 48 hours OR,
ii. □ Nifedipine (e.g. procardia®): 10 mg p.o. NOW, then 10 mg every 20 minutes up
to a total of 30 mg, or until uterine activity declines (whichever occurs first) then, iii. □ Nifedipine 10-20 mg p.o. every _______hours(for up to 48 hours)
OB TRANSPORT ORDERS:
1. □ Transport worksheet completed and to go with patient
2. □ History and Physical to be completed by transferring physician/CNM
3. □ Prenatal records to go with patient
4. □ Copy of patient chart and a copy of all laboratory studies to go with patient
5. □ Auscultate FHT’s and assess and document uterine activity:
a. prior to transport b. Every 15-30 minutes en route c. upon arrival 6. □ Continuous IV fluids as ordered above
7. □ Vital signs: BP & pulse: Q15-30 minutes en route
8. □ For any urgent or emergent situation en route call the TRANSFERRING PHYSICIAN
_________________________________ __________________________
Physician/Provider
Revised 1/7/14

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