Unique Plan Description: Respiratory Failure (FH)
Plan Selection Display: Respiratory Failure (FH)
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2020-04-22 19:44:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2025-06-25 09:58:44
Available at all facilities: Yes

Respiratory Failure (FH)
Laboratory
	Culture Sputum
		T;N, Routine, Induced, spec type = Sputum, Sputum
	Blood Gases Arterial (ABG) - MH/WH/JE
		T;N, Stat, spec type = Blood
		T+1;0400, Routine, Q24H, spec type = Blood
		T+1;0400, Routine, spec type = Blood
		T;N+30, Timed, spec type = Blood
			Comment: To be done 30 min after intubation
	Blood Gases Arterial (ABG) - FH
		T;N, Stat, spec type = Blood
		T+1;0400, Routine, Q24H, spec type = Blood
	ProBNP
		T;N, Routine, spec type = Blood
	CK
		T;N, Routine, spec type = Blood
	hs Troponin T
		T;N, Routine, spec type = Blood
	CKMB
		T;N, Routine, spec type = Blood
	Thyroid Panel
		T;N, Routine, spec type = Blood
	Electrolytes
		T;N, Routine, spec type = Blood
	Hepatic Function Panel
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
	Renal Function Panel
		T;N, Routine, spec type = Blood
	Acetaminophen Level
		T;N, Routine, spec type = Blood
	Alcohol
		T;N, Routine, spec type = Blood
	Toxicology Screen DAU
		T;N, Routine, Urine Random, spec type = Urine
	Salicylate Level
		T;N, Routine, spec type = Blood
Diagnostic Tests
	Chest 1 View
		T;N, Respiratory Distress
	Chest 2 View
		T;N, Stat
		T;N, Routine
Cardiac
	ECG
		T;N, Routine, Indication: Abnormal Stress Test, DAILY, 3, Dose(s)/Time(s)
		T+1;0600, Routine
		T;N, Routine
		T;N, Stat
	Echo w Doppler resting
		T;N, Stat
		T;N, Routine
Medications

	albuterol 2.5 mg/3 mL (0.083%) inh soln
		3 mL, Solution-Nebulization, NEBULIZED, Q1H, PRN shortness of breath
		3 mL, Solution-Nebulization, NEBULIZED, Q4H, PRN shortness of breath
		3 mL, Solution-Nebulization, NEBULIZED, Q6H, PRN shortness of breath
		3 mL, Solution-Nebulization, NEBULIZED, Q4H, for shortness of breath
		3 mL, Solution-Nebulization, NEBULIZED, Q6H, for shortness of breath
	albuterol CFC free 90mcg/inh inh aerosol
		2 puff, Aerosol, Inhalation, QID
		1 puff, Aerosol, Inhalation, Q4H, PRN shortness of breath
		2 puff, Aerosol, Inhalation, Q4H, PRN shortness of breath
		2 puff, Aerosol, Inhalation, QID, PRN shortness of breath
	levalbuterol 1.25 mg/3 ml inhalation solution
		3 mL, Solution-Nebulization, NEBULIZED, Q8H
		3 mL, Solution-Nebulization, NEBULIZED, QID
		3 mL, Solution-Nebulization, NEBULIZED, Q2H, PRN for shortness of breath
		3 mL, Solution-Nebulization, NEBULIZED, Q2H
		3 mL, Solution-Nebulization, NEBULIZED, Q1H, PRN for shortness of breath
	albuterol-ipratropium 2.5 mg-0.5 mg/3 mL inhalation solution
		3 mL, Solution-Nebulization, NEBULIZED, TID
		3 mL, Solution-Nebulization, NEBULIZED, BID
		3 mL, Solution-Nebulization, NEBULIZED, Once
		3 mL, Solution-Nebulization, NEBULIZED, Q4H
		3 mL, Solution-Nebulization, NEBULIZED, QID, PRN wheezing and/or shortness of breath
			Comment: (maximum: 3 mL every 4 hours)
		3 mL, Solution-Nebulization, NEBULIZED, Q4H, PRN wheezing and/or shortness of breath
			Comment: (maximum: 3 mL every 4 hours)
		3 mL, Solution-Nebulization, NEBULIZED, Q6H, PRN wheezing and/or shortness of breath
			Comment: (maximum: 3 mL every 4 hours)
		3 mL, Solution-Nebulization, NEBULIZED, QID
	Combivent Respimat 20 mcg-100 mcg/inh inhalation aerosol
		1 puff, Aerosol, Inhalation, Q4H
		1 puff, Aerosol, Inhalation, QID
		1 puff, Aerosol, Inhalation, BID
	ipratropium 0.02% inhalation solution
		2.5 mL, Solution-Nebulization, NEBULIZED, Q6H-Sch
	Atrovent HFA 17 mcg/inh inhalation aerosol
		1 puff, Aerosol, Inhalation, QID
		For (ICU) patients who are able to receive enteral medications and in whom stress ulcer prophylaxis is indicated,  UpToDate recommends an oral (PPI) rather than an alternative prophylactic agent (Grade 1B)(NOTE)*
	pantoprazole
		40 mg, Tablet-Enteric-Coated, By Mouth, DAILY
	pantoprazole IV
		40 mg, Injection, IV Push, DAILY
			Comment: Change to PO [same dose and frequency]when patient tolerating oral / enteral nutrition and receiving other oral medications.  RP: Leave Ad Hoc on IDSR stating IV-->PO Conversion
	famotidine
		20 mg, Injection, IV Push, BID
			Comment: Change to PO [same dose and frequency]when patient tolerating oral / enteral nutrition and receiving other oral medications.  RP: Leave Ad Hoc on IDSR stating IV-->PO Conversion
		20 mg, Injection, IV Push, DAILY
			Comment: CrCl < 30ml/minChange to PO [same dose and frequency]when patient tolerating oral / enteral nutrition and receiving other oral medications.  RP: Leave Ad Hoc on IDSR stating IV-->PO Conversion
		UpToDate recommends NOT using uninterrupted sedative-analgesic infusions to sedate critically ill patients (Grade 1B). Intermittent infusions, continuous infusions directed by a sedation protocol, or daily interruption of continuous infusions are preferab(NOTE)*
		For patients receiving more than one sedative-analgesic medication, the opioid should be tapered last so that the patient does not awake in pain.((NOTE)*
	fentaNYL
		25 mcg, Injection, IV Push, Q10MIN, PRN sedation
	LORazepam Injectable
		0.5 mg, Injection, IV Push, Once
		1 mg, Injection, IV Push, Once
		0.5 mg, Injection, IV Push, Q4H, PRN anxiety
		1 mg, Injection, IV Push, Q4H, PRN anxiety
	midazolam
		2 mg, Injection, IV Push, Once
			Comment: Loading dose.
		2 mg, Injection, IV Push, Q15MIN, PRN sedation
		Adequate sedation and analgesia are essential prior to initiating therapy with neuromuscular blocking agents.(NOTE)*
		The body of evidence suggests that the administration of short-term (up to 48 hours) neuromuscular blockade to patients with acute respiratory distress syndrome (ARDS) who have severe gas exchange abnormalities (eg, PaO2/FiO2 less than or equal to 120 mmH(NOTE)*
	cisatracurium
		0.15 mg/kg, Solution-Injection, IV Push, Once
			Comment: Determine supramaximal TOF setting before giving cisatracurium, begin continuous infusion after bolus dose.  Use cisatracrium if patient has hepatic dysfunction or creatinine clearance <50 mL/min (do not give bolus).
	cisatracurium 100mg/NS 50 mL
		100 mg, EVERY BAG, 1 mcg/kg/min, T;N
		50 mL, IV, T;N
			Comment: Conc: 2 mg/mL.  Determine supramaximal TOF setting before giving cisatracurium, begin continuous infusion after bolus dose.  Use cisatracrium if patient has hepatic dysfunction or creatinine clearance <50 mL/min (do not give bolus). Rate: begin at 1 mcg/kg/min and titrate to keep at 2 twitches with TOF.  Range: 0.5 to 3 mcg/kg/min, up to 10 mcg/kg/min.  NMB infusion adjustments: 0 twitches= hold NMB for 60 minutes, reassess TOF, and adjust NMB.  If TOF remains at 0, notify physician.  1 twitch= decrease NMB infusion by 50%.  2 twitches(GOAL)= maintain current infusion rate.  3 twitches= increase infusion rate by 10%.  4 twitches= increase infusion rate by 25%.                                                                                                     Retest TOF 10-15 minutes after a bolus dose or when continuous infusion of NMBD is given/initiated/changed. Retest every 2 to 4 hours after a clinically stable and satisfactory level of blockade is achieved.
Patient Care
	Patient Education
		T;N, Instructions: Patient Education
	Cardiac Telemetry Monitoring
		
Therapies
	No Respiratory Protocol, per MD
		
	Pulse Oximetry Spot Check RT
		T;N, Once
	Bronchodilator Therapy per Respiratory Protocol (FH)
		T;N
	Consult Respiratory Therapy-Assess and Treat
		T;N, Routine
			Comment: Respiratory Failure, Evaluate pts respiratory care needs, determine indications for RT, and suggest appropriate modalities
	Pulse Oximetry Spot Check RT
		T;N, Once
Consults/Follow-up
	Consult Cardiologist
		Reason for Referral: respiratory failure
	Consult Pulmonologist
		Reason for Referral: respiratory failure
	Consult Infectious Disease
		Reason for Referral: respiratory failure

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase