PLACE LABEL HERE

BRONCHOSCOPY

ORDERS

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).

Diagnosis: ______

PRE BRONCHOSCOPY ORDERS

1.Bronchoscopy Procedure Date: ______Preferred Time: ______

2.  No IV access: insert INT

3. Blood Glucose finger stick monitoring pre-procedure for diabetics

4. Urine hCG for any menstruating female ≥ 12 years of age

5.Oxygen per protocol #34431

Pre-op Medications:

6. IV Fluids: LR 500 ml IV at keep vein open rate

If patient has renal insufficiency: NS 500 ml IV at keep vein open rate

Other: ______

7.Albuterol 2.5 mg and Atrovent (ipratropium) 0.5 mg aerosol 30 min prior to procedure

8.  Robinul (glycopyrrolate) 0.2 mg IM x 1 dose 30 min prior to procedure

9.Xylocaine (lidocaine) 4%, 4 ml aerosol 15 min prior to procedure

  1.  Xopenex (levalbuterol) 0.63 mg aerosol 30 min prior to procedure
  2. Atropine 0.4 mg IM x 1 dose, give 30 min prior to procedure
  3. Phenergan (promethazine) 25 mg IM x 1 dose, give 30 min prior to procedure

13. Fentanyl 25 mcg IV x 1 dose pre procedure, after consent is signed

14. Other: ______

______

DateTimePhysician SignaturePID Number

BRONCHOSCOPY INTRA-PROCEDURAL MEDICATIONS (Incremented during procedure)

  1. Cetacaine (benzocaine/tetracaine/butaben) x 1 spray for < 2 sec to pharynx immediately prior to procedure x 1 dose
  2. Xylocaine (lidocaine) jelly 2%,apply topically to nares x 1 dose, immediately prior to procedure
  3. Procedure Irrigant

Xylocaine (lidocaine) 1%, 2– 10ml for procedure irrigation

Xylocaine (lidocaine) 2%, 2 – 10 ml for procedure irrigation

Xylocaine (lidocaine) 1% with epinephrine, 2 – 10 ml for procedure irrigation

Xylocaine (lidocaine) 2% with epinephrine, 2 – 10 ml for procedure irrigation

  1. Morphine 1 - 2 mg IV q 5 min prn sedation during procedure
  2. Fentanyl 25 - 50 mcg IV q 2 min prn sedation during procedure
  3. Versed (midazolam) 0.5 - 2 mgIVq 2 min prn sedation during procedure
  4. Other: ______
  5. Labetolol 10 mg IV x 1 dose prn SBP > 160 mm Hg
  6. Reversal Medications, if needed

Narcan (naloxone) 0.4 to 2 mg IV prn opioid reversal. May repeat in 2-3 minx 1 dose.

Romazicon (flumazenil)0.2 mg IV prn benzodiazepine reversal. May repeat in 45 seconds then q 60 seconds, up

to a max of 1 mg.

Copy to pharmacy.Order writer’s initials ______

*3-15613* FORM 3-15613 REV. 05/2015 Page 1 of 2

PLACE LABEL HERE

BRONCHOSCOPY

ORDERS

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).

POST BRONCHOSCOPY ORDERS

1.Portable chest x-ray Reason: Status Post Bronchoscopy. Call results to: ______

2.Blood Glucose Finger Stick monitoring post-procedure on diabetics

3.Albuterol 2.5 mg aerosol x 1 prior to discharge

4.Atrovent (ipratropium) 0.5 mg aerosol x 1 prior to discharge

5.POST BRONCHOSCOPY OUTPATIENT ORDERS

NPO until 60 min after last dose of topical anesthetic or Other: ______

May go home when discharge criteria met, per Sedation Guidelines policy #520-29

6.POST BRONCHOSCOPY INPATIENT ORDERS

NPO until60 min after last dose of topical anesthetic

Return to floor when PAR score ≥ 9 or at pre-procedure level; if PAR ≤ 8 discharge by physician orders

Vital signs upon return to floor at 60 min, then per unit routine

Activity: If ambulatory, up with help first time, then as previously ordered

Oxygen per protocol (form #34431)

ADDITIONAL ORDERS:

______

______

______

______

______

______

______

______

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-15613 REV. 05/2015 Page 2 of 2