Long Term Care Tube Fe Order Trackereding Orders - Physician'S Order Sheet
ADVERTISEMENT
1
2Long Term Care TUBE FEEDING ORDERS
PHYSICIAN'S ORDER SHEET
ALL ORDERS WILL BE FULFILLED UNLESS CROSSED OUT
AFTER EACH ORDER IS PROPERLY CHECKED, FAX ORDER SHEET
TO PHARMACY WHETHER OR NOT ORDERS INVOLVE MEDICATION.
√
Check ( )
√
Check ( )
Each
ALLERGY
Pharmacy
Order As
Orders
Transcribed
DATE:
TIME:
( Military Time )
I.
CHECK ONE: [ A ] Pump; [ B ] Bolus; or [ C ] Gravity
[ A ]
Tube Feeding of ___________________ (product) via ___________________
tube via Pump at _________ ml per hour. Total Volume _________ ml's. Begin at
________ am/pm. End when total volume has been infused.
- Check tube for correct placement and patency before administering medication,
starting pump and tube flushes.
- Flush ___________ tube with ____________ ml of water (q x hrs or q x / day).
- Check tube for residuals before starting each feeding. If residual > 100ml, hold feeding.
- Recheck in 1 hour. If residual is still > 100ml's, notify MD for direction.
- Flush tube with 30ml of H2O before & after each medication administration.
- Change Spike Tubing every 24 hours.
- Change Y-Connector every week and PRN.
- Mouth & Nares care each shift.
- Change Syringe each day and PRN.
- Elevate head of bed 30-45 degrees during and 2 hours after feeding.
[ B ]
Tube Feeding of ___________________ (product) via ___________________
tube. Give _________ ml Bolus _____________ (q x hrs, or x times per day).
- Check tube for correct placement and patency before administering medication and
tube flushes.
- Flush ___________ tube with ____________ ml's of water (q x hrs or q x / day).
- Check tube for residuals before starting each feeding. If residual > 100ml, hold feeding.
- Recheck in 1 hour. If residual is still > 100ml's, notify MD for direction.
- Flush tube with 30ml of H2O before & after each medication administration.
- Mouth & Nares care each shift.
- Change Syringe each day and PRN.
- Elevate head of bed 30-45 degrees during and 2 hours after feeding.
[ C ]
Tube Feeding of ___________________ (product) via ___________________
tube via Gravity at _________ ml per hour. Total Volume _________ ml's. Begin at
________ (military time). End when total volume has been infused.
- Check tube for correct placement and patency before administering medication and
tube flushes.
- Flush ___________ tube with ____________ ml's of water (q x hrs or q x / day).
- Check tube for residuals before starting each feeding. If residual > 100ml, hold feeding.
- Recheck in 1 hour. If residual is still > 100ml's, notify MD for direction.
- Flush tube with 30ml of H2O before & after each medication administration.
- Change Spike Tubing every 24 hours.
- Change Y-Connector every week and PRN.
- Mouth & Nares care each shift.
- Change Syringe each day and PRN.
- Elevate head of bed 30-45 degrees during and 2 hours after feeding.
II.
Add ______ scoops of Promod/day to provide ______ gms of protein and ______ calories.
III.
Total feeding provides _______ cal, _______ gms of protein and _______ ml of free water.
Telephone Order by: ______________________
Time: ____________
FAXED BY/TIME: TIME NOTED:
Doctor's Signature ____________________________________,MD Date __________
Military Time > >
Nurse's Signature / Title___________________________________________________
USE BALL POINT PEN ONLY - PRESS FIRMLY
PART OF THE MEDICAL RECORD
Tube Feeding Physicians Order Sheet_LONG TERM CARE_MEDICAL AFFAIRS
PAGE 1 of 2
8850342 Rev 05/05
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business