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Perinatalhospice.org

A THERAPEUTICALLY EQUIVALENT PRODUCT MAY BE DISPENSED AND ADMINISTERED UNLESS CHECKED IN THE LEFT COLUMN.
DATE AND TIME
NEONATAL COMFORT CARE ORDERS
MUST BE ENTERED
– DISCHARGE
ALLERGIES:
Weight: _____________ kg
Check (✓) all that apply and fill in the blank if applicable
1.

May discharge to:
Other __________________________
Medical Diagnosis: __________________________________________
Code Status:
Full Code
See DNAR Form
Breast milk or Formula _____________ as tolerated by breast, bottle, feeding tube, or syringeFeeding tube type: Corpak Size _______ UnweightedIf needed place a Corpak for home care Size ___________ Unweighted Offer Non-pharmacologic Comfort Measures Prn: Swaddling, Holding, and Pacifier
Offer Oral Sucrose per policy for mild to moderate pain Neonatal Infant Pain Scale (NIPS) less than 4
Pain Control:
A. Short-acting or Breakthrough Pain Medications

Opioids need not be held for respiratory depression in actively dying patients.
Morphine ____mg (0.2 – 0.5 mg/kg/dose) Po q ____ HRS Prn severe pain NIPS score greater than 4Acetaminophen ____mg (10 –15 mg/kg/dose) Po or PR q ____HRS Prn mild pain Note: Max dose = 90 mg/kg/day if greater than 36 weeks; 60 mg/kg/day if 32 – 36 weeks B. Long-acting Pain Medications
Opioids need not be held for respiratory depression in actively dying patients.
Methadone ____mg (0.05 – 0.1 mg/kg/dose) Po q ____HRS C. Gastric Pain
Famotidine suspension (8 mg/mL) ______mg (0.5 mg/kg/dose) Po q 12 hours, or
Other: _______________________________________________
Dyspnea: Order opioids here if patient not already receiving opioids for pain.
Morphine ____mg (0.2 – 0.5 mg /kg/dose) Po q ___HRS Prn dyspnea
or
Lorazepam ____mg (0.1 mg /kg/dose) Po q ___HRS Prn dyspnea
____ % Oxygen ____ liters/min. by with humidification via neonatal/infant nasal cannula (indicated for
hypoxemia; may be helpful in other cases)
Anxiety/Agitation
Lorazepam ____mg (0.1 mg /kg/dose) Po q ____HRS Prn agitation. May give IV if unable to tolerate Po
or
Diphenhydramine ____mg (1 mg /kg/dose) Po q ____HRS Prn agitation
10. Secretions
Control with medications is preferred as suctioning can be uncomfortable for the patient.
Note: Minimizing fluids will help decrease symptoms
Reposition q 2-4 HRS as toleratedGlycopyrrolate ____mCg (40 – 100 mCg /kg/dose) Po q ___HRS Prn secretions Portable suction equipment with suction catheters 11. Fever
May consider additional non-pharmacologic measures such as bathing.
Acetaminophen ____mg (10 –15 mg /kg/dose) Po or PR q ____HRS Prn Temp greater than ____°CNote: Max dose = 90 mg/kg/day if greater than 36 weeks; 60 mg/kg/day if 32 – 36 weeks 12. Diarrhea
Loperamide ____ mg (0.08 – 0.24mg /kg/DAY in divided doses) Po q ___ HRS Prn diarrhea (Do not exceed 2 mg/dose), or
12-hour Chart Check___________________________ RN DATE: _______ / _____ / _____ TIME:____________
T.O. __________________________________________Taken by: ______________________________________Title:______________________
TRANSCRIBED BY: ______________ ____/____/ ____, TIME:___________ NOTED BY:_______________ ____/____/ ____, TIME:___________
PHYSICIAN SIGNATURE: ________________________________________________________ DATE:________________ TIME: ____________
PRINTED NAME/ID:
(FOR MEDICATION/BIOLOGICALS T.O. ORDERS ONLY, COUNTER-SIGN ABOVEWITHIN 48 HOURS, AND INCLUDE THE DATE/TIME AUTHENTICATED) NEONATAL COMFORT
CARE ORDERS – DISCHARGE
PHYSICIAN’S ORDERS

Source: http://perinatalhospice.org/uploads/St._Joseph_Comfort_Care_DC.pdf

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