/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/delegationpractice-protocols/,/clinical/cckm-tools/content/delegationpractice-protocols/inpatient-delegation-protocols/,/clinical/cckm-tools/content/delegationpractice-protocols/inpatient-delegation-protocols/related/,

/clinical/cckm-tools/content/delegationpractice-protocols/inpatient-delegation-protocols/related/name-97325-en.cckm

201605126

page

100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Delegation/Practice Protocols,Inpatient Delegation Protocols,Related

Tube Feeding - Pediatric - Supplemental

Tube Feeding - Pediatric - Supplemental - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols, Related


IP - Tube Feeding - Pediatric - Supplemental [4293]
Pediatric Enteral Nutrition Guidelines for Tube
Feeding
URL: https://uconnect.wisc.edu/servlet/Satellite?
cid=1121383617931&pagename=B_EXTRANET_UWHC_POLICIES%
2FFlexGroup%2FShow_Manual_Category&c=FlexGroup
Patient Care Orders
Patient Monitoring - General [135148]
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting today, Routine
If Conditional, What Condition?
Patient Monitoring - Cotinuous Tube Feeding [135166]
Glucose, POC [IPGLUCOSE] EVERY 6 HRS IF NPO/ CONT. TUBE FEEDING/ OR TPN,
Starting today For 48 Hours, Routine
If Conditional, What Condition?
Patient Monitoring - Tube Feeding Bolus [135167]
Glucose, POC [IPGLUCOSE] 30 MINUTES BEFORE CYCLIC TUBE FEEDING, Starting
today For 48 Hours, Routine
If Conditional, What Condition?
Patient Monitoring - Gastric Feedings [135171]
For Gastric Feedings [NURMON0060] SEE COMMENTS, Starting today, - Measure and document
residual every 4 hours for 48 hours
- Hold tube feeding for 1 hour if residual greater than 250
milliliters
- Recheck residual after 1 hour and restart tube feeding at
previous rate if residual is less than 250 milliliters
- Restart tube feeding at previous rate if residual is less than
250 milliliters
- Notify Physician if tube feeding residual is still greater than
250 milliliters
Patient Monitoring - Small Bowel Feeding [135176]
For Small Bowel Feeding [NURMON0060] SEE COMMENTS, Starting today, - Monitor GI tolerance
closely
- Hold tube feeding if there are sudden changes in abdominal
exam, GI function, or hemodynamic status
Notify Provider [135185]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): 150 during the first 48 hours of
tube feeding administration
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other:
Nutrition
Diet [135187]
Tube Feeding With Tray [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet:
Page 1 of 7
Pr i nt ed by STRAKA, KEVIN F [KFS1] at 9/23/2013 1:13:50 PM
Copyright © 2013 University of Wisconsin Hospital and Clinics Authority


Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail): TUBE FEEDING WITH TRAY;
Tube Feeding Management:
Room Service Class:
Tube Feeding No Tray [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
Page 2 of 7
Pr i nt ed by STRAKA, KEVIN F [KFS1] at 9/23/2013 1:13:50 PM
Copyright © 2013 University of Wisconsin Hospital and Clinics Authority


detail): TUBE FEEDING NO TRAY;
Tube Feeding Management:
Room Service Class: RS3-ROOM SERVICE NON-SELECT
Tube Feeding With PN [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail): TUBE FEEDING WITH TNA;
Tube Feeding Management:
Room Service Class:
Tube Feeding Strict NPO [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Page 3 of 7
Pr i nt ed by STRAKA, KEVIN F [KFS1] at 9/23/2013 1:13:50 PM
Copyright © 2013 University of Wisconsin Hospital and Clinics Authority


Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail): TUBE FEEDING STRICT NPO
Tube Feeding Management:
Room Service Class:
Tube Feeding NPO Except Medications [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail): TUBE FEEDING NPO EXCEPT MEDICATIONS
Tube Feeding Management:
Room Service Class:
Tube Feeding NPO With Ice Chips [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Page 4 of 7
Pr i nt ed by STRAKA, KEVIN F [KFS1] at 9/23/2013 1:13:50 PM
Copyright © 2013 University of Wisconsin Hospital and Clinics Authority


Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail): TUBE FEEDING NPO WITH ICE CHIPS
Tube Feeding Management:
Room Service Class:
Tube Feeding NPO With Sips of Water [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail): TUBE FEEDING NPO WITH SIPS OF WATER
Tube Feeding Management:
Room Service Class:
Tube, Nasojejunal, J-tube (DOBHOFF or JEJUNOSTOMY) [135188]
Tube Feeding, Continuous [NUT0002] EFFECTIVE NOW, Starting today, Routine
Products (Adult / Adolescent / Pediatric):
Products (Infant):
Continuous Start Rate: *** mL/hr
Advance Rate by: *** mL/hr
Advance Rate Frequency: ***
Continuous Goal Rate: *** mL/hr
Flush With: ***
Flush Volume: *** mL
Flush Frequency: ***
Tube Feeding, Cyclic [NUT0003] EFFECTIVE NOW, Starting today, Routine
Products (Adult / Adolescent / Pediatric):
Products (Infant):
Rate: *** mL/hr
Start Time: ***
Page 5 of 7
Pr i nt ed by STRAKA, KEVIN F [KFS1] at 9/23/2013 1:13:50 PM
Copyright © 2013 University of Wisconsin Hospital and Clinics Authority


End Time: ***
Flush With: ***
Flush Volume: *** mL
Flush Frequency: ***
Tube, Nasogastric, Gastrostomy, Percutaneous Endoscopic Gastrostomy, (PEG-Tube) [135189]
Tube Feeding, Continuous [NUT0002] EFFECTIVE NOW, Starting today, Routine
Products (Adult / Adolescent / Pediatric):
Products (Infant):
Continuous Start Rate: *** mL/hr
Advance Rate by: *** mL/hr
Advance Rate Frequency: ***
Continuous Goal Rate: *** mL/hr
Flush With: ***
Flush Volume: *** mL
Flush Frequency: ***
Tube Feeding, Cyclic [NUT0003] EFFECTIVE NOW, Starting today, Routine
Products (Adult / Adolescent / Pediatric):
Products (Infant):
Rate: *** mL/hr
Start Time: ***
End Time: ***
Flush With: ***
Flush Volume: *** mL
Flush Frequency: ***
Tube Feeding, Bolus [NUT0004] EFFECTIVE NOW, Starting today, Routine
Products (Adult / Adolescent / Pediatric):
Products (Infant):
Initial Bolus Volume: *** mL
Advance Volume By: *** mL
Bolus Frequency: ***
Goal Bolus Volume: *** mL
Free Water: ***/day
Special Instructions: ***
Laboratory
Laboratory [135190]
ELECTROLYTES [LYTE] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] EVERY MONDAY AND THURSDAY, Starting today with First
Occurrence As Scheduled For 4 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Consults
Consults [135191]
Consult Nutrition (Inpatient) [CON0043] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Delegate to Initiate and Manage Tube Feeding:
Delegate to Initiate Feeding Tube Placement Order Set:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
Initiation of tube feeding
Consult Surgical Nutrition Support (Inpatient) [CON0106] ONCE, Starting today
Intent: Consult and Recommend (Write Orders)
Reason for Consult:
Initiation of tube feeding.
Consult Diabetes Management (Inpatient) [CON0022] ONCE, Starting today
Page 6 of 7
Pr i nt ed by STRAKA, KEVIN F [KFS1] at 9/23/2013 1:13:50 PM
Copyright © 2013 University of Wisconsin Hospital and Clinics Authority


Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Initiation of tube feeding for
patients being followed by diabetes management
Page 7 of 7
Pr i nt ed by STRAKA, KEVIN F [KFS1] at 9/23/2013 1:13:50 PM
Copyright © 2013 University of Wisconsin Hospital and Clinics Authority