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/clinical/cckm-tools/content/order-sets/ambulatory/transplant/name-112159-en.cckm

201711332

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100

UWHC,UWMF,

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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,Transplant

Kidney Transplant Biopsy - OP - Adult Procedure [3699]

Kidney Transplant Biopsy - OP - Adult Procedure [3699] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Transplant


Kidney Transplant Biopsy - OP - Adult Procedure [3699]
Lab Orders
Labs - Pre-Biopsy [106890]
Prothrombin Time/INR [PT] Status: Future, Expected: 8/4/2017 Approximate,
Expires: 8/5/17, Office collect, Routine
Platelet Count [PLT] Status: Future, Expected: 8/4/2017 Approximate,
Expires: 8/5/17, Office collect, Routine
Glucose, POC [IPGLUCOSE] Status: Future, Expected: 8/4/2017 Approximate,
Expires: 8/5/17, Back Office, Routine
HLA Class I Donor Specific AB by Luminex
[HCDSA1B]
Status: Future, Expected: 8/4/2017 Approximate,
Expires: 8/5/17, Office collect, Routine
HLA Class II Donor Specific AB by Luminex
[HCDSA2B]
Status: Future, Expected: 8/4/2017 Approximate,
Expires: 8/5/17, Office collect, Routine
BK Virus, Quantitative by PCR [HCBKVPCR] Status: Future, Expected: 8/4/2017 Approximate,
Expires: 8/5/17, Office collect, Routine
Labs - Post-Biopsy [106914]
Hemoglobin [HGB] Status: Future, Expected: 8/4/2017 Approximate,
Expires: 8/5/17, Office collect, STAT, 3 hours post-
procedure.
Post-biopsy labs. Clinic to send specimen
Hematocrit [HCT] Status: Future, Expected: 8/4/2017 Approximate,
Expires: 8/5/17, Office collect, STAT, 3 hours post-
procedure.
Post-biopsy labs. Clinic to send specimen
Glucose, POC [IPGLUCOSE] Status: Future, Expected: 8/4/2017 Approximate,
Expires: 8/5/17, Back Office, Routine
Imaging Orders
Imaging [106894]
Biopsy Ultrasound Guided - Transplanted Kidney
- Right (if requested today) [R76942]
ONCE-ON SPECIFIC DATE, Starting today For 1
Occurrences, Routine
Site/ organ to biopsy? Right Kidney
Is this a Fine Needle Aspiration or Core Biopsy? Core
Radiology Specialty Area: ULTRASOUND
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
For Scheduling purposes, is the patient claustrophobic
or require any form of sedation? Note: ordering
provider is responsible for prescribing oral anxiolytic or
ordering sedation services.
Is patient on anticoagulation therapy? If yes, specify
coagulation disorder and current medications in
comments box at bottom.
Transport Method: No Transporter Needed
Page 1 of 4
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 1:57:51 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Biopsy Ultrasound Guided - Transplanted Kidney
- Left (if requested today) [R76942]
ONCE-ON SPECIFIC DATE, Starting today For 1
Occurrences, Routine
Site/ organ to biopsy? Left Kidney
Is this a Fine Needle Aspiration or Core Biopsy? Core
Radiology Specialty Area: ULTRASOUND
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
For Scheduling purposes, is the patient claustrophobic
or require any form of sedation? Note: ordering
provider is responsible for prescribing oral anxiolytic or
ordering sedation services.
Is patient on anticoagulation therapy? If yes, specify
coagulation disorder and current medications in
comments box at bottom.
Transport Method: No Transporter Needed
Intravenous Therapy
IV Therapy [106891]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
sodium chloride 0.9% infusion [64367] at 20 mL/hr, Intravenous, CONTINUOUS
Discontinue one hour after biopsy
Premedications for Needle Insertion [106310]
Use lidocaine topical dressing kit for stable patient, no lidocaine allergies, have at least 30
minutes time prior to needing to use IV
Sodium chloride (bacteriostatic) 0.9% intradermal: Useful for patients requiring urgent IV
access; onset is within 1 minute. Choice of medication should be based on patient’s previous
experience/preference, history of lidocaine allergy and ease of access.
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, peripheral line
insertion - see Admin Instructions
Do NOT apply to area greater than 200 square
centimeters (maximum 2.5 g/site; maximum 4 sites
per hour, 6 times per day). Do NOT leave on longer
than 2 hours. Use for stable patient, no allergies to
lidocaine, with at least 30 minutes time prior to IV use
lidocaine (XYLOCAINE) 1% injection [39034] 0.1-0.4 mL, Intradermal, PRN, peripheral line insertion
- see Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge
needle to inject solution and create a wheal. Wait 30
seconds to 1 minute then insert IV catheter into center
of wheal. Use if IV is needed within 30 minutes.
Choice of medication should be based on patient’s
previous experience/preference, history of lidocaine
allergy and ease of access
Page 2 of 4
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 1:57:51 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

sodium chloride (bacteriostatic) 0.9 % injection
[50585]
0.05-0.1 mL, Intradermal, PRN, peripheral line
insertion - see Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge
needle to inject solution and create a wheal. Wait 30
seconds to 1 minute then insert IV catheter into center
of wheal. Use if IV is needed within 30 minutes.
Choice of medication should be based on patient’s
previous experience/preference, history of lidocaine
allergy and ease of access
Premedication for Needle Insertion [30232]
Lidocaine [152737]
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, prior to needle sticks
to reduce pain. See "LMX Use Instructions" order in
Active Orders report or the Admin Instructions for
application details
FOR PATIENTS 5 Kg OR LESS: Do NOT apply to
area greater than 100 square centimeters.
(maximum 1 g/site; maximum 1 site per hour, 6
times per day).
FOR PATIENTS 5.1-10 Kg: Do NOT apply to area
greater than 100 square centimeters. (maximum 1
g/site; maximum 2 sites per hour, 6 times per day).
FOR PATIENTS GREATER THAN 10 Kg: Do NOT
apply to area greater than 200 square centimeters.
(maximum 2.5 g/site; maximum 4 sites per hour, 6
times per day).
For patients less than 1 year old do NOT leave on
longer than 1 hour. For patients 1 year or older do
NOT leave on longer than 2 hours
LMX Use Instructions for Premedication Prior to
Needle Insertion [NURCOM0095]
Details
Medications - Clinic Administered
Non-categorized [117735]
midazolam (VERSED) injection RANGE [750056] 1-4 mg, Intravenous, ONCE PRN For 1 Doses,
sedation for biopsy
lidocaine 1 % vial [39034] Subcutaneous, ONCE PRN For 1 Doses
sodium bicarbonate [800214] 5-10 mEq, Other, ONCE PRN For 1 Doses, Injection
Site Pain
Mix 5-10 mL with lidocaine immediately prior to biopsy
for subcutaneous administration.
Hypertension [106903]
cloNIDINE (CATAPRES) tab [35979] 0.1 mg, Oral, EVERY 30 MINUTES PRN For 3 Doses,
for SBP greater than 170 mmHg or DBP greater than
100 mmHg
hydrALAZINE (APRESOLINE) injection [800109] 10-20 mg, Intravenous, EVERY 1 HOUR PRN, for
SBP greater than 170 mmHg or DBP greater than 100
mmHg
For second line therapy. Administer if unable to
tolerate orally or no response to first line therapy and
heart rate is more than 85 beats per minute.
Patient Care Orders
Nursing Orders [106910]
Page 3 of 4
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 1:57:51 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Nursing Communication - Monitoring (Vital Signs)
[NURMON0060]
SEE COMMENTS, Vital signs every 15 minutes x 4,
then every 30 minutes x 4, then every one hour x 1.
Nursing Communication - Monitoring (Oxygen)
[NURMON0060]
SEE COMMENTS, Oxygen per 3 liter nasal cannula if
O2 sat is less than 90%, or if patient experiences
hypotension, tachycardia, or restlessness.
Nursing Communication - Activity (Bed Rest)
[NURACT0011]
SEE COMMENTS, Bed rest for 4 hours post-biopsy,
bathroom privileges 1 hour after biopsy.
Nursing Communication - Diet [NURDIE0013] SEE COMMENTS, NPO first hour.
Nursing Communication - Wound Care
[NURWND0018]
SEE COMMENTS, Check biospy site with post-biopsy
scheduled vital sign checks; apply 5 pound sandbag to
site for 1st hour.
Notify [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 180
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg): 110
If diastolic blood pressure < (mmHg): 60
If temperature > (C):
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 50
If respiratory rate >: 30
If respiratory rate <: 8
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Hematocrit drops 4 points or greater,Signs of
hematoma or bleeding,Signs of hematuria
Diagnosis
Diagnosis [106915]
Kidney replaced by transplant [V42.0.ICD-9-CM] Kidney replaced by transplant
Aftercare following organ transplant [V58.44.ICD-
9-CM]
Aftercare following organ transplant
Complication of transplanted kidney [136143] Complications of transplanted kidney
Cytomegaloviral disease [078.5.ICD-9-CM] Cytomegaloviral disease
Abnormal blood chemistry [193915] Other abnormal blood chemistry
Pancreas replaced by transplant [V42.83.ICD-9-
CM]
Pancreas replaced by transplant
Proteinuria [791.0.ICD-9-CM] Proteinuria
Viral infection [464453] Unspecified viral infection, in conditions classified
elsewhere and ofunspecified site
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
END OF SMARTSET [4852]
Other Chief Complaint
Page 4 of 4
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 1:57:51 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org