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OP - Biopsy - Pediatric Diagnostics - Preprocedure [4615]

OP - Biopsy - Pediatric Diagnostics - Preprocedure [4615] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, HOD, Diagnostics/Sedation


SmartSet: OP - BIOPSY - PEDIATRIC DIAGNOSTICS - PREPROCEDURE
(ID:4615)
General Information
Display name: OP - Biopsy - Pediatric Diagnostics - Preprocedure
Type: General
Merge priority: 0
Version comment:
Content source:
Synonyms: 1. Pediatric Liver Biopsy
2. .DIAGNOSTICS
3. .SEDATION
4. .DX
SmartSet notes:
Description:
Web information: Title URL
1.
Questionnaire:
Configuration
Isolation
Isolation Status
Isolation - Contact - Clostridium Difficile CONTINUOUS, Separate order must be placed for
isolation cart., Peds Diagnostic
Isolation - Contact - MRSA CONTINUOUS, Separate order must be placed for
isolation cart., Peds Diagnostic
Isolation - Contact - VRE CONTINUOUS, Separate order must be placed for
isolation cart., Peds Diagnostic
Isolation - Protective Precautions - Panel
Protective Precautions CONTINUOUS
Reason for Protective Precautions:
Protective - Positive Pressure Room CONTINUOUS
Isolation - Airborne - TB-Pulmonary
Confirmed/Suspect
CONTINUOUS, Separate order must be placed for
isolation cart., Peds Diagnostic
Page 1 of 11
Printed by STRAKA, KEVIN F [KFS1] at 2/16/2017 4:28:59 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Patient Care Orders
Activity
Activity - Ad lib CONTINUOUS, Routine
AD LIB: ad lib
AMBULATE:
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Peds Diagnostic
Nutrition
NPO Except Medications EFFECTIVE NOW, Starting S, Routine
Patient Type: Pediatric
Diet Type: NPO
NPO Diet: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
Peds Diagnostic
Non-categorized Patient Care Orders
Notify Surgical Pathology of Biopsy Procedural
Time (263-6242)
Provider to Notify: Other (Comment)
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):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other:
Peds Diagnostic
Page 2 of 11
Printed by STRAKA, KEVIN F [KFS1] at 2/16/2017 4:28:59 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Notify Surgical Pathology when Specimen will
be Sent (263-6242)
Provider to Notify: Other (Comment)
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):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other:
Peds Diagnostic
Measure Height ONCE For 1 Occurrences, Routine, Peds Diagnostic
Measure Weight ONCE For 1 Occurrences, Routine
Weigh With?
Weigh when?
Peds Diagnostic
Contingency Parameters for Patients Less than 7 Months of Age
Notify Provider On-call 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):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Preprocedure INR is greater than 1.4
Peds Diagnostic
Contingency Parameters for Patients 7 Months to 3 Years of Age
Page 3 of 11
Printed by STRAKA, KEVIN F [KFS1] at 2/16/2017 4:28:59 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Notify Provider On-call 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):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Preprocedure INR is greater than 1.4
Peds Diagnostic
Contingency Parameters for Patients 3 to 7 Years of Age
Notify Provider On-call 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):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Preprocedure INR is greater than 1.4
Peds Diagnostic
Contingency Parameters for Patients 7 to 11 Years of Age
Notify Provider On-call 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):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Preprocedure INR is greater than 1.4
Peds Diagnostic
Contingency Parameters for Patients 11 Years of Age and Older
Page 4 of 11
Printed by STRAKA, KEVIN F [KFS1] at 2/16/2017 4:28:59 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Notify Provider On-call 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):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Preprocedure INR is greater than 1.4
Peds Diagnostic
Intravenous Therapy
Premedications for Needle Insertion
Lidocaine
lidocaine (LMX) 4% topical dressing kit 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
Peds Diagnostic
LMX Use Instructions for Premedication Prior to
Needle Insertion
Peds Diagnostic
IV Fluids
Insert and Maintain Peripheral IV CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Peds Diagnostic
dextrose 5%-NaCl 0.2% infusion at 125 mL/hr, Intravenous, CONTINUOUS, Peds
Diagnostic
Page 5 of 11
Printed by STRAKA, KEVIN F [KFS1] at 2/16/2017 4:28:59 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

dextrose 5%-NaCl 0.2% with KCl 20 mEq/L
infusion
at 125 mL/hr, Intravenous, CONTINUOUS, Peds
Diagnostic
dextrose 5%-NaCl 0.45% infusion Intravenous, CONTINUOUS, Peds Diagnostic
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L
infusion
at 125 mL/hr, Intravenous, CONTINUOUS, Peds
Diagnostic
Medications - Preprocedure
Preprocedure
lidocaine (LMX 4) 4 % cream Topical, ONCE For 1 Doses
NOTE: Apply topically once 30 minutes prior to
biopsy
Peds Diagnostic
Blood Bank
Test
TYPE AND SCREEN STAT - RN COLLECT For 1 Occurrences, Routine,
As good clinical practice and for patient safety, the
Transfusion Service will automatically crossmatch 2
packed RBCs on all patients with antibodies to
ensure blood would be available in the event it is
needed. If you would like to opt out of this automatic
order for this patient please contact the UWHC Blood
Bank at (608) 263-8367 or The American Center Lab
at (608) 234-6600 as appropriate., Peds Diagnostic
Laboratory
Laboratory - Percutaneous Liver Biopsy
HCG, QUALITATIVE, URINE STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
PROTHROMBIN TIME/INR STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
PTT STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
Page 6 of 11
Printed by STRAKA, KEVIN F [KFS1] at 2/16/2017 4:28:59 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
GGT STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
ELECTROLYTES STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
BUN STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
CREATININE STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
GLUCOSE STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
CALCIUM STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
BILIRUBIN, TOTAL STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
PROTEIN, TOTAL STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
ALBUMIN STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
ALKALINE PHOSPHATASE STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
Page 7 of 11
Printed by STRAKA, KEVIN F [KFS1] at 2/16/2017 4:28:59 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

AST/SGOT STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
ALT/SGPT STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
Laboratory - Liver Transplant
CBC WITH DIFFERENTIAL STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
ELECTROLYTES STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
ALBUMIN STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
ALKALINE PHOSPHATASE STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
ALT/SGPT STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
AST/SGOT STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
BILIRUBIN, TOTAL STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
BUN STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
CALCIUM STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
Page 8 of 11
Printed by STRAKA, KEVIN F [KFS1] at 2/16/2017 4:28:59 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

CREATININE STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
GGT STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
GLUCOSE STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
LIPID PANEL STAT - RN COLLECT For 1 Occurrences, Routine,
Test includes Cholesterol, Total; HDL Cholesterol;
Triglyceride; LDL cholesterol, calculated; and non-
HDL cholesterol.
Patient must fast for 12-14 hours and be heparin free
for 48 hours prior to specimen collection. The patient
can only have water or black coffee during the fasting
period.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
MAGNESIUM STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
PHOSPHATE STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
URINALYSIS WITH MICROSCOPY STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
PROTEIN/CREATININE RATIO, URINE STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
PROTHROMBIN TIME/INR STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
BK VIRUS, QUANTITATIVE BY PCR STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
Page 9 of 11
Printed by STRAKA, KEVIN F [KFS1] at 2/16/2017 4:28:59 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

BK VIRUS, QUANTITATIVE BY PCR, URINE STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
CMV QUANTITATIVE BY PCR STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
EBV QUANTITATIVE BY PCR STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
CYCLOSPORINE STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
MYCOPHENOLATE STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
SIROLIMUS STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
TACROLIMUS LEVEL STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
HLA CLASS I DONOR SPECIFIC AB BY
LUMINEX
STAT - RN COLLECT For 1 Occurrences, Routine
Indicate organ for transplant:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
HLA CLASS II DONOR SPECIFIC AB BY
LUMINEX
STAT - RN COLLECT For 1 Occurrences, Routine
Indicate organ for transplant:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
Diagnostic Tests and Imaging
Pathology
US DEEP DOPPLER Status: Future, Expires: M+14, Normal, Routine
BIOPSY ULTRASOUND GUIDED Status: Future, Expires: M+11, Normal, Routine
Page 10 of 11
Printed by STRAKA, KEVIN F [KFS1] at 2/16/2017 4:28:59 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Criteria
Suggestions:
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Restrict SmartSet:
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Pended/Held orders
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Page 11 of 11
Printed by STRAKA, KEVIN F [KFS1] at 2/16/2017 4:28:59 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org