/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/hod/,/clinical/cckm-tools/content/order-sets/hod/diagnosticssedation/,

/clinical/cckm-tools/content/order-sets/hod/diagnosticssedation/name-97795-en.cckm

201709261

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,HOD,Diagnostics/Sedation

OP - Fever and Neutropenia - Pediatric Diagnostics - Supplemental [4741]

OP - Fever and Neutropenia - Pediatric Diagnostics - Supplemental [4741] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, HOD, Diagnostics/Sedation


OP - Fever & Neutropenia - Pediatric Diagnostics - Supplemental [4741]
Isolation Status
Isolation [127765]
Isolation - Protective Precautions - Panel
[116356]
Protective Precautions [ISO0001] CONTINUOUS
Reason for Protective Precautions:
Protective - Positive Pressure Room
[NURCOM0109]
CONTINUOUS
Patient Care Orders
Vital Signs [127768]
Vital Signs [NURMON0013] SEE COMMENTS For Until specified, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 15 minutes times 4, then every 2 hours times 6,
then every 4 hours., Peds Diagnostic
Nutrition [127769]
Neutropenic Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: Diet Modifications
Diet Modifications: Neutropenic
Bedside Meal Instructions:
Room Service Class:
Peds Diagnostic
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Peds Diagnostic
Clear Liquid Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: Diet Modifications
Diet Modifications: Liquid
Liquid: Clear Liquid
No Red or Purple Dye:
Liquid Thickness:
Bedside Meal Instructions:
Room Service Class:
Peds Diagnostic
NPO Except Medications [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: NPO
NPO Diet: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
Peds Diagnostic
Page 1 of 8
Printed by STRAKA, KEVIN F [KFS1] at 9/14/2017 12:30:01 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Strict NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: NPO
NPO Diet: Strict NPO
Bedside Meal Instructions:
Room Service Class:
Peds Diagnostic
Respiratory [127770]
Pulse Oximetry - STAT [NURMON0009] ONCE For 1 Occurrences, STAT, Discontinue
postprocedure hour 6., Peds Diagnostic
Pulse Oximetry [NURMON0009] SEE COMMENTS, Routine, Every 15 minutes times 4,
then every 2 hours times 6, then every 4 hours., Peds
Diagnostic
Oxygen Therapy [RT0032] CONTINUOUS, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device:
Attempt to Wean Off Oxygen?
Peds Diagnostic
Non-Categorized Patient Care Orders [127771]
Measure Weight [NURMON0015] 1X DAILY, Routine
Weigh With?
Weigh when? AM
Peds Diagnostic
Measure Height [NURMON0052] ONCE For 1 Occurrences, Routine, Peds Diagnostic
Contingency Parameters for Patients Less than 7 Months of Age [127772]
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): ***
If blood glucose < (mg/dL): ***
If pain score >: ***
Pulse Oximetry < (%): ***
If urine output < (mL): ***
Other: Oxygen is initiated
Peds Diagnostic
Contingency Parameters for Patients 7 Months to 3 Years of Age [127775]
Page 2 of 8
Printed by STRAKA, KEVIN F [KFS1] at 9/14/2017 12:30:01 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

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): ***
If blood glucose < (mg/dL): ***
If pain score >: ***
Pulse Oximetry < (%): ***
If urine output < (mL): ***
Other: Oxygen is initiated
Peds Diagnostic
Contingency Parameters for Patients 3 to 7 Years of Age [127776]
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): ***
If blood glucose < (mg/dL): ***
If pain score >: ***
Pulse Oximetry < (%): ***
If urine output < (mL): ***
Other: Oxygen is initiated
Peds Diagnostic
Contingency Parameters for Patients 7 to 11 Years of Age [127778]
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): ***
If blood glucose < (mg/dL): ***
If pain score >: ***
Pulse Oximetry < (%): ***
If urine output < (mL): ***
Other: Oxygen is initiated
Peds Diagnostic
Contingency Parameters for Patients 11 Years of Age and Older [127779]
Page 3 of 8
Printed by STRAKA, KEVIN F [KFS1] at 9/14/2017 12:30:01 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

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): ***
If blood glucose < (mg/dL): ***
If pain score >: ***
Pulse Oximetry < (%): ***
If urine output < (mL): ***
Other: Oxygen is initiated
Peds Diagnostic
Intravenous Therapy
Premedications for Needle Insertion [126859]
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
Peds Diagnostic
LMX Use Instructions for Premedication Prior to
Needle Insertion [NURCOM0095]
Peds Diagnostic
IV Fluids [127737]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Peds Diagnostic
sodium chloride 0.9% BOLUS - Note: Suggested
dose 10 mL/kg/dose [730003]
10 mL/kg, Intravenous, PRN For 3 Doses
Blood pressure less than *** mmHG. Give over 15
minutes.
for 15 Minutes, Peds Diagnostic
Page 4 of 8
Printed by STRAKA, KEVIN F [KFS1] at 9/14/2017 12:30:01 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

dextrose 5%-NaCl 0.2% infusion - - NOTE:
Suggested dose 1.5-2 x maintenance rate or 125
mL/m2 [51615]
at 125 mL/hr, Intravenous, CONTINUOUS
Via alternate lumen to facilitate easier administration
of antibiotic administration.
NOTE: Suggested dose 1.5-2 x maintenance rate of
125 mL/m2.
Peds Diagnostic
dextrose 5%-NaCl 0.45% infusion - NOTE:
Suggested dose 1.5-2 x maintenance rate or 125
mL/m2 [51613]
Intravenous, CONTINUOUS
Via alternate lumen to facilitate easier administration
of antibiotic administration
NOTE: Suggested dose 1.5-2 x maintenance rate or
125 mL/m2
Peds Diagnostic
Medications - Anti-Infectives
Anti-infectives [127739]
Management of Fever and Neutropenia - Pediatric
- Inpatient/Ambulatory/Emergency Department -
Clinical Practice Guideline
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/?path=/content/cpg/oncology/name-
116777-en.cckm
cetriaxone (ROCEPHIN) intraVENOUS - NOTE:
Order for clinically stable, low-risk patients
(Maximum Dose = 2 g) [800027]
50 mg/kg, Intravenous, ONCE For 1 Doses
Administer after blood cultures are obtained and within
1 hour of admission. Order MD please notify
pharmacy of STAT antibiotic request. Please use last
weight obtained within 30 days for dosing.
Peds Diagnostic
cefepime (MAXIPIME) intraVENOUS - NOTE:
Order for high-risk patients, or clinically unstable
patients regardless of risk category Give first dose
STAT - suggested dose 50 mg/kg/dose
(Maximum 2 g/dose) [800016]
50 mg/kg, Intravenous, ONCE For 1 Doses
Administer after blood cultures are obtained and within
1 hour of admission. Ordering MD please notify
pharmacy of STAT antibiotic request. Please use last
weight obtained within 30 days for dosing
Peds Diagnostic
vancomycin (VANCOCIN) intravenous - NOTE:
Give first dose STAT - suggested dose 15
mg/kg/dose (Maximum Dose 2000 mg) Order for
patient who is clinically unstable, has acute
myeloid leukemia, has a history of methicillin-
resistant Staphylococcus aureus or beta-lactam-
resistant Streptococcus spp., or has received
high-dose cytarabine. Consider ordering if the
patient has grade 3 or 4 mucositis, hospital-
acquired pneumonia, concern for skin and soft
tissue infection, or concern for catheter-related
infection. [800084]
15 mg/kg, Intravenous, ONCE For 1 Doses
Administer after blood cultures are obtained and within
one hour of admission. Ordering MD please notify
Pharmacy of STAT antibiotic request. Please use last
weight obtained within 30 days for dosing.
Patients with IgE mediated allergy or severe
reaction to beta-lactams [229997]
vancomycin (VANCOCIN) intraVENOUS - NOTE:
Maximum Dose = 2000 mg [800084]
15 mg/kg, Intravenous, ONCE For 1 Doses
Administer after blood cultures are obtained and
within 1 hour of admission. Ordering MD please
notify pharmacy of STAT antibiotic request. Please
use last weight obtained within 30 days for dosing.
Peds Diagnostic
aztreonam (AZACTAM) intraVENOUS - NOTE:
Order for patients with cephalosporin allergy or
severe penicillin allergy Maximum Dose = 2
grams [800013]
30 mg/kg, Intravenous, ONCE For 1 Doses
Administer after blood cultures are obtained and
within 1 hour of admission. Ordering MD please
notify pharmacy of STAT antibiotic request. Please
use last weight obtained within 30 days for dosing.
Peds Diagnostic
Medications - General
Page 5 of 8
Printed by STRAKA, KEVIN F [KFS1] at 9/14/2017 12:30:01 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Steroids - Stress Dose [127742]
hydrocortisone sodium succinate injection - Note:
Suggested dosed 25 mg/m2/dose (Maximum 100
mg/dose) [800189]
25 mg/m2, Intravenous, EVERY 8 HOURS For 48
Hours
Administer over 3 minutes
Note: Suggested dosed 25 mg/m2/dose (Maximum
100 mg/dose)
Peds Diagnostic
Laboratory
STAT [127780]
CBC WITH DIFFERENTIAL [CBC] 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 [LYTE] 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 [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 [CA] 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 [CRET] 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 [GLU] 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
MAGNESIUM [MAG] 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 [PHOS] 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 8
Printed by STRAKA, KEVIN F [KFS1] at 9/14/2017 12:30:01 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
STAT - RN COLLECT For 1 Occurrences, Routine,
For optimum diagnosis of sepsis, sample 3-4 sites
only on the first day of a septic episode. Cultures on
subsequent days are of minimal diagnostic value.
Culture detects bacteria, Candida and Cryptococcus.
If filamentous fungi are suspected see Culture, Blood,
Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition?
Peds Diagnostic
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
STAT - RN COLLECT For 1 Occurrences, Routine,
For optimum diagnosis of sepsis, sample 3-4 sites
only on the first day of a septic episode. Cultures on
subsequent days are of minimal diagnostic value.
Culture detects bacteria, Candida and Cryptococcus.
If filamentous fungi are suspected see Culture, Blood,
Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition?
Peds Diagnostic
PROTHROMBIN TIME/INR [PT] 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 [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
FIBRINOGEN [GM1320] 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
D-DIMER, QUANT [GM1332] 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
With First Void [127781]
URINALYSIS, NO MICROSCOPY [UACHEM] ONCE 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
CULTURE, URINE WITH GRAM STAIN
[HCURNCS]
ONCE For 1 Occurrences, Routine
Does patient have an indwelling urinary catheter?
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 8
Printed by STRAKA, KEVIN F [KFS1] at 9/14/2017 12:30:01 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Diagnostic Tests & Imaging
Diagnostic and Imaging [186575]
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Peds Diagnostic
Page 8 of 8
Printed by STRAKA, KEVIN F [KFS1] at 9/14/2017 12:30:01 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org