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OP - Arginine/Clonidine Hormone Stimulation Test Delegation Protocol - Pediatric Diagnostics - Supplemental [5250]

OP - Arginine/Clonidine Hormone Stimulation Test Delegation Protocol - Pediatric Diagnostics - Supplemental [5250] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, HOD, Diagnostics/Sedation


OP - Arginine/Clonidine Hormone Stimulation Test Delegation Protocol -
Pediatric Diagnostics - Supplemental [5250]
Imaging Preparatory and Recovery Orders –
Pediatric –AFCH Diagnostic Imaging and
Therapeutic
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/?path=/content/delegationpractice-
protocols/ambulatory-delegation-protocols/name-
97359-en.cckm
All Stimulation Test Patients
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
Stimulation Test Orders
Arginine/Clonidine Growth Hormone Stimulation Test [153465]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed? Yes
Peds Diagnostic
sodium chloride flush 0.9% 10 mL injection
[785055]
Flush, PRN Starting today For 8 Hours, flush/line care,
Peds Diagnostic
Vital Signs - Baseline [NURMON0013] ONCE, Starting today For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Obtain once prior to test., Peds Diagnostic
Page 1 of 3
Printed by SPENCER, LINDSEY M [LMS033] at 12/21/2017 5:33:57 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Monitor Blood Pressure and Heart Rate
[NURMON0013]
EVERY 30 MINUTES, Starting today For Until
specified, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Monitor Blood Pressure and Heart Rate every 30
minutes post clonidine until 150 minutes after
administration and vital signs are stable., Peds
Diagnostic
Activity: Bedrest [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: with bathroom privileges
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Patient should remain recumbent throughout
stimulation testing. (May sleep during testing.), Peds
Diagnostic
Notify Pediatric Endocrine Fellow
[NURCOM0001]
Provider to Notify: Provider
Notify based on: Blood Pressure,Other
Other: Significant change in clinical status
If systolic blood pressure > (mmHg): 20 mmHg below
baseline reading
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
Decrease in blood pressure can be expected 30 to 60
minutes after oral clonidine administration and may
last up to 8 hours. Contact Pediatric Endocrine Fellow
on call for questions or concerns about blood pressure
readings during test., Peds Diagnostic
Glucose, POC [IPGLUCOSE] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, Glucose, POC should always
be ordered in conjunction with orders for
hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
Collect prior to test. If blood glucose less than 65
mg/dL, call physician before beginning test.
Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia management
and monitoring as indicated in the Hypoglycemia
Management (Pediatric Panel), Peds Diagnostic
Page 2 of 3
Printed by SPENCER, LINDSEY M [LMS033] at 12/21/2017 5:33:57 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

GROWTH HORMONE - BASELINE [HCHGH] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, The reference laboratory has
patient preparation instructions. Refer to the ARUP
reference link below for more information on this test
and discuss with patient as appropriate.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
IGF-1 (INSULIN-LIKE GROWTH) - BASELINE
[XIGF1]
STAT - RN COLLECT, 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?
Obtain baseline IgF-1 level, Peds Diagnostic
GROWTH HORMONE [HCHGH] CONDITIONAL - RN COLLECT, Starting today For 5
Occurrences, Routine, The reference laboratory has
patient preparation instructions. Refer to the ARUP
reference link below for more information on this test
and discuss with patient as appropriate.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Obtain 1st level 30
minutes after the start of the arginine administration
(prior to clonidine), subsequent levels should be drawn
at 30, 60, 90, 120, &150 minutes post CLONIDINE
(i.e. 2nd level approximately 60 minutes post start of
arginine infusion).,Label time samples with number of
minutes post-administration of each individual agent.
Label timed samples with number of minutes post-
administration of each individual agent., Peds
Diagnostic
arginine (R-GENE) infusion [44194] 500 mg/kg, Intravenous, ONCE Starting today For 1
Doses
Administer prior to clonidine via 0.2 or 0.22 micron in-
line filter over 30 minutes. Central line recommended.
Maximum dose = 22.5 grams. For any questions
regarding the dosing of arginine or clonidine please
call Endocrine RN on call if after 8 am, otherwise call
Pediatric Endocrine Fellow on call if before 8 am
for 30 Minutes, Peds Diagnostic
cloNIDINE (CATAPRES) suspension [780248] 150 mcg/m2, Oral, ONCE Starting today For 1 Doses
(NOTE DOSING BASED ON BSA): Administer 150
mcg/m2. (Maximum Dose = 150 mcg.) Give 30
minutes after start of arginine infusion (and after the
Growth Hormone level has been drawn post arginine
infusion. )For any questions regarding the dosing of
arginine or clonidine please call Endocrine RN on call
if after 8 am, otherwise call Pediatric Endocrine Fellow
on call if before 8 am.
Pharmacy may change formulation to tablet based on
patient preference.
Peds Diagnostic
Page 3 of 3
Printed by SPENCER, LINDSEY M [LMS033] at 12/21/2017 5:33:57 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org