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/clinical/cckm-tools/content/order-sets/inpatient/burn/name-97819-en.cckm

201712349

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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Burn

IP - Small Burn and Wound - Pediatric - Admission [1522]

IP - Small Burn and Wound - Pediatric - Admission [1522] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Burn


IP - Small Burn and Wound - Pediatric - Admission [1522]
Admission Status
Level of Care (Single Response) [186484]
*An admit patient order has already been written, but the level of care at which the patient
should be placed still needs to be identified.
Place Patient on General Care [ADT0018] General Care, has already been signed. This order
will ensure that the patient is placed at the appropriate
level of care.
Place Patient on Intermediate Care (IMC)
[ADT0018]
Intermediate Care, has already been signed. This
order will ensure that the patient is placed at the
appropriate level of care.
Place Patient on Intensive Care (ICU) [ADT0018] Intensive Care, has already been signed. This order
will ensure that the patient is placed at the appropriate
level of care.
Admit to Inpatient (Single Response) [188296]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-
only surgery, or a previously-authorized inpatient
stay. Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status (Single Response) [82665]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-only
surgery, or a previously-authorized inpatient stay.
Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Page 1 of 13
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12/2017CCKM@uwhealth.org

Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status [7248]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-only
surgery, or a previously-authorized inpatient stay.
Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Anticipated Discharge [151652]
Anticipated Discharge Date [ADT0016] Anticipated Discharge Date:
Patient Care Orders
Vital Signs [20339]
Vital Signs [NURMON0013] EVERY 4 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Activity (Single Response) [22471]
Ambulate 4x daily, Chair 3x daily [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE: 4x daily
CHAIR: 3x daily
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Page 2 of 13
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12/2017CCKM@uwhealth.org

Strict Bedrest [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: strict bedrest
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Burn Positioning [97620]
Burn and Graft Positioning and Splinting
[NURWND0030]
CONTINUOUS, Starting today, Routine
Burn Location #1:
Position:
Frequency:
Burn Location #2:
Position:
Frequency:
Burn Location #3:
Position:
Frequency:
Burn Location #4:
Position:
Frequency:
Burn Location #5:
Position:
Frequency:
Burn Positioning - Head - Neck - Ears
[NURWND0030]
CONTINUOUS, Routine
Burn Location:
Elevate:
Position:
Frequency:
Nutrition (Single Response) [182841]
Diet - Protein/Calorie High [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: Diet Modifications
Diet Modifications: High Protein/High Calorie
Bedside Meal Instructions:
Room Service Class:
Burn patient - please send automatic breakfast tray
Diet - Custom [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type:
Bedside Meal Instructions:
Room Service Class:
Burn patient - please send automatic breakfast tray
Nutrition - other [187202]
SetSupplemental" Order -Tube Feeding Orders, Refer to "Tube Feeding For
NPO for Procedure - Hold Diet 8 hours - NOTE:
Modify start time as appropriate [DIE0007]
CONTINUOUS NPO, Starting today For 8 Hours,
Routine
NPO For Which Procedure?
Modifiers:
- NPO solids and full liquids at *** (6 hours prior to
sedation)
- NPO breast milk at *** (4 hours prior to sedation)
- Clear liquids at *** (2 hours prior to sedation)
Page 3 of 13
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12/2017CCKM@uwhealth.org

Nourishments & Supplements [NUT0005] EFFECTIVE NOW, Starting today, Routine
Medical Food / Oral Supplement(s): OTHER
PRODUCTS (COMMENT)
Nourishment / Snack Item(s):
Schedule:
Medical Food/Oral Supplement(s) per patient
preference.
Encourage PO Intake [NURDIE0008] CONTINUOUS, Starting today, Routine
RN to Mix Protein Modular with Beverages
[DIE0011]
Instructions for Patient: RN to Mix Protein Modular
with Beverages
Routine, CONTINUOUS, Starting today
Measure Caloric Intake [NURDIE0011] 1X DAILY, Starting today For 8 Weeks, Routine
Respiratory [187204]
Oxygen Therapy [RT0032] PRN, Starting today, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Provide Manual Resuscitator at Bedside [RT0039] CONTINUOUS, Starting today, Routine
ETCO2 Monitoring [RT0006] RT PRN, Starting today, Routine, For sedation
monitoring.
Pulse Oximetry [NURMON0009] PRN, Starting today, Routine
Incentive Spirometry [NURTRT0018] EVERY 2 HOURS, Starting today, Routine
Cough And Deep Breathe [NURTRT0019] EVERY 2 HOURS, Starting today, Routine
Blow Bubbles [NURTRT0047] 4X DAILY, Starting today, Routine
Wound Care [134699]
Burn Care - Burn Care [NURWND0025] CONTINUOUS, Starting today, Routine
Burns Site:
Burns Treatment/Dressing (Must also enter separate
medication order to obtain drug):
Dressing Change Frequency:
Wash Wound:
Wound Airing:
Burn Care - Donor Site Care [NURWND0019] CONTINUOUS, Starting today, Routine
Donor Site Site:
Location:
Wash Wound:
Wound Airing:
Burn Care - Meshed Graft Care [NURWND0020] CONTINUOUS, Routine
Meshed Graft Site:
Meshed Dressing:
Wash Wound:
Wound Airing:
Burn Care - Open Wound Care [NURWND0024] CONTINUOUS, Starting today, Routine
Wound Type:
Wound Site:
Wound Care Frequency:
Wash With:
Topical Therapy (Must also enter separate medication
order to obtain drug):
Inner Dressing:
Additional Layers:
Compression Layer:
Page 4 of 13
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Burn Care - Sheet Graft Care [NURWND0021] CONTINUOUS For Until specified, Routine
Sheet Graft Site:
Sheet Graft (Dry) Dressing:
Sheet Graft First Dressing Change:
Wound Airing:
Wound Vacuum [136891]
Wound Vacuum [NURWND0013] CONTINUOUS, Routine
Wound Vacuum Site:
Type of Suction:
DPC (Intermittent Suction) Frequency:
If VAC is leaking or alarming, and troubleshooting is
not effective, notify the service that is managing the
VAC. Per manufacturer recommendations, a VAC
dressing without active therapy for more than 2
hours should be removed. If managing service
verifies removal of VAC dressing, the dressing
should be removed, wound should be cleansed and
irrigated with NS, and a wet to dry dressing should
be applied. If active bleeding develops suddenly or
in large amounts during V.A.C. therapy or if frank
(bright red) blood is seen in the tubing or in the
canister immediately stop V.A.C therapy(clamp
tubing and turn therapy off), leave dressing in place
and notify managing service or covering physician,
as dressing will need to be removed and source of
bleeding must be controlled.
Vacuum Assisted Closure - KCI [EQP0030] CONTINUOUS, Routine
Measure Drain Output [NURTAD0005] EVERY 8 HOURS, Routine
Burn and Wound Topical Medications [230817]
silver sulfadiazine (SILVADENE) 1% cream
[42081]
Topical, 2 X DAILY PRN, Burn Care
Per wound care order
mafenide (SULFAMYLON) 5% topical packet
[59500]
50 g, Irrigation, EVERY 6 HOURS
Per wound care order
bacitracin ointment [49271] Topical, 2 X DAILY PRN, Open wounds as needed
Per wound care order
ointment base (HYDROPHOR) ointment [56186] Topical, 2 X DAILY PRN, Burn wound Care
Per wound care order
Intake and Output [22559]
hour = ICU level of care 1
hours = ICU or IMC level of care2
hours = IMC or General Care level of care4
hours = General Care level of care8
Measure Intake And Output [NURMON0005] EVERY 4 HOURS, Routine
Non-Categorized Patient Care Orders [22561]
Monitor Distal Pulses and Capillary Refill of
Burned Extremities [NURCOM0022]
SEE COMMENTS, Starting today For 24 Hours, Every
hour times 24.
Measure Height [NURMON0052] ONCE, Starting today For 1 Occurrences, Routine,
Obtain immediately upon admission.
Measure Weight [NURMON0015] ONCE, Starting today For 1 Occurrences, Routine
Weigh With?
Weigh when?
Obtain immediately upon admission.
Cardio-Respiratory Monitor - Pediatric - Without
Rhythm [139420]
Page 5 of 13
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Cardio-Respiratory Monitor - Pediatric - Without
Rhythm [NURMON0074]
INTERMITTENT (MAY REMOVE WHEN OFF
UNIT/BATHING), Routine, Please complete the
Notify Provider order below, including specification
for apnea > *** seconds. If indicated, order pulse
oximetry separately.
Device Present:
Device Mode:
Device Low Rate Limit (BPM):
Notify Provider:
Notify [NURCOM0001] Provider to Notify: Provider
Notify based on:
Notify provider for apnea > 20 seconds
Place Emergency Drug Card on Patient Monitor
[NURCOM0022]
CONTINUOUS, Starting today
Contingency Parameters [13756]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 100
If systolic blood pressure < (mmHg): 78
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 39
If temperature < (C):
If heart rate > (bpm): 180
If heart rate < (bpm): 90
If respiratory rate >: 50
If respiratory rate <: 25
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL): 1 mL/kg/hour
Other:
Contingency Parameters [13757]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 118
If systolic blood pressure < (mmHg): 85
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 39
If temperature < (C):
If heart rate > (bpm): 160
If heart rate < (bpm): 80
If respiratory rate >: 40
If respiratory rate <: 20
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL): 1 mL/kg/hour
Other:
Contingency Parameters [13758]
Page 6 of 13
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 118
If systolic blood pressure < (mmHg): 87
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 39
If temperature < (C):
If heart rate > (bpm): 140
If heart rate < (bpm): 75
If respiratory rate >: 30
If respiratory rate <: 18
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL): 1 mL/kg/hour
Other:
Contingency Parameters [13759]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 125
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 39
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 70
If respiratory rate >: 24
If respiratory rate <: 14
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL): 1 mL/kg/hour
Other:
Contingency Parameters [13760]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 140
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 39
If temperature < (C):
If heart rate > (bpm): 110
If heart rate < (bpm): 60
If respiratory rate >: 22
If respiratory rate <: 12
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL): 1 mL/kg/hour
Other:
Intravenous Therapy
Premedication for Needle Insertion [30232]
Lidocaine [152737]
Page 7 of 13
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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
IV Fluids [20770]
lactated ringers infusion [38890] Intravenous, CONTINUOUS
Discontinue with good oral intake. Restart when NPO
for procedure.
dextrose 5%-NaCl 0.2% infusion [51615] Intravenous, CONTINUOUS
Discontinue with good oral intake. Restart when NPO
for procedure.
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Medications - Admission-specific
Vaccines - NOTE: Order for patients who have not received a tetanus containing vaccine within the last
5 years (Single Response) [20750]
diphtheria-tetanus toxoid (PEDS) 25-5 LFU/0.5ML
injection - NOTE: Order for patients less than 7
years of age who have not received a tetanus
containing vaccine within the last 5 years
[153613]
0.5 mL, Intramuscular, ONCE For 1 Doses
NOTE: Order for patients less than 7 years of age
tetanus-diphtheria toxoids ADULT (TENIVAC)
injection - NOTE: Order for patients 7 years of
age and older [46712]
0.5 mL, Intramuscular, ONCE For 1 Doses
NOTE: Order for patients lessgreater than or equal to
7 years of age who have not received a tetanus
containing vaccine within the last 5 years
Multivitamin Supplementation (Single Response) [20753]
multivitamin with minerals chew tab PEDS -
NOTE: Order for patients less than 2 years of age
[800237]
30 mg, Oral, 1 X DAILY
May crush and mix with liquid or food if patient unable
to chew medication
multivitamin with minerals chew tab PEDS - -
NOTE: Order for patients 2-8 years of age
[800237]
60 mg, Oral, 1 X DAILY
NOTE: Order for patients 2-8 years of age
multivitamin with minerals chew tab PEDS -
NOTE: Order for patients 9-11 years of age
[800237]
120 mg, Oral, 1 X DAILY
NOTE: Order for patients 9-11 years of age
multivitamin with mineral tab - NOTE: Order for
patients equal to or greater than 12 years of age
[800240]
1 tab, Oral, 1 X DAILY
NOTE: Order for patients equal to or greater than 12
years of age
Medications - General
Page 8 of 13
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12/2017CCKM@uwhealth.org

Sedation (Single Response) [137490]
IV Sedation for Burn Care [231690]
midazolam (VERSED) injection - NOTE:
Suggested dose 0.05-0.2 mg/kg [800197]
0.05-0.2 mg/kg, Intravenous, ONCE PRN For 1
Doses, sedation, anxiety at time of wound care or
therapy
NOTE: Moderate Sedation for Wound Care. To Be
Given by MD/NP only. IV push rate 1 mg/minute
NOTE: Suggested dose 0.05-0.2 mg/kg
ketAMINE (KETALAR) injection - NOTE:
Suggested Dose 1-5 mg/kg Maximum Dose =
300 mg [800191]
1-5 mg/kg, Intravenous, ONCE PRN For 1 Doses,
anxiety at time of wound care or therapy
Administer over 2 minutes
NOTE: Moderate Sedation for Wound Care. To Be
Given by MD/NP only.
NOTE: Suggested Dose 1-5 mg/kg
Oral Sedation for Burn Care [230923]
midazolam (VERSED) syrup - NOTE: Suggested
dose 0.2-0.5 mg/kg Maximum Dose = 10 mg
[60487]
0.2-0.5 mg/kg, Oral, ONCE PRN For 1 Doses,
anxiety at time of wound care or therapy
NOTE: Moderate Sedation for Wound Care. To Be
Given by MD/NP only
NOTE: Suggested dose 0.2-0.5 mg/kg
ketAMINE (KETALAR) soln - NOTE: Suggested
Dose 6-10 mg/kg Maximum Dose = 500 mg
[785017]
6-10 mg/kg, Oral, ONCE PRN For 1 Doses, anxiety
at time of wound care or therapy
NOTE: Moderate Sedation for Wound Care. To Be
Given by MD/NP only.
NOTE: Suggested Dose 6-10 mg/kg
Analgesics - Acetaminophen - PRN (Single Response) [182522]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 10-15
mg/kg (Maximum 650 mg/dose) [800005]
10 mg/kg, Oral, 4 X DAILY
For temperature greater than 39 degrees celsius or
See Pain Management Algorithm for the Selection of
As-Needed Analgesics.
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
NOTE: Suggested dose 10-15 mg/kg (Maximum 650
mg/dose)
acetaMINOPHEN (TYLENOL) disintegrating tab -
NOTE: Suggested dose 10-15 mg/kg (Maximum
650 mg/dose) [64412]
Oral, 4 X DAILY
For temperature greater than 39 degrees celsius or
See Pain Management Algorithm for the Selection of
As-Needed Analgesics.
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
NOTE: Suggested dose 10-15 mg/kg (Maximum 650
mg/dose)
acetaMINOPHEN (TYLENOL) tab - NOTE:
Suggested dose 10-15 mg/kg (Maximum 650
mg/dose) [34149]
Oral, 4 X DAILY
For temperature greater than 39 degrees Celsius or
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
NOTE: Suggested dose 10-15 mg/kg (Maximum 650
mg/dose)
Analgesics - Opioids - Oral (Single Response) [230819]
Oxycodone Solution (Maximum 10 mg) [242892]
oxycodone 5 MG/5ML soln [45975] 0.05-0.1 mg/kg, Oral, 2 X DAILY PRN, pain
For the prevention of pain associated with
woundcare. Give one hour prior to wound care
therapy, OK to combine with PRN oxycodone dose
oxycodone 5 MG/5ML soln [45975] 0.1 mg/kg, Oral, EVERY 4 HOURS PRN, pain
Page 9 of 13
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 6:59:57 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Oxycodone Tablet (Maximum 10 mg) [242890]
oxycodone tab - NOTE: Suggested Dose
0.05-0.1 mg/kg [45976]
Oral, 2 X DAILY PRN, pain
For the prevention of pain associated with
woundcare. Give one hour prior to wound care
therapy, OK to combine with PRN oxycodone dose
oxycodone tab - NOTE: Suggested Dose - 0.1
mg/kg [45976]
Oral, EVERY 4 HOURS PRN, pain
Analgesics - Opioids - Intravenous (Single Response) [20759]
MORPHine PF injection - NOTE: Suggested dose
0.05-0.1 mg/kg (Maximum 2 mg/dose) [800122]
Intravenous, EVERY 5 MINUTES PRN, pain, For pain
at time of wound care or therapy
NOTE: Suggested dose 0.05-.01 mg/kg (Maximum 2
mg/dose)
FENTanyl PF injection RANGE [750047] 0.5-1 mcg/kg, Intravenous, EVERY 5 MINUTES PRN,
For pain at time of wound care or therapy, for 1
Minutes
Sucrose for Oral Analgesia [242883]
sucrose (SWEET-EASE) 24 % buccal soln
[794009]
Oral, EVERY 4 HOURS PRN, pain
For pain or potentially painful procedures. May use in
conjunction with an opioid
Antiemetics - Oral (Single Response) [182524]
ondansetron (ZOFRAN) soln - NOTE: Suggested
dose 0.1 mg/kg/dose (Maximum 4 mg/dose)
[54843]
0.1 mg/kg, Oral, EVERY 12 HOURS PRN,
nausea/vomiting
First Line Therapy
NOTE: Suggested dose 0.1 mg/kg/dose (Maximum 4
mg/dose)
ondansetron (ZOFRAN ODT) disintegrating tab -
NOTE: order on patients greater than 40 kg and
able to take tabs [64224]
4 mg, Oral, EVERY 12 HOURS PRN, nausea/vomiting
First Line Therapy
NOTE: Suggested dose 0.1 mg/kg/dose (Maximum 4
mg/dose)
Anti-emetics - IV [187197]
ondansetron (ZOFRAN) injection - NOTE:
Suggested dose 0.1 mg/kg/dose (Maximum 4
mg/dose) [800202]
0.1 mg/kg, Intravenous, EVERY 12 HOURS PRN,
nausea/vomiting
First line therapy if unable to take medications by
mouth or enteral tube OR if immediate effect is
needed
NOTE: Suggested dose 0.1 mg/kg/dose (Maximum 4
mg/dose)
Bowel Management - Scheduled (Single Response) [185897]
Bowel Management - For patients less than 3
years old [185898]
polyethylene glycol (MIRALAX) oral packet
[61829]
8.5 g, Oral, 1 X DAILY
docusate sodium (COLACE) soln [74449] 10 mg, Oral, 2 X DAILY
Bowel Management - For patients 3-6 years old
[185899]
polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 1 X DAILY
docusate sodium (COLACE) soln [74449] 20 mg, Oral, 2 X DAILY
Bowel Management - For patients who are 6
years old or older and CANNOT take pills
[185900]
polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 1 X DAILY
docusate sodium (COLACE) soln [74449] 50 mg, Oral, 2 X DAILY
Bowel Management - For patients who are 6
years old or older and CAN take pills [185901]
Page 10 of 13
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12/2017CCKM@uwhealth.org

polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 1 X DAILY
senna-docusate (SENOKOT S) 8.6-50 MG per
tab [60530]
1 tab, Oral, 2 X DAILY
Bowel Management - PRN (Single Response) [185902]
phosphate (FLEET PEDIATRIC) enema - NOTE:
Order for patients less than 12 years old [37522]
1 enema, Rectal, 1 X DAILY PRN, constipation
NOTE: Order for patients less than 12 years old
phosphate (FLEET) enema - NOTE: Order for
patients 12 years old or older [37517]
1 enema, Rectal, 1 X DAILY PRN, constipation
NOTE: Order for patients 12 years old or older
Anxiolytics (Single Response) [20763]
Younger than 12 years old panel (Single
Response) [242898]
midazolam (VERSED) syrup [60487] Oral, 1 X DAILY PRN, Anxiety
For anxiety associated with invasive interventions or
for anxiety at time of wound care/therapy
midazolam (VERSED) injection - NOTE:
Suggested dose 0.025-0.05 mg/kg (max dose 1
mg/dose) [800197]
Intravenous, EVERY 10 MINUTES PRN, sedation,
Anxiety
For anxiety associated with invasive interventions or
for anxiety at time of wound care/therapy.
12 years and older panel [242899]
midazolam (VERSED) injection - NOTE:
Suggested dose 0.025-0.05 mg/kg (max dose 1
mg/dose) [800197]
Intravenous, EVERY 10 MINUTES PRN, sedation,
Anxiety
For anxiety associated with invasive interventions or
for anxiety at time of wound care/therapy
Protein Supplement [194895]
protein supplement (RESOURCE
BENEPROTEIN) oral packet [118845]
1-2 packet, Oral, EVERY 1 HOUR PRN, Protein
Supplementation, Choice of protein supplement per
patient preference
To be added to oral non-protein containing food or
drink.
protein supplement no carb (PROSOURCE) soln
[140269]
1-2 packet, Oral, EVERY 1 HOUR PRN, Protein
Supplementation, Choice of protein supplement per
patient preference
To be added to oral non-protein containing food or
drink.
Laboratory
Laboratory - Pregnancy Test [187228]
patient had pregnancy test if female between menarche & menopause and any of: (1) Obtain
patient says she "could" be pregnant. unprotected intercourse, (2) patient missed menses, (3)
Urine, Pregnancy Test [UPREG] STAT, 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?
Pre-Op Day Of Procedure
Laboratory [22573]
CBC WITHOUT DIFFERENTIAL [HEMO] 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] 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?
Page 11 of 13
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12/2017CCKM@uwhealth.org

BUN [BUN] 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?
CREATININE [CRET] 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?
GLUCOSE [GLU] 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?
URINALYSIS, WITHOUT MICROSCOPY
[UACHEM]
ONCE, 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?
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [225795]
ECG - 12 Lead (PEDS) [EKG0014] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
X-RAY CHEST PA & LAT VIEWS [R71020] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Radiology Specialty Area: GENERAL IMAGING
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
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting today 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? Bedside
Transport Method: Floor Determined/Entered
Consults
Consults [22521]
Consult Child Life Specialist (Inpatient)
[CON0014]
ONCE, Starting today For 1 Occurrences, Routine
Activity Level: ABLE TO PLAY IN ROOM OR HSCT
HALLWAY
Reason for Consult: OTHER (Status post pediatric
large burn)
Consult Pediatric Health Psychology (Inpatient)
[CON0202]
ONCE, Routine, Please notify consulting provider if
patient needs to be seen same day (Monday-Friday)
or if special assessment needs.
Reason for Consult: Status post pediatric large burn
Page 12 of 13
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Occupational Therapy Consult: ADL
Training
Consult Pediatric Hospitalist (Inpatient)
[CON0135]
ONCE
Intent: Consult and Recommend (No Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Comprehensive
pediatric evaluation of child with burns
Non-urgent - OK to plan consult evaluation during
work day.
Consult PICU [CON0189] ONCE
Reason for consult:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult: Mobility
Training
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: OTHER
Pediatric Burn
CONSULT TO PEDS CHILD PROTECTION
[1009215]
ONCE, Starting today For 1 Occurrences, Routine
Consults - Patient is greater than 5 years old and expected to stay in hospital greater than 2 days
[187264]
hospital greater than 2 orders if patient is greater than 5 years old and expected to stay in Select
days.
Consult Vocational Services (Inpatient)
[CON0085]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: School Re-Integration
Consult School [CON0153] ONCE, Starting today For 1 Occurrences, Routine,
The consulting provider needs to be verbally notified
of this order. A link to Web Paging is available below.
Reason for Consult:
Can this consult be done via video?
BestPractice
No Hospital Problems have yet been identified. [107035]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing.
Page 13 of 13
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 6:59:57 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org