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IP - Tonsillectomy - Pediatric - Postoperative [2822]

IP - Tonsillectomy - Pediatric - Postoperative [2822] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, ENT


IP - Tonsillectomy - Pediatric - Postoperative [2822]
Admission Status
Level of Care (Single Response) [187485]
*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:
Post-Op/Phase II
Admit to Observation (Single Response) [188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admit to Outpatient Short Stay (Single Response)
[188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admission Status [103187]
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:
Post-Op/Phase II
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
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Service:
Post-Op/Phase II
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admission Status [84059]
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:
Post-Op/Phase II
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Patient Care Orders
Vital Signs [87739]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 2 hours times 2, then every 4 hours., Post-Op/Phase II
Patient Monitoring [103189]
Cardio-Respiratory Monitor - Pediatric - Without Rhythm
[139420]
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:
Post-Op/Phase II
Notify [NURCOM0001] Provider to Notify: Provider
Notify based on:
Notify provider for apnea > 20 seconds, Post-Op/Phase II
Activity [87740]
Ad Lib [NURACT0008] CONTINUOUS, Starting today, Routine
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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:
Post-Op/Phase II
Elevate Head Of Bed [NURACT0002] Equal to (degrees):
Greater than (degrees): 30
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting today, Post-Op/Phase II
Activity - Ear Tubes with Tonsillectomy [103188]
Keep Ears Dry [NURACT0011] CONTINUOUS, Starting today, Post-Op/Phase II
Keep Soapy Water Out of Ears [NURACT0011] CONTINUOUS, Starting today, Post-Op/Phase II
Nutrition [87741]
Soft Diet: Palate or Tonsillectony & Adenoidectomy
[NUT0001]
EFFECTIVE NOW, Starting today, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24): TONSILS/ADENOIDS-SOFT;
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail):
Tube Feeding Management:
Room Service Class:
Post-Op/Phase II
Mechanical Soft [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: Diet Modifications
Diet Modifications: Consistency
Solid Consistency: Mechanical Soft
Liquid Thickness:
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Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
NPO [NUT0001] EFFECTIVE NOW, Starting today For Until specified, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
STRICT NPO
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail):
Room Service Class:
Strict NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: NPO
NPO Diet: Strict NPO
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
Clear Liquid Diet [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24): CLEAR LIQUID;
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Page 4 of 9
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org

Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail):
Room Service Class:
Post-Op/Phase II
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: Thin
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
Respiratory [87742]
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today, Routine, Post-Op/Phase II
Oxygen Therapy [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%):
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 92
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Post-Op/Phase II
Intake and Output [87743]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today, Routine, Post-Op/Phase II
Non-Categorized Patient Care Orders [87744]
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With?
Weigh when?
Post-Op/Phase II
Contingency Parameters for Patients Less than 6 Months Old [87745]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 100
If systolic blood pressure < (mmHg): 65
If diastolic blood pressure > (mmHg): 65
If diastolic blood pressure < (mmHg): 45
If temperature > (C): 38.5
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 < (%): 90
If urine output < (mL):
Other: Pain not controlled with ordered analgesics or ordered
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interventions,FiO2 > 0.5
Post-Op/Phase II
Contingency Parameters for Patients 7 Months through 2 Years Old [87746]
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): 38.5
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 < (%): 90
If urine output < (mL):
Other: Pain not controlled with ordered analgesics or ordered
interventions,FiO2 > 0.5
Post-Op/Phase II
Contingency Parameters for Patients 3 through 6 Years Old [87747]
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): 38.5
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 < (%): 90
If urine output < (mL):
Other: Pain not controlled with ordered analgesics or ordered
interventions,Bleeding from oral cavity,FiO2 > 0.5
Post-Op/Phase II
Contingency Parameters for Patients 7 through 10 Years Old [87748]
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): 38.5
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 < (%): 90
If urine output < (mL):
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Other: Pain not controlled with ordered analgesics or ordered
interventions,Bleeding from oral cavity,FiO2 > 0.5
Post-Op/Phase II
Contingency Parameters for Patients 11 Years and Older [87749]
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): 38.5
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 < (%): 90
If urine output < (mL):
Other: Pain not controlled with ordered analgesics or ordered
interventions,Bleeding from oral cavity,FiO2 > 0.5
Post-Op/Phase II
Intravenous Therapy
IV Fluids [88260]
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS, Post-Op/Phase II
dextrose 5%-lactated ringers infusion [44897] Intravenous, CONTINUOUS, Post-Op/Phase II
sodium chloride 0.9% infusion [64367] Intravenous, CONTINUOUS, Post-Op/Phase II
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Post-Op/Phase II
sodium chloride flush 0.9% 10 mL injection [785055] Flush, PRN, flush/line care
Flush per VAD guidelines
Post-Op/Phase II
Discontinue IV Fluids and Cap Line When Adequate
Oral Intake [NURVAD0053]
CONTINUOUS, Starting today For Until specified, Post-
Op/Phase II
Premedication for Needle Insertion [84317]
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
Post-Op/Phase II
LMX Use Instructions for Premedication Prior to Needle
Insertion [NURCOM0095]
Post-Op/Phase II
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Medications - General
Analgesics - Non-opioids (Scheduled) [87754]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 15 mg/kg
(Maximum 650 mg/dose) [800005]
15 mg/kg, Oral, EVERY 6 HOURS For 12 Doses
NOTE: Suggested dose 15 mg/kg (Maximum 650 mg/dose)
Post-Op/Phase II
acetaMINOPHEN (TYLENOL) suppository - NOTE:
Suggested dose 15 mg/kg (Maximum 650 mg/dose)
[43994]
Rectal, EVERY 6 HOURS For 12 Doses
Administer if patient unable to take oral formulation
No more than 4 grams acetaminophen per 24 hours for adults
or 15 mg/kg per dose for peds <40 kg
NOTE: Suggested dose 15 mg/kg (Maximum 650 mg/dose)
Post-Op/Phase II
ibuprofen (MOTRIN) 100 mg/5 mL susp - NOTE:
Suggested dose 10 mg/kg (Maximum 600 mg/dose)
[45376]
10 mg/kg, Oral, EVERY 6 HOURS For 12 Doses
NOTE: Suggested dose 10 mg/kg (Maximum 600 mg/dose)
Post-Op/Phase II
Analgesics - Non-opioids (PRN) [143985]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 15 mg/kg
(Maximum 650 mg/dose) [800005]
15 mg/kg, Oral, EVERY 6 HOURS PRN Starting 5/30/16,
pain/fever, For temperature greater than 38.2 degrees
Celsius, or mild to moderate pain or multimodal therapy. Give
with ibuprofen
NOTE: Suggested dose 15 mg/kg (Maximum 650 mg/dose)
Post-Op/Phase II
acetaMINOPHEN (TYLENOL) suppository - NOTE:
Suggested dose 15 mg/kg (Maximum 650 mg/dose)
[43994]
Rectal, EVERY 6 HOURS PRN Starting 5/30/16, pain/fever,
For temperature greater than 38.2 degrees Celsius, or mild to
moderate pain or multimodal therapy. Give if unable to
tolerate orally
NOTE: Suggested dose 15 mg/kg (Maximum 650 mg/dose)
Post-Op/Phase II
ibuprofen (MOTRIN) 100 mg/5 mL susp - NOTE:
Suggested dose 10 mg/kg (Maximum 600 mg/dose)
[45376]
10 mg/kg, Oral, EVERY 6 HOURS PRN Starting 5/30/16,
pain, For temperature greater than 38.2 degrees Celsius, or
mild to moderate pain, or multimodal therapy. Give with
acetaminophen
NOTE: Suggested dose 10 mg/kg (Maximum 600 mg/dose)
Post-Op/Phase II
Analgesics - Opioids [87755]
Note: No Opiods [950013] 4 X DAILY (NOTE ACKNOWLEDGE), Post-Op/Phase II
MORPHine PF injection - NOTE: Suggested dose 0.05 -
0.1 mg/kg (Maximum 2 mg/dose) [800122]
0.05-0.1 mg/kg, Intravenous, EVERY 2 HOURS PRN, pain,
For moderate to severe pain and unable to take oral opioid
NOTE: Suggested dose 0.05 - 0.1 mg/kg (Maximum 2
mg/dose)
Post-Op/Phase II
oxycodone soln - NOTE: Suggested dose 0.1 - 0.2
mg/kg (Maximum 5 mg/dose) [45975]
0.1-0.2 mg/kg, Oral, EVERY 4 HOURS PRN, pain, For
moderate to severe pain
NOTE: Suggested dose 0.1 - 0.2 mg/kg (Maximum 5
mg/dose)
Post-Op/Phase II
Anti-emetics [141870]
ondansetron (ZOFRAN) injection - NOTE: Suggested
dose 0.1 mg/kg/dose (Maximum 4 mg/dose) [800202]
0.1 mg/kg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Administer as first line therapy
NOTE: Suggested dose 0.1 mg/kg (Maximum 4 mg/dose)
Post-Op/Phase II
diphenhydramine (BENADRYL) injection [800106] 0.5 mg/kg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting, Administer as second line therapy when
unresponsive to first line therapy within 30 minutes, Post-
Op/Phase II
Non-categorized Medications [202767]
nalbuphine (NUBAIN) injection - Maximum Dose = 2.5
mg [39994]
0.05 mg/kg, Intravenous, EVERY 6 HOURS PRN, pain, 1st
Line Pruiritis, for 3 Minutes
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Anti-infectives [103199]
amoxicillin (AMOXIL) 250 MG/5ML susp [34527] 40 mg/kg, Oral, 2 X DAILY, Post-Op/Phase II
clindamycin (CLEOCIN) 75 MG/5ML soln - NOTE:
Suggested dose 10 mg/kg/dose (Maximum 600
mg/dose) [74681]
10 mg/kg, Oral, 3 X DAILY For 7 Days
NOTE: Suggested dose 10 mg/kg/dose (Maximum 600
mg/dose)
Post-Op/Phase II
Flushes [87758]
sodium chloride 0.9% flush 10 mL injection [785055] Flush, PRN, flush/line care
Flush per VAD guidelines
Post-Op/Phase II
Sucrose for Oral Analgesia [110668]
sucrose (SWEET-EASE) 24% buccal soln [794009] Oral, PRN, pain, mild pain or potentially painful procedures.
See Admin Instructions, Post-Op/Phase II
Otic - For Patients with Ear Tubes and Tonsillectomy [103200]
ciprofloxacin-dexamethasone (CIPRODEX) 0.3-0.1%
otic susp [73602]
3 drop, 3 X DAILY For 3 Days, Post-Op/Phase II
ciprofloxacin (CETRAXAL) 0.2 % otic soln [136381] 5 drop, 2 X DAILY For 3 Days, Post-Op/Phase II
ofloxacin (OCUFLOX) 0.3 % ophthalmic soln [55774] 3 drop, 3 X DAILY For 3 Days
Give ophthalmic soln via otic route
Post-Op/Phase II
sulfacetamide-prednisolone (CETAPRED) 10-0.23 %
ophthalmic soln [111967]
3 drop, Ears (Each), 3 X DAILY For 3 Days
Give ophthalmic soln via otic route
Post-Op/Phase II
Consults
Consults [87760]
Consult Pediatric Hospitalist (Inpatient) [CON0135] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Call back number:
Post-Op/Phase II
BestPractice
No Hospital Problems have yet been identified [107363]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing., Post-Op/Phase II
Page 9 of 9
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