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/clinical/cckm-tools/content/order-sets/inpatient/general-surgery/name-98322-en.cckm

201706156

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,General Surgery

IP - Fundoplication with G-Tube - Open - Pediatric - Postoperative [2876]

IP - Fundoplication with G-Tube - Open - Pediatric - Postoperative [2876] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, General Surgery


IP - Fundoplication with G Tube - Open - Pediatric - Postoperative [2876]
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 [116802]
Page 1 of 10
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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
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
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis [130622]
Sequential Compression Device (SCD) Panel
(TREATMENT AND SUPPLY) [206111]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Post-Op/Phase II
Page 2 of 10
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Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Post-Op/Phase II
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Starting today, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
Post-Op/Phase II
Patient Care Orders
Vital Signs [88770]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 1 hour times 2, then every 2 hours times 2,
then every 4 hours., Post-Op/Phase II
Patient Monitoring [88771]
Cardio-Respiratory Monitor - Pediatric - Without
Rhythm [139420]
Cardio-Respiratory Monitor - Pediatric - Without
Rhythm [NURMON0074]
CONTINUOUS, 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] CONTINUOUS
Provider to Notify: Provider
Notify based on:
Notify provider for apnea > 20 seconds, Post-
Op/Phase II
Activity [88772]
Turn Patient [NURACT0011] SEE COMMENTS, Starting today For Until specified,
Turn patient every 2 hours on Operative Day., Post-
Op/Phase II
Ambulate At Least 3 Times Daily [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE: 3x daily
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
Page 3 of 10
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05/2017CCKM@uwhealth.org

Ad Lib [NURACT0008] 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:
Nutrition [89408]
: guideline for advancing enteral feedings Suggested
Once out of the PACU, start with 1/3 goal rate of feedings and advance to 2/3 of goal rate after
tube for -8 hours, advance to full feeding rate after 16 hours. Hold feeding and vent g
tube should be -abdominal distention, discomfort, or retching. For children on CPAP or BiPAP, g
vented continuously while positive pressure ventilation is being administered to avoid abdominal
distention.
Pediatric Enteral Nutrition Guidelines for Tube
Feeding
URL: https://uconnect.wisc.edu/clinical/references/clinical-
nutrition-resources/nutrition-guidelines-and-enteral-
formularies/resources/name-33916-en.file
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:
Post-Op/Phase II
Respiratory [91374]
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today, Routine, Post-
Op/Phase II
Cough And Deep Breathe [NURTRT0019] EVERY 1 HOUR, Starting today, Routine, While
awake., Post-Op/Phase II
Incentive Spirometry [NURTRT0018] EVERY 1 HOUR, Starting today, Routine, While
awake., Post-Op/Phase II
Blow Bubbles [NURTRT0047] EVERY 1 HOUR, Starting today, Routine, While
awake., Post-Op/Phase II
Gastrostomy Tube Care [89410]
Maintain Gastrostomy Tube for Alimentation -
Drainage via Continuous Vent [NURTAD0035]
CONTINUOUS, Starting today, Routine
Drainage Options: Continuous Vent
Flush With:
Irrigant Volume (mL):
Flush Frequency:
Site Assessment Frequency:
Care Frequency: SEE COMMENTS
Wash With:
Primary Dressing:
Secondary Dressing:
* Gastrostomy Tube securely taped at all times.
* G-tube site should be cleansed once daily using a
Q-tip and water.
* Extension device should be secured with a grip-lock
at all times when attached.
* When G-tube is not being used, extension device
should be disconnected to prevent
tugging/dislodgement., Post-Op/Phase II
Page 4 of 10
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Maintain Gastrstomy Tube for Alimentation -
Drainage via Dependent Drainage
[NURTAD0035]
CONTINUOUS, Routine
Drainage Options: Dependent Drainage
Flush With: Water
Irrigant Volume (mL):
Flush Frequency:
Site Assessment Frequency:
Care Frequency: SEE COMMENTS
Wash With:
Primary Dressing:
Secondary Dressing:
* Gastrostomy Tube securely taped at all times.
* G-tube site should be cleansed once daily using a
Q-tip and water.
* Extension device should be secured with a grip-lock
at all times when attached.
* When G-tube is not being used, extension device
should be disconnected to prevent
tugging/dislodgement.
* Clamp Gastrostomy tube for 30 minutes following
oral med administration.
Provide Patient Education [NURCOM0025] ONCE, Routine, Health Facts for You # 4227 "Caring
for Your Child's G-tube
G-tube Cares [NURCOM0022] ONCE, - Incorporate caregivers in g-tube site care
and administering of medications/feeds/flushes as
soon as possible to prepare them for discharge.
- Prepare Emergency Kit for Home-Going: 1) Order
red robinson catheter from central supply in the
current g-tube french size and one size smaller. 2)
Provide Grip-locks and Split 2x2 Gauze.
Intake and Output [88775]
Measure Intake And Output [NURMON0005] EVERY 4 HOURS, Starting today, Routine, Post-
Op/Phase II
Non-Categorized Patient Care Orders [89412]
Measure Weight [NURMON0015] 1X DAILY, Starting today For Until specified, Routine
Weigh With?
Weigh when?
Post-Op/Phase II
Measure Weight - On Admission
[NURMON0015]
ONCE, Starting today For 1 Occurrences, Routine
Weigh With?
Weigh when?
Post-Op/Phase II
Measure Height - On Admission [NURMON0052] ONCE, Starting today For 1 Occurrences, Routine,
Post-Op/Phase II
Maintain Urinary Catheter [NURELM0013] CONTINUOUS, Routine, To discontinue this order,
enter a new order for "Discontinue Urinary Catheter".
To modify this order, enter a new order for "Maintain
Urinary Catheter" and make the necessary changes
in the new order.
Type:
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Post-Op/Phase II
Contingency Parameters for Patients Less than 6 Months Old [135345]
Page 5 of 10
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Notify Provider [NURCOM0001] CONTINUOUS
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 < (%): 95
If urine output < (mL):
Other:
Post-Op/Phase II
Contingency Parameters for Patients 7 Months through 2 Years Old [135346]
Notify Provider [NURCOM0001] CONTINUOUS
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 < (%): 93
If urine output < (mL):
Other:
Post-Op/Phase II
Contingency Parameters for Patients 3 through 6 Years Old [135347]
Page 6 of 10
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Notify Provider [NURCOM0001] CONTINUOUS
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 < (%): 93
If urine output < (mL):
Other:
Post-Op/Phase II
Contingency Parameters for Patients 7 through 10 Years Old [135348]
Notify Provider [NURCOM0001] CONTINUOUS
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 < (%): 93
If urine output < (mL):
Other:
Post-Op/Phase II
Contingency Parameters for Patients 11 Years and Older [135349]
Page 7 of 10
Printed by STRAKA, KEVIN F [KFS1] at 5/30/2017 1:27:35 PM
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05/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] CONTINUOUS
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 < (%): 93
If urine output < (mL):
Other:
Post-Op/Phase II
Intravenous Therapy
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
IV Fluids - NOTE: Suggested dose 4 mL/kg/hr for first 10 kg; 2 mL/kg/hr for next 10 kg; 1 mL/kg/hr for
every kg greater than 20 kg (Single Response) [88783]
dextrose 5%-NaCl 0.2% with KCl 20 mEq/L
infusion [44909]
Intravenous, CONTINUOUS, Post-Op/Phase II
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L
infusion [44910]
Intravenous, CONTINUOUS, Post-Op/Phase II
Medications - General
Analgesics - Acetaminophen - Scheduled (Single Response) [131815]
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 72 Hours,
Post-Op/Phase II
Page 8 of 10
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acetaMINOPHEN (TYLENOL) tab [34149] Oral, EVERY 6 HOURS For 72 Hours, Post-
Op/Phase II
acetaMINOPHEN (TYLENOL) suppository -
NOTE: Suggested dose 20 mg/kg. Must order in
whole suppository size (maximum 650 mg/dose)
[43994]
Rectal
Use if unable to tolerate oral medications
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
Post-Op/Phase II
Analgesics - NSAID - Scheduled (Single Response) [187906]
ketOROLAC (TORADOL) injection - NOTE:
Suggested dose 0.5 mg/kg (Maximum 15
mg/dose) [800050]
0.5 mg/kg, Intravenous, EVERY 6 HOURS For 72
Hours, Post-Op/Phase II
ibuprofen (MOTRIN) susp - NOTE: Suggested
dose 10 mg/kg (Maximum 600 mg/dose) [45376]
10 mg/kg, Oral, EVERY 6 HOURS For 72 Hours,
Post-Op/Phase II
Analgesics - Acetaminophen - PRN (Starting in 72 hours) (Single Response) [187907]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 15 mg/kg
(Maximum 650 mg/dose) [800005]
15 mg/kg, Oral, EVERY 4 HOURS PRN Starting
6/2/17, pain, Mild pain or multimodal therapy., Post-
Op/Phase II
acetaMINOPHEN (TYLENOL) tab - NOTE:
Suggested dose 15 mg/kg (maximum 650
mg/dose) [34149]
Oral, EVERY 4 HOURS PRN Starting 6/2/17, pain,
Mild pain or multimodal therapy, Post-Op/Phase II
acetaMINOPHEN (TYLENOL) suppository -
NOTE: Suggested dose 20 mg/kg. Must order in
whole suppository size (Maximum 650 mg/dose)
[43994]
Rectal, EVERY 6 HOURS PRN Starting 6/2/17, pain,
Mild pain or multimodal therapy
Use if unable to tolerate oral medications
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
Post-Op/Phase II
Analgesics - NSAID - PRN (Starting in 72 hours) (Single Response) [224578]
ibuprofen (MOTRIN) susp - NOTE: Suggested
dose 10 mg/kg (Maximum 600 mg/dose) [45376]
10 mg/kg, Oral, EVERY 6 HOURS PRN Starting
6/2/17, pain, Mild to Moderate Pain or Multimodal
therapy, Post-Op/Phase II
ibuprofen (MOTRIN) tab - NOTE: Suggested
dose 10 mg/kg (Maximum 600 mg/dose) [38353]
Oral, EVERY 6 HOURS PRN Starting 6/2/17, pain,
Mild to Moderate Pain or Multimodal Therapy, Post-
Op/Phase II
Analgesics - Opioids (Oral) - PRN (Single Response) [187909]
oxycodone 5 MG/5ML soln RANGE – (Maximum
20 mg/dose) [750031]
0.1-0.2 mg/kg, Oral, EVERY 4 HOURS PRN, pain,
Moderate/Severe Pain, Post-Op/Phase II
oxycodone tab RANGE – NOTE: Suggested
dose 0.1-0.2 mg/kg (Maximum 20mg/dose)
[750032]
Oral, EVERY 4 HOURS PRN, pain, Moderate/Severe
Pain, Post-Op/Phase II
Analgesics - Opioids (Intravenous) - PRN (Single Response) [187910]
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, Moderate/Severe Pain and unable to take oral
opioid
Use if unable to tolerate oral medications
Post-Op/Phase II
HYDROmorphone PF (DILAUDID) injection -
NOTE: suggested dose 0.01-0.02 mg/kg
(Maximum 0.4 mg/dose) [800120]
0.01-0.02 mg/kg, Intravenous, EVERY 2 HOURS
PRN, pain, Moderate/Severe Pain and unable to take
oral opioid
Use if unable to tolerate oral medications
Post-Op/Phase II
Anti-emetics [88788]
ondansetron (ZOFRAN) injection - NOTE:
Suggested dose 0.1 mg/kg (Maximum 4
mg/dose) [800202]
0.1 mg/kg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
NOTE: Suggested dose 0.1 mg/kg (Maximum 4
mg/dose)
Post-Op/Phase II
Page 9 of 10
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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05/2017CCKM@uwhealth.org

Gastric (Single Response) [89426]
pantoprazole (PROTONIX) intraVENOUS -
Maximum Dose = 40 mg [800119]
1 mg/kg, Intravenous, Post-Op/Phase II
pantoprazole (PROTONIX) susp - Maximum
Dose = 40 mg [780113]
1 mg/kg, Oral, 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
Consults
Consults [132208]
Consult Nutrition (Inpatient) [CON0043] ONCE, Routine
Reason for Consult: Nutrition Assessment w/
Recommendations
Delegate to Initiate and Manage Tube Feeding:
Delegate to Initiate Feeding Tube Placement Order
Set:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
Post-Op/Phase II
Consult Case Management (Inpatient)
[CON0013]
ONCE For 1 Occurrences, Routine
Reason for Consult:
Can this consult be done via video?
Post-Op/Phase II
Consult Pediatric Anesthesia Pain Service
[CON0166]
ONCE, Routine
Reason for Consult:
Can this consult be done via video?
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 10 of 10
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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05/2017CCKM@uwhealth.org