/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/inpatient/,/clinical/cckm-tools/content/order-sets/inpatient/general-surgery/,

/clinical/cckm-tools/content/order-sets/inpatient/general-surgery/name-98343-en.cckm

201710300

page

100

UWHC,UWMF,

Tools,

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

IP - Trauma - Pediatric - Admission [1321]

IP - Trauma - Pediatric - Admission [1321] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, General Surgery


IP - Trauma - Pediatric - Admission [1321]
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 [103244]
PICUGrade IV Solid Organ Injuries Should Be Admitted to All
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 14
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 10:39:48 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status [130990]
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:
Patient Care Orders
Vital Signs [17238]
Grade I thru III - Solid Organ Injury - 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 4, then every 4 hours
Grade IV thru V - Solid Organ Injury - Vital Signs
[NURMON0013]
SEE COMMENTS, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every hour times 12, then every 2 hours times 6, then
every 4 hours.
General Trauma - Vital Signs [NURMON0013] EVERY 4 HOURS, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Pediatric Early Warning Signs [NURMON0060] SEE COMMENTS, Starting today, Every 4 hours,
Post-Op/Phase II
Page 2 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 10:39:48 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Patient Monitoring [137712]
Cardio-Respiratory Monitor - Pediatric - With
Rhythm [139419]
Cardio-Respiratory Monitor - Pediatric - With
Rhythm [NURMON0014]
CONTINUOUS, Routine, Most pediatric patients do
NOT require rhythm analysis. 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: Symptomatic Change in
Rhythm,Serious Arrhythmia
Notify [NURCOM0001] Provider to Notify: Provider
Notify based on:
Notify provider for apnea > 20 seconds
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:
Notify [NURCOM0001] Provider to Notify: Provider
Notify based on:
Notify provider for apnea > 20 seconds
Assess Neurologic Status [NURMON0006] SEE COMMENTS, Starting today with First
Occurrence As Scheduled For Until specified, Routine,
Every hour times 8, then every 2 hours times 4, then
every 4 hours.
Neurovascular Checks [NURMON0045] SEE COMMENTS, Starting today with First
Occurrence As Scheduled, Routine
Location:
Every hour times 8, then every 2 hours times 4, then
every 4 hours.
Activity [17465]
Grade I thru III - Isolated Liver/Spleen Injury -
Bredrest For 1 Night [NURACT0008]
CONTINUOUS, Starting today For 1 Days, 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:
Bedrest for 1 night (isolated liver/spleen injury - Grade
I thru IV). May use bathroom with assistance after 24
hours.
Page 3 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 10:39:48 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Grade IV thru V - Isolated Liver/Spleen Injury -
Bredrest For 2 Nights [NURACT0008]
CONTINUOUS, Starting today For 2 Days, 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:
Bedrest for 2 nights (isolated liver/spleen injury -
Grade V). May use bathroom with assistance after 24
hours.
Bedrest [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: other (comment)
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Logroll [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: strict logroll
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Flat In Bed [NURACT0011] CONTINUOUS, Starting today
Reverse Trendelenberg [NURACT0005] Type: Reverse Trendelenberg
Routine, CONTINUOUS, Starting today
Elevate Head Of Bed - 30 Degrees
[NURACT0002]
Equal to (degrees): 30
Greater than (degrees):
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting today For Until
specified
Keep Head of Bed Flat [NURACT0002] Equal to (degrees): 0
Greater than (degrees):
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting today
Page 4 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 10:39:48 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Ambulate with Assistance [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB:
AMBULATE: with assistance
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Ad Lib [NURACT0008] CONTINUOUS, Starting today For Until specified,
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:
Cervical Spine Precautions (Single Response) [211468]
Cervical Spine Precautions [PRECAU0005] CONTINUOUS, Routine, Cervical Spine Precautions:
Cervical collar at all times.
No pillow behind head.
No lifting anything greater than 10 pounds.
No lifting of arms over head.
C-Spine Cleared [NURTRT0060] CONTINUOUS, Routine
Thoracic/Lumbar Spine Precautions (Single Response) [211469]
Thoracic/Lumbar Spine Precautions
[PRECAU0009]
CONTINUOUS, Routine, Thoracic/Lumbar Spine
Precautions:
Head of bed less than 30 degrees unless otherwise
stated.
Head of bed flat for log rolling side to side.
T/L-Spine Cleared [NURTRT0061] CONTINUOUS, Routine
Nutrition [17470]
NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: NPO
NPO Diet: Strict NPO
Bedside Meal Instructions:
Room Service Class:
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:
Clear Liquid Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type:
Page 5 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 10:39:48 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Respiratory - NOTE: Order ETCO2 Monitoring for Patients on Mechanical Ventilation [17471]
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today For 24 Hours, Routine
Oxygen Therapy [RT0032] CONTINUOUS, Starting today For Until specified,
Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device:
Attempt to Wean Off Oxygen? Yes
Provide Manual Resuscitator at Bedside [RT0039] CONTINUOUS, Starting today For Until specified,
Routine
Wound Care [17472]
Wound Care [NURWND0015] CONTINUOUS, Starting today For Until specified,
Routine
Wound Type: Abrasion (Abrasions and lacerations)
Wound Site:
Wound Location:
Assess Frequency:
Care Frequency: 1X DAILY
Wash With: Soap and Water
Irrigate/Rinse With:
Apply (Must also enter separate medication order to
obtain drug):
Primary Dressing:
Secondary Dressing:
Intake and Output [103245]
Measure Intake And Output [NURMON0005] EVERY 4 HOURS, Starting today, Routine
Non-Categorized Patient Care Orders [17474]
PMT Collar - No Pillow [NURTRT0014] CONTINUOUS, Starting today, Routine
Type: PMT Collar
Wearing schedule:
No pillow.
NG Tube Placement - Pediatric [121658]
Insert and Maintain Nasogastric Tube
[NURTAD0014]
CONTINUOUS, Routine
Options: Low, Continuous Suction
Flush with:
Flush Frequency: EVERY 8 HOURS
Clamp NG Tube:
Check Residual:
Does this need to be inserted/placed?
Device Status:
Recommendations for flush quantity:
For patients < 30 kg, use 1mL of fluid per 1 kg.
For patients >30 kg, 30 mLs of fluid should be
sufficient.
In general, consider the amount of fluid needed to
clear the tube and patient’s fluid status before
determining flush quantity.
Page 6 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 10:39:48 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

lidocaine-oxymetazoline 3%-0.01% (PEDS) nasal
spray [785104]
Nasal, ONCE For 1 Doses
For numbing prior to feeding tube insertion. Slowly
spray the chosen nostril once, if required may repeat
x1 in opposite nostril. Angle toward back of throat
spraying the anterior nostril and wait 30-60 seconds
before introducing more local anesthetic into the
nostril. Caution: Entire bottle should not be used for
insertion of tube. Discard excess solution when
procedure completed.
X-RAY ABDOMEN AP VIEW (KUB) [R74000] CONDITIONAL For 3 Days, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered
by this exam? Evaluate nasogastric tube placement
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
If Conditional, What Condition? Evaluate nasogastric
tube placement. The location of nasogastric tube
should be confirmed prior to the instillation of fluids,
medications, or feedings. Refer to Policy 2.20
Enteral Tubes Used for Instillation of Fluids,
Medications, or Feeding
Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, Starting today For Until specified,
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: Indwelling Single Lumen
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Maintain Chest Tube [NURTAD0001] CONTINUOUS, Starting today For Until specified,
Routine
Location:
Position: N/A - Single Location
Drainage Options: -20 cm wall suction
Site Assessment Frequency:
Care Frequency:
Wash With:
Primary Dressing:
Secondary Dressing:
Measure Height - On Admission [NURMON0052] ONCE, Starting today For 1 Occurrences, Routine
Measure Weight - On Admission [NURMON0015] ONCE, Starting today For 1 Occurrences, Routine
Weigh With?
Weigh when?
Contingency Parameters for Patients Less than 6 Months Old [135340]
Page 7 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 10:39:48 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

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 < (%): 95
If urine output < (mL):
Other:
Contingency Parameters for Patients 6 Months through 2 Years (PCA Pediatric) [135341]
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): 38.5 or erythema at catheter site
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <: 12
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >: 5
Pulse Oximetry < (%): 90 or need for supplemental
oxygen
If urine output < (mL):
Other: Sedation >3,If patient is on Acute Pain Service,
notify surgical team first to determine if pain is related
to a surgical complication, then notify Acute Pain
Service by paging #7246 or "PAIN". If patient not on
Acute Pain Service, notify team who placed PCA order
Contingency Parameters for Patients 3 through 6 Years Old [135342]
Page 8 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 10:39:48 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@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): 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:
Contingency Parameters for Patients 7 through 10 Years Old [135343]
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 < (%): 93
If urine output < (mL):
Other:
Contingency Parameters for Patients 11 Years and Older [135344]
Page 9 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 10:39:48 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@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): 38.5 or erythema at catheter site
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <: 8
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >: 5
Pulse Oximetry < (%): 90 or need for supplemental
oxygen
If urine output < (mL):
Other: Sedation > 3,If patient is on Acute Pain Service,
notify surgical team first to determine if pain is related
to a surgical complication, then notify Acute Pain
Service by paging #7246 or "PAIN". If patient not on
Acute Pain Service, notify team who placed PCA order
Intravenous Therapy
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) [17584]
dextrose 5 %-NaCl 0.9% infusion [51641] Intravenous, CONTINUOUS
NOTE: 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
Premedication for Needle Insertion [30232]
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
LMX Use Instructions for Premedication Prior to
Needle Insertion [NURCOM0095]
Details
Medications - General
Analgesics - Acetaminophen - Oral - Scheduled (Single Response) [234775]
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
Page 10 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 10:39:48 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

acetaMINOPHEN (TYLENOL) suppository -
NOTE: Suggested dose 20 mg/kg. Must order in
whole suppository size (Maximum 650 mg/dose)
[43994]
Rectal, EVERY 6 HOURS For 72 Hours
acetaMINOPHEN (TYLENOL) tab [34149] Oral, EVERY 6 HOURS For 72 Hours
Analgesics - NSAIDS - Oral - Scheduled - NOTE: Do NOT order ibuprofen in patients with solid organ
injury [131805]
ibuprofen (MOTRIN) susp - NOTE: Do NOT order
ibuprofen in patients with solid organ injury
Suggested dose 10 mg/kg (Maximum 600
mg/dose) [45376]
10 mg/kg, Oral, EVERY 6 HOURS PRN For 72 Hours,
pain
Analgesics - Acetaminophen - Oral - PRN - Starting in 72 hours (Single Response) [234826]
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
10/26/17, pain
Administer for mild pain
Maximum 5 doses/day
acetaMINOPHEN (TYLENOL) suppository -
NOTE: Suggested dose 20 mg/kg (Maximum 650
mg/dose) [43994]
Rectal, EVERY 4 HOURS PRN Starting 10/26/17,
pain
Administration Instructions to read: Administer for
mild pain and patient is unable to tolerate oral
medications. Maximum 5 doses/day.
Analgesics - NSAIDS - Oral - PRN - Starting in 72 hours - NOTE: Do NOT order ibuprofen in patients with
solid organ injury [131808]
ibuprofen (MOTRIN) susp - NOTE: Do NOT order
ibuprofen in patients with solid organ injury
Suggested dose 10 mg/kg (Maximum 600
mg/dose) [45376]
10 mg/kg, Oral, EVERY 6 HOURS PRN Starting
10/26/17, pain
Administer for mild to moderate pain or multimodal
therapy
NOTE: Do NOT order ibuprofen in patients with solid
organ injury Suggested dose 10 mg/kg (Maximum 600
mg/dose)
Analgesics - Acetaminophen - Oral - PRN (Single Response) [132476]
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, pain
Administer for mild pain
Maximum 5 doses/day
acetaMINOPHEN (TYLENOL) suppository -
NOTE: Suggested dose 20 mg/kg (Maximum 650
mg/dose) [43994]
Rectal, EVERY 4 HOURS PRN, pain
Administer for mild pain and patient is unable to
tolerate oral medications. Maximum 5 doses/day.
acetaMINOPHEN (TYLENOL) tab [34149] Oral, EVERY 6 HOURS PRN, pain
Analgesics - NSAIDS - Oral - PRN (Single Response) [234930]
ibuprofen (MOTRIN) tab - NOTE: Do NOT order
ibuprofen in patients with solid organ injury
Suggested dose 10 mg/kg (Maximum 600
mg/dose) [38353]
Oral, EVERY 6 HOURS PRN, pain
Administer for mild to moderate pain or multimodal
therapy
ibuprofen (MOTRIN) susp - NOTE: Do NOT order
ibuprofen in patients with solid organ injury
Suggested dose 10 mg/kg (Maximum 600
mg/dose) [45376]
10 mg/kg, Oral, EVERY 6 HOURS PRN, pain
Administer for mild to moderate pain or multimodal
therapy
NOTE: Do NOT order ibuprofen in patients with solid
organ injury Suggested dose 10 mg/kg (Maximum 600
mg/dose)
Note: No NSAIDS [950012] 4 X DAILY (NOTE ACKNOWLEDGE)
Analgesics - Opioids - Oral - PRN (Single Response) [234932]
oxycodone soln RANGE - (Maximum 20 mg/dose)
[750031]
0.1-0.2 mg/kg, Oral, EVERY 3 HOURS PRN, pain
Administer for severe pain
oxycodone tab RANGE - NOTE: Suggested dose
0.1 - 0.2 mg/kg (Maximum 20 mg/dose) [750032]
Oral, EVERY 3 HOURS PRN, pain
Administer for severe pain
Analgesics - Opioids - Intravenous - PRN (Single Response) [234933]
Page 11 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 10:39:48 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

MORPHine PF injection - NOTE: suggested dose
0.05 - 0.1 mg/kg (Maximum 2 mg/dose) [750057]
0.05-0.1 mg/kg, Intravenous, EVERY 2 HOURS PRN,
pain, Severe pain
Administer if unable to take PO.
for 4 Minutes
HYDROmorphone PF (DILAUDID) injection -
NOTE: suggested dose 0.01 - 0.02 mg/kg
(Maximum 0.4 mg/dose) [750050]
0.01-0.02 mg/kg, Intravenous, EVERY 2 HOURS
PRN, Severe pain
Administer if unable to take PO.
for 3 Minutes
Anti-emetics [17587]
ondansetron (ZOFRAN) injection - NOTE: First
line agent - Suggested dose 0.1 mg/kg/dose
(Maximum 4 mg/dose) [800202]
0.1 mg/kg, Intravenous, EVERY 8 HOURS PRN,
nausea, nausea/vomiting
NOTE: First line agent - Suggested dose 0.1
mg/kg/dose (Maximum 4 mg/dose)
prochlorperazine (COMPAZINE) injection -
NOTE: Do not order for patients under 2 years of
age Second Line Agent Suggested dose 0.1-0.15
mg/kg/dose (Maximum 10 mg/dose) [750059]
0.1-0.15 mg/kg, Intravenous, EVERY 8 HOURS PRN,
nausea/vomiting
Second line therapy if unresponsive after 30 minutes
to first line agent and patient unable to tolerate orally.
Suggested dose 0.1-0.15 mg/kg/dose (Maximum 10
mg/dose)
If ordered IV: push slowly, max rate 5 mg/minute.
prochlorperazine (COMPAZINE) tab - NOTE: Do
not order for patients under 2 years of age
Second Line agent - Suggested dose 0.1-0.15
mg/kg/dose (Maximum 10 mg/dose) [750035]
Oral, EVERY 8 HOURS PRN, nausea/vomiting
Second line therapy if unresponsive after 30 minutes
to first line agent and patient unable to tolerate orally.
Suggested dose 0.1-0.15 mg/kg/dose (Maximum 10
mg/dose)
Bowel Management [131810]
senna-docusate (SENOKOT S) 8.6-50 MG per
tab - NOTE: Suggested dose 1 or 2 tablets one or
two times a day [60530]
Oral
Hold for loose stool
polyethylene glycol (MIRALAX) oral packet -
NOTE: For patients less than 25 kg [61829]
8.5 g, Oral, 1 X DAILY
Dissolve in 4 ounces of water
NOTE: For patients less than 25 kg
polyethylene glycol (MIRALAX) oral packet -
NOTE: For patients 25 kg or greater [61829]
17 g, Oral, 1 X DAILY
Dissolve in 8 ounces of water
NOTE: For patients 25 kg or greater
Gastric [17591]
famotidine (PEPCID) intraVENOUS - NOTE:
Maximum Dose = 20 mg [800279]
0.25 mg/kg, Intravenous, EVERY 12 HOURS
Anti-infectives [17592]
cefazolin (ANCEF) intraVENOUS [800000] 30 mg/kg, Intravenous, EVERY 8 HOURS
cefoxitin (MEFOXIN) intraVENOUS [800022] 40 mg/kg, Intravenous, ON CALL For 1 Doses
Non-categorized [17593]
bacitracin-polymyxin b (POLYSPORIN) 500-
10000 UNIT/GM ointment [34991]
Topical, 2 X DAILY
Apply to abrasions and lacerations
Sucrose for Oral Analgesia [110384]
sucrose (SWEET-EASE) 24% buccal soln
[794009]
Oral, PRN, pain, mild pain or potentially painful
procedures. See Admin Instructions
Laboratory
For Patients with Isolated Liver or Spleen Injury (Grade I-V) - Draw 6, 12, and 24 Hours Post Injury
[17255]
HEMOGLOBIN [HGB] EVERY 6 HOURS For 3 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
For Patients with Other Trauma [17479]
Page 12 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 10:39:48 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

HEMOGLOBIN [HGB] NEXT AM For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Consults
Consults [17259]
Pediatric Inpatient Pain Management —Order consult for patients with a history of chronic pain
-nonpatients that may benefit from additional pharmacologic and/or and new acute pain or
pharmacologic recommendations
Pediatric Anesthesia Pain Service—Order consult for patients who may benefit from a PCA or
pain needs.with significant acute
Child Protection Team—Order consult for any non-accidental trauma or concern for neglect
and/or abuse. Include patients that were unrestrained in a MVC, underage drivers of motor
vehicles or ATVs
Consult Pediatric Rehab (Inpatient) [CON0138] ONCE
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Trauma
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 Traumatic Injury
Consult Child Life Specialist (Inpatient)
[CON0014]
ONCE, Routine
Activity Level: OTHER (COMMENT) (Per Trauma
order set)
Reason for Consult: OTHER (Trauma Admission)
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Routine
Reason for Physical Therapy Consult:
Consult Speech Therapy (Inpatient) - NOTE: For
Patients with Positive Loss of Consciousness
[CON0077]
ONCE, Routine
Patient Type: Pediatric
Reason for Speech Therapy Consult: Positive Loss of
Consciousness/Concussion
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Routine
Reason for Occupational Therapy Consult:
Consult Social Work (Inpatient) [CON0076] ONCE, Routine
Reason for Consult: OTHER (S/P Trauma Injury)
Is this a STAT consult?
Can this consult be done via video?
Consult Pediatric Pain Management (Inpatient)
[CON0165]
ONCE, Routine
Pain Problem: CHRONIC
Reason for Consult: OTHER (COMMENT)
(Pharmacologic and Non-Pharmacologic
Recommendations)
Can this consult be done via video?
Consult Pediatric Anesthesia Pain Service
[CON0166]
ONCE, Routine
Reason for Consult: Patient-Controlled Analgesia Or
Continuous Catheter Management
Can this consult be done via video?
Consult Child Abuse Suspicion [CON0159] 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:
BestPractice
Page 13 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 10:39:48 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

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 14 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 10:39:48 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org