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/clinical/cckm-tools/content/order-sets/inpatient/girenal/name-98298-en.cckm

201710299

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UWHC,UWMF,

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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,GI/Renal

IP - Peritoneal Dialysis - Adult - Supplemental [4883]

IP - Peritoneal Dialysis - Adult - Supplemental [4883] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, GI/Renal


IP - Peritoneal Dialysis - Adult - Supplemental [4883]
Procedure Management
Procedure Orders [145055]
Continuous Ambulatory Peritoneal Dialysis
(CAPD) [NURTRT0050]
CONTINUOUS, Routine
Alternate Dialysis Solutions:
Dialysate Solution: 1.5% Dextrose Quantity:
Dialysate Solution: 2.5% Dextrose Quantity:
Dialysate Solution: 4.25% Dextrose Quantity:
Number of Exchanges per 24 Hours:
Exchange Volume (mL):
Manual Exchange Schedule:
Warm Dialysate Bags to Body Temperature with
K-Pad (Plus or Minus 4 Degrees):
Type of Bag/Machine:
Continuous Cyclic Peritoneal Dialysis (CCPD)
[NURTRT0051]
CONTINUOUS, Routine
Number of Exchanges Per Night:
Dialysate Solution: 1.5% Dextrose Quantity:
Dialysate Solution: 2.5% Dextrose Quantity:
Dialysate Solution: 4.25% Dextrose Quantity:
Total Treatment Time:
Number of Cycles:
Fill Volume (mL):
Volume of Last Fill (mL):
Dwell Time (Minutes):
Type of Bag/Machine:
Patient Care Orders
Fluid Monitoring [142696]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Routine
Measure Weight Daily After Treatment Complete
[NURMON0015]
1X DAILY, Starting today, Routine
Weigh With? Other (Comment)
Weigh when? (after PD complete)
Use standing scale is patient ambulatory. Obtain
weight after peritoneal dialysis treatment completed.
Nursing Communication - Monitoring
[NURMON0060]
CONTINUOUS, In Doc Flowsheets, document
peritoneal drain fluid characteristics.
Nursing Communication - Ultrafiltration
[NURMON0060]
CONTINUOUS, In Doc Flowsheets, document total
ultrafiltration
Exit Site Care [144018]
Nursing Communication - Wound Care - Wound
Less Than 4 Weeks Old [NURWND0018]
1X DAILY, If new peritoneal dialysate catheter exit site
is less than 4 weeks old, dressing care will be done by
PD nurse per Wisconsin Dialysis, Inc protocol.
Nursing Communication - Wound Care - Wound
Greater Than 4 Weeks Old [NURWND0018]
1X DAILY, Exit care - Cleanse with sodium
hypochlorite 0.114% (ExSept) solution provided by PD
nurse. Allow to dry for 2 minutes. Apply Antibiotic
cream with sterile cotton swab. Redress with 2x2's
and patient's choice of tape. Secure catheter well to
ABD to avoid pulling on the site.
Contingency Parameters [144671]
Page 1 of 3
Printed by WILLIAMS, HEATHER R [HRS0] at 10/25/2017 9:56:31 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): ***
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other:
Notify Home Dialysis Nurse on Call
[NURCOM0022]
CONTINUOUS, During business hours Monday-Friday
8:00am - 4:30pm call 608-270-5643 or during the
evening and on weekends call 608-262-2122 and ask
for the Home Dialysis Nurse on call for any of the
following:
-If the drain bag is cloudy
-If the drain amount is less than half of the previous fill
volume
-If multiple cycler alarms
-If dressing is soiled, wet, or loose.
Medications
Medications - Procedure Specific [145060]
gentamicin 0.1 % cream [37857] Topical, 1 X DAILY
Apply to peritoneal dialysis exit site, after exit site
care.
Tube Care [234552]
Sodium Hypochlorite 0.55% (Alcavis) Solution
[NURCOM0022]
ONCE For 1 Occurrences, When connecting and
disconnecting from cycler soak end of transfer set in
sodium hypochlorite 0.55% solution (Alcavis) per
Wisconsin Dialysis, Inc protocol.
Erythropietic Factors (Single Response) [145054]
darbepoetin alfa (ARANESP) injection [800036] Subcutaneous
Probiotic [200227]
-therapeutic broadconsider the use of probiotics in immunocompetent patients receiving Please
-4th generation cephalosporins, betaspectrum antibiotics, such as fluoroquinolones, 3rd and
diarrhea clindamycin to prevent antibiotic associated lactamase inhibitors, and -lactam/beta
lactobacillus rhamnosus GG (CULTURELLE) cap
[152674]
1 cap, Oral, 1 X DAILY
Peritoneal Dialysis Treatment
Fresenius Continuous Ambulatory Peritoneal Dialysis [234217]
peritoneal dialysis soln [700442] Intraperitoneal, CONTINUOUS
peritoneal dialysis soln Delflex-LC/1.5% Dextrose
(Stay Safe) [700442]
Intraperitoneal, CONTINUOUS
peritoneal dialysis soln Delflex-LC/2.5% Dextrose
(Stay Safe) [700442]
Intraperitoneal, CONTINUOUS
Fresenius Continuous Cycling Peritoneal Dialysis [234218]
peritoneal dialysis soln [700442] Intraperitoneal, CONTINUOUS
Page 2 of 3
Printed by WILLIAMS, HEATHER R [HRS0] at 10/25/2017 9:56:31 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

peritoneal dialysis soln Delflex LC/1.5% Dextrose
[700442]
Intraperitoneal, CONTINUOUS
peritoneal dialysis soln Delflex-LC/2.5% Dextrose
[700442]
Intraperitoneal, CONTINUOUS
peritoneal dialysis soln Delflex LC/4.25%
Dextrose [700442]
Intraperitoneal, CONTINUOUS
Baxter Continuous Ambulatory Peritoneal Dialysis [234220]
peritoneal dialysis soln [700442] Intraperitoneal, CONTINUOUS
peritoneal dialysis soln Ultrabag/1.5% Dextrose
[700442]
Intraperitoneal, CONTINUOUS
peritoneal dialysis soln Ultrabag/2.5% Dextrose
[700442]
Intraperitoneal, CONTINUOUS
Baxter Continuous Cycling Peritoneal Dialysis [234219]
peritoneal dialysis soln [700442] Intraperitoneal, CONTINUOUS
peritoneal dialysis soln Dianeal LC/1.5% Dextrose
[700442]
Intraperitoneal, CONTINUOUS
peritoneal dialysis soln Dianeal LC/2.5% Dextrose
[700442]
Intraperitoneal, CONTINUOUS
peritoneal dialysis soln Dianeal LC/4.25%
Dextrose [700442]
Intraperitoneal, CONTINUOUS
peritoneal dialysis soln Extraneal 7.5% [700442] Intraperitoneal, CONTINUOUS
Systemic Antibiotics [234264]
levofloxacin (LEVAQUIN) tab - Loading Dose -
For patients with severe or immediate IgE-
mediated beta-lactam allergy or intolerance
[54885]
750 mg, Oral, ONCE For 1 Doses
levofloxacin (LEVAQUIN) tab - Maintenance Dose
- For patients with severe or immediate IgE-
mediated beta-lactam allergy or intolerance
[54885]
500 mg, Oral, EVERY OTHER DAY Starting 10/27/17
Note: Nephrology will determine the vancomycin
dose [950018]
EVERY 72 HOURS
Note: Nephrology will determine the vancomycin dose
Laboratory
Laboratory [145061]
CELL COUNT, PERITONEAL FLUID [HCPECC] ONCE For 1 Occurrences, Routine
Indicate specimen source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CULTURE, BODY FLUID, AER/ANA WITH
GRAM STAIN [HCWABF]
ONCE For 1 Occurrences, Routine, UWHC Only: Use
blood culture bottles for peritoneal, pericardial, pleural,
synovial and dialysate fluids.
Indicate source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
VANCOMYCIN [HCVANC] ONCE, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 3 of 3
Printed by WILLIAMS, HEATHER R [HRS0] at 10/25/2017 9:56:31 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org