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201608235

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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 - Hemodialysis - Pediatric - Procedure [2487]

IP - Hemodialysis - Pediatric - Procedure [2487] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, GI/Renal


IP - Hemodialysis - Pediatric - Procedure [2487]
Patient Care Orders
Vital Signs [80681]
Vital Signs [NURMON0013] EVERY 15 MINUTES, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
During procedure., Dialysis
Patient Monitoring and Post Hemodialysis Weight [103153]
Measure Weight Before Dialysis- Patient
Standing if Able [NURMON0015]
ONCE, Starting today For 1 Occurrences, Routine
Weigh With?
Weigh when?
Dialysis
Measure Weight After Dialysis- Patient Standing
if Able [NURMON0015]
ONCE, Starting today For 1 Occurrences, Routine
Weigh With?
Weigh when?
Dialysis
Contingency Parameters [80682]
Text Page Pediatric Nephrologist when
Hemodialysis Treatment has Started
[NURCOM0022]
ONCE, Starting today For 1 Occurrences, Dialysis
Discontinue all Orders Related to Hemodialysis
When Hemodialysis Treatment is Complete
[NURCOM0022]
ONCE, Starting today For 1 Occurrences, Dialysis
Notify Pediatric Nephrologist [NURCOM0001] Provider to Notify: Other (Comment)
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:
Dialysis
Procedure Management
Procedure Management/Equipment Settings [80684]
Page 1 of 9
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

Hemodialysis - Pediatric [DIAL0007] ONCE, Starting today For 1 Occurrences, Routine
Modality Type:
Length of Treatment (hours):
Target Weight (kg):
Fluid Removal (L):
Access Site Location:
Access Site Side:
Membrane Dialyzer:
Tubing:
Blood Flow Rate (mL/minute):
Dialysate Flow Rate (mL/min):
Dialysate Potassium (mEq/Liter) and Calcium
(mEq/Liter):
Dialysate Bicarbonate (mEq/Liter). Limits: 20 - 40
mEq/Liter: 35 mEq/L
Dialysate Sodium (mEq/Liter). Limits: 130 - 155
mEq/Liter: 139 mEq/L
Crit-line Monitor. Normal limits 3-8%: No
Pediatric Dialyzer and Tubing Resource
Use Blood Flow Rates appropriate to the tubing used.
Do not exceed arterial pressure greater than -250 or
venous pressures greater than +300.
TUBING – Prime Volume, Normal BFR, Max BFR,
and Blood Pump Setting:
Small Peds: 29 mL, 50 - 80 mL/min, 83
mL/min, 2.6 mm
Medium Peds: 52 mL, 80 - 150 mL/min, 274
mL/min, 4.8 mm
Large Peds: 73 mL, 150 - 250 mL/min, 465
mL/min, 6.4 mm
StreamLine Adult: 109 mL, 200 - 500 mL/min, 600
mL/min, 8 mm
Gambro: 103 mL, 200 - 500 mL/min, 600
mL/min, 6.4 mm
DIALYZERS – Prime Volume, Size (meters2):
F3: 24 mL, 0.4
F4: 42 mL, 0.7
Revaclear: 84 mL, 1.4
Revaclear MAX: 100 mL, 1.8
Asahi Rexeed: 112 mL, 2.1, Dialysis
Standard Prime (Single Response) [103008]
sodium chloride 0.9% BOLUS [730003] Intravenous, ONCE For 1 Doses
Standard prime for Hemodialysis
Dialysis
albumin human 25% infusion [44037] Intravenous, ONCE For 1 Doses
Hang to gravity. Albumin tubing needed.
Standard prime for Hemodialysis
Dialysis
albumin human 5% infusion [44038] Intravenous, ONCE For 1 Doses
Hang to gravity. Albumin tubing needed.
Standard prime for Hemodialysis
Dialysis
Page 2 of 9
Printed by LIND, JANNA S [JSL237] at 8/15/2016 10:48:26 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT, Starting today For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Volume-Reduced (May be pre-selected based on
history):
Consent Status:
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose: 10
mL/kg body weight., Please write volume on blood
product bag. Use Reconstituted Blood to Prime
System.
Reconstituted Whole Blood volume: *** and product
HCT: ***
Return patient's blood post-dialysis? ***, Dialysis
Standard Prime (Single Response) [185840]
sodium chloride 0.9% IV BOLUS [730003] Intravenous, ONCE For 1 Doses
Standard prime for Hemodialysis
Dialysis
albumin human 25% infusion [44037] Intravenous, ONCE For 1 Doses
Hang to gravity. Albumin tubing needed.
Standard prime for Hemodialysis
Dialysis
albumin human 5% infusion [44038] Intravenous, ONCE For 1 Doses
Hang to gravity. Albumin tubing needed.
Standard prime for Hemodialysis
Dialysis
Page 3 of 9
Printed by LIND, JANNA S [JSL237] at 8/15/2016 10:48:26 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 1 UNIT, Starting today For 1 Occurrences, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Consent Status:
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL., Please write volume
on blood product bag. Use Reconstituted Blood to
Prime System.
Reconstituted Whole Blood volume: *** and product
HCT: ***
Return patient's blood post-dialysis? ***, Dialysis
Lock [80636]
Refer to Pediatric Catheter Lock Management Order Set [3562] for orders after dialysis
sodium chloride 0.9% flush 10 mL injection
[785055]
Flush, PRN, flush/line care
Flush each port of dialysis/apheresis catheter with
every use
Dialysis
anticoagulant citrate compound 4% injection -
NOTE: Order for patients who are actively
bleeding or who are allergic to heparin [785039]
0.8-2 mL, Intravenous, PRN, catheter care
Following sodium chloride flush, cap off each port
with printed volume plus 0.1 mL. If no volume printed
on catheter refer to Policy #1.28 Care of the
Hemodialysis/Apheresis Catheters
Dialysis
heparin 1000 units/mL vial [45303] 1,000 units, Other, PRN, catheter care
Following sodium chloride flush, cap off each port
with printed volume plus 0.1 mL. If no volume printed
on catheter refer to Policy #1.28 Care of the
Hemodialysis/Apheresis Catheters. Do NOT use for
the initial 24 hours after catheter placed
Dialysis
Anticoagulants [80630]
heparin 100 units/mL 5 mL injection - NOTE: For
patients 8 kg or less. Loading dose. Suggested
dose 10-15 units/kg [64978]
Intravenous, ONCE For 1 Doses
Initial dose while on Hemodialysis
NOTE: Loading dose. Suggested dose 10-15 units/kg
Dialysis
Page 4 of 9
Printed by LIND, JANNA S [JSL237] at 8/15/2016 10:48:26 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

heparin 100 units/mL 5 mL injection - NOTE: For
patients 8 kg or less. Subsequent dose.
Suggested dose 5-7.5 units/kg [64978]
Intravenous, EVERY 1 HOUR PRN, flush/line care
SUBSEQUENT DOSES WHILE ON HEMODIALYSIS
Note: Subsequent dose. Suggested dose 5-7.5
units/kg
Dialysis
heparin 1000 units/mL vial - NOTE: For patients
greater than 8 kg. Loading dose. Suggested dose
10-15 units/kg [45303]
Intravenous, ONCE For 1 Doses
Initial dose while on Hemodialysis
Note: Loading dose. Suggested dose 10-15 units/kg
Dialysis
heparin 1000 units/mL vial - NOTE: For patients
greater than 8 kg. Subsequent dose. Suggested
dose 5-7.5 units/kg [45303]
Intravenous, EVERY 1 HOUR PRN
SUBSEQUENT DOSES WHILE ON HEMODIALYSIS
Note: Maintenance dose. Suggested dose 5-7.5
units/kg
Dialysis
sodium chloride 0.9% BOLUS [730003] 50-200 mL, Intravenous, PRN, filter clotting
Observe for clots in hemofilter and venous trap. Add
flush volume into UFR calculations
Dialysis
Custom Dialysate Bath - Prepared By Pharmacy
Centrisol Part A (SB-130) [135897]
Centrisol Part A (SB-130) (K 0 mEq, bicarb 33
mEq, Ca 0 mEq, Na 137 mEq, Mg 0.75 mEq, Cl
100.75 mEq, acetate 4 mEq, dextrose 200
mg/dL) 3.78 L dialysis soln [700617]
Other, EVERY 1 HOUR For 2 Doses, Dialysis
Intravenous Therapy
IV Therapy [80633]
mannitol 25 % vial - NOTE: First dose.
Suggested dose 0.5 g/kg [39352]
0.5 g/kg, Intravenous, ONCE For 1 Doses
**Examine for Crystals** Administer with 0.22 micron
filter
Initial dose to be given at the start of Hemodialysis.
Give in perioperative/procedure area.
NOTE: First dose. Suggested dose 0.5 g/kg
mannitol 25% vial - NOTE: Second dose.
Suggested dose 0.5 g/kg [39352]
0.5 g/kg, Intravenous, ONCE For 1 Doses
**Examine for Crystals** Administer with 0.22 micron
filter
To be given *** minutes into hemodialysis. Give in
perioperative/procedure area.
NOTE: Second dose. Suggested dose 0.5 g/kg
albumin human 25% infusion [44037] Intravenous, ONCE For 1 Doses
albumin human 25% infusion [44037] Intravenous, ONCE For 1 Doses
Hang to gravity. Albumin tubing needed.
To be given *** minutes into hemodialysis
Medications
Hypotension [81082]
albumin human 25% infusion [44037] 1 g/kg, Intravenous, PRN - NOTIFY PHARMACY
WHEN NEEDED, hypotension - see Admin
Instructions
Hang to gravity. Albumin tubing needed.
For systolic blood pressure less than *** mmHg
Page 5 of 9
Printed by LIND, JANNA S [JSL237] at 8/15/2016 10:48:26 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

sodium chloride 0.9% BOLUS [730003] Intravenous, PRN, hypotension - see Admin
Instructions
For systolic blood pressure less than *** mmHg In
periop/procedure area
Erythropoietic Factors (Single Response) [80635]
darbepoetin alfa (ARANESP) injection - 25 mcg
[800036]
25 mcg, Subcutaneous, ONCE For 1 Doses, Dialysis
darbepoetin alfa (ARANESP) injection - 40 mcg
[800036]
40 mcg, Subcutaneous, ONCE For 1 Doses, Dialysis
darbepoetin alfa (ARANESP) injection [800036] Subcutaneous, ONCE For 1 Doses, Dialysis
Patient Medication Guide: darbepoetin
(ARANESP) [950045]
ONCE For 1 Doses, Dialysis
Laboratory
Draw Before Hemodialysis [80685]
this order setorders to be drawn after hemodialysis need to be ordered seperately from Any
ALBUMIN [ALB] STAT - RN COLLECT, 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? Draw before
Hemodialysis
Dialysis
ELECTROLYTES [LYTE] STAT - RN COLLECT, 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? Draw before
Hemodialysis
Dialysis
GLUCOSE [GLU] STAT - RN COLLECT, 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? Draw before
Hemodialysis
Dialysis
BUN [BUN] STAT - RN COLLECT, 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? Draw before
Hemodialysis
Dialysis
CREATININE [CRET] STAT - RN COLLECT, 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? Draw before
Hemodialysis
Dialysis
Page 6 of 9
Printed by LIND, JANNA S [JSL237] at 8/15/2016 10:48:26 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

CALCIUM [CA] STAT - RN COLLECT, 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? Draw before
Hemodialysis
Dialysis
CBC WITH DIFFERENTIAL [CBC] STAT - RN COLLECT, 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? Draw before
Hemodialysis
Dialysis
CBC WITHOUT DIFFERENTIAL [HEMO] STAT - RN COLLECT, 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? Draw before
Hemodialysis
Dialysis
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, For optimum diagnosis of
sepsis, sample 3-4 sites only on the first day of a
septic episode. Cultures on subsequent days are of
minimal diagnostic value. Culture detects bacteria,
Candida and Cryptococcus. If filamentous fungi are
suspected see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition? Draw before
Hemodialysis
Dialysis
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, For optimum diagnosis of
sepsis, sample 3-4 sites only on the first day of a
septic episode. Cultures on subsequent days are of
minimal diagnostic value. Culture detects bacteria,
Candida and Cryptococcus. If filamentous fungi are
suspected see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition? Draw before
Hemodialysis
Dialysis
FERRITIN [FER] STAT - RN COLLECT, 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? Draw before
Hemodialysis
Dialysis
Page 7 of 9
Printed by LIND, JANNA S [JSL237] at 8/15/2016 10:48:26 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

HEMOGLOBIN [HGB] STAT - RN COLLECT, 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? Draw before
Hemodialysis
Dialysis
HEMATOCRIT [HCT] STAT - RN COLLECT, 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? Draw before
Hemodialysis
Dialysis
IRON AND TRANSFERRIN W/ TIBC,
SATURATION [FETRANS]
STAT - RN COLLECT, 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?
Dialysis
PHOSPHATE [PHOS] STAT - RN COLLECT, 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? Draw before
Hemodialysis
Dialysis
POTASSIUM [K] STAT - RN COLLECT, 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? Draw before
Hemodialysis
Dialysis
PTH [HCPTHIN] STAT - RN COLLECT, 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? Draw before
Hemodialysis
Dialysis
VANCOMYCIN [HCVANC] STAT - RN COLLECT, 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? Draw before
Hemodialysis
Dialysis
Draw on New Admissions [104516]
HEPATITIS B CORE AB, TOTAL [HBCAB] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Draw before Hemodialysis, Dialysis
Page 8 of 9
Printed by LIND, JANNA S [JSL237] at 8/15/2016 10:48:26 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

HEPATITIS B SURFACE AB (IMMUNE
STATUS) [HBSABI]
STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Draw before Hemodialysis, Dialysis
HEPATITIS C AB [HCV] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw before
Hemodialysis
Dialysis
HEPATITIS B SURFACE AG [HBSAG] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Draw before Hemodialysis, Dialysis
Draw After Hemodialysis [80686]
BUN [BUN] CONDITIONAL - RN COLLECT, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw after
Hemodialysis per protocol on dialysis unit
Dialysis
Page 9 of 9
Printed by LIND, JANNA S [JSL237] at 8/15/2016 10:48:26 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org