/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/hospital-wide/,

/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98186-en.cckm

201709255

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Hospital-wide

IP - Brain Dead Donor (BDD) Delegation Protocol - Pediatric - Supplemental [4287]

IP - Brain Dead Donor (BDD) Delegation Protocol - Pediatric - Supplemental [4287] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Brain Dead Donor (BDD) Delegation Protocol - Pediatric - Supplemental
[4287]
set.for organ procurement must have been obtained prior to use of this order Consent
Patient Care Orders
Refer to Policy 4.31 Organ & Tissue Donation URL: https://uconnect.wisc.edu/policies/clinical/uwhc-
clinical/uwhc-wide/legal-affairs/431.policy
Vital Signs [191504]
Measure Blood Pressure [NURMON0019] EVERY 1 HOUR, Routine
BP Source:
BP Location:
BP Position:
BP Restrictions:
Measure Heart Rate [NURMON0056] EVERY 1 HOUR, Routine
Measure Temperature [NURMON0029] EVERY 1 HOUR, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
Pulse Oximetry [NURMON0009] EVERY 1 HOUR, Routine
Measure Central Venous Pressure
[NURMON0002]
EVERY 2 HOURS, Routine
Measure Arterial Pressure [NURMON0060] EVERY 1 HOUR
Patient Monitoring [113119]
Measure Urine Output [NURMON0012] EVERY 1 HOUR, Routine
GI/GU [113120]
NG Tube Placement - Pediatric [121658]
Insert and Maintain Nasogastric Tube
[NURTAD0014]
CONTINUOUS, Routine
Options: Low, Intermittent Suction
Flush with:
Flush Frequency: EVERY 8 HOURS
Clamp NG Tube:
Check Residual:
Does this need to be inserted/placed?
Device Status: Not Ready For Use
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.
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.
Page 1 of 18
Printed by O'BRIEN, RYLEY P [RPO249] at 9/12/2017 2:49:28 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

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, 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: End of Life Care
Initiate Urinary Catheter Removal Protocol? (NP/PA
must select "No"): No
Details: To Dependent Drainage
Does this need to be inserted/placed?
Respiratory [114174]
chlorhexidine (PERIDEX) soln MULTIDOSE -
NOTE: Order For Patients on Mechanical
Ventilation [792004]
5 mL, Mouth/Throat, 2 X DAILY
Use to swab oral cavity. D/C when patient no longer
on ventilation
Elevate Head Of Bed [NURACT0002] Equal to (degrees):
Greater than (degrees): 30
Less than (degrees): 45
Other options:
Routine, CONTINUOUS
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms? Evaluate for Lung
Procurement and Lung Measurements
What specific question(s) would you like answered by
this exam? Evaluate for Lung Procurement and Lung
Measurements
Relevant recent/past history? Evaluate for Lung
Procurement and Lung Measurements
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Page 2 of 18
Printed by O'BRIEN, RYLEY P [RPO249] at 9/12/2017 2:49:28 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting tomorrow For
1 Occurrences, Routine
Current signs and symptoms? Evaluate for Lung
Procurement
What specific question(s) would you like answered by
this exam? Evaluate for Lung Procurement
Relevant recent/past history? Evaluate for Lung
Procurement
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting 9/14/17 For 1
Occurrences, Routine
Current signs and symptoms? Evaluate for Lung
Procurement
What specific question(s) would you like answered by
this exam? Evaluate for Lung Procurement
Relevant recent/past history? Evaluate for Lung
Procurement
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting 9/15/17 For 1
Occurrences, Routine
Current signs and symptoms? Evaluate for Lung
Procurement
What specific question(s) would you like answered by
this exam? Evaluate for Lung Procurement
Relevant recent/past history? Evaluate for Lung
Procurement
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting 9/16/17 For 1
Occurrences, Routine
Current signs and symptoms? Evaluate for Lung
Procurement
What specific question(s) would you like answered by
this exam? Evaluate for Lung Procurement
Relevant recent/past history? Evaluate for Lung
Procurement
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Page 3 of 18
Printed by O'BRIEN, RYLEY P [RPO249] at 9/12/2017 2:49:28 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

BLOOD GASES [HCBGAS] CONDITIONAL - RN COLLECT For 4 Occurrences,
STAT
Indicate FIO2: Per DCD Protocol
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? 30 minutes after
increase FiO2 to 100% if change in ventilation (seems
clinicals indicated) t+3
Consult Pulmonary Medicine (Inpatient)
[CON0065]
ONCE
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Bronchoscopy - To
evaluate for lung procurement. Assess all lobes and
upper airway.
Respiratory [113121]
chlorhexidine (PERIDEX) soln MULTIDOSE -
NOTE: Order For Patients on Mechanical
Ventilation [792004]
15 mL, Mouth/Throat, 2 X DAILY
Use to swab oral cavity. D/C when patient no longer
on ventilation
Elevate Head Of Bed [NURACT0002] Equal to (degrees):
Greater than (degrees): 30
Less than (degrees): 45
Other options:
Routine, CONTINUOUS
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms? Evaluate for Lung
Procurement and Lung Measurements
What specific question(s) would you like answered by
this exam? Evaluate for Lung Procurement and Lung
Measurements
Relevant recent/past history? Evaluate for Lung
Procurement and Lung Measurements
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting tomorrow For
1 Occurrences, Routine
Current signs and symptoms? Evaluate for Lung
Procurement
What specific question(s) would you like answered by
this exam? Evaluate for Lung Procurement
Relevant recent/past history? Evaluate for Lung
Procurement
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Page 4 of 18
Printed by O'BRIEN, RYLEY P [RPO249] at 9/12/2017 2:49:28 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting 9/14/17 For 1
Occurrences, Routine
Current signs and symptoms? Evaluate for Lung
Procurement
What specific question(s) would you like answered by
this exam? Evaluate for Lung Procurement
Relevant recent/past history? Evaluate for Lung
Procurement
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting 9/15/17 For 1
Occurrences, Routine
Current signs and symptoms? Evaluate for Lung
Procurement
What specific question(s) would you like answered by
this exam? Evaluate for Lung Procurement
Relevant recent/past history? Evaluate for Lung
Procurement
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting 9/16/17 For 1
Occurrences, Routine
Current signs and symptoms? Evaluate for Lung
Procurement
What specific question(s) would you like answered by
this exam? Evaluate for Lung Procurement
Relevant recent/past history? Evaluate for Lung
Procurement
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
BLOOD GASES [HCBGAS] CONDITIONAL - RN COLLECT For 4 Occurrences,
STAT
Indicate FIO2: Per DCD Protocol
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? 30 minutes after
increase FiO2 to 100% if change in ventilation (seems
clinicals indicated) t+3
Consult Pulmonary Medicine (Inpatient)
[CON0065]
ONCE
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Bronchoscopy - To
evaluate for lung procurement. Assess all lobes and
upper airway.
Cardiac [114590]
ECG - 12 Lead With Rhythm Strip (PEDS)
[EKG0018]
ONCE, Routine
Reason for exam: HEART OR LUNG TRANSPLANT
Page 5 of 18
Printed by O'BRIEN, RYLEY P [RPO249] at 9/12/2017 2:49:28 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Transthoracic Resting Echocardiogram (PEDS)
[ECH0012]
Current signs and symptoms? Brain death
What specific question(s) would you like answered by
this exam? Evaluate for potential cardiac donation
Relevant recent/past history? Brain death
To whom can we send the results of the study?
(include clinician and location): Peds ICU Attending
Do you want Agitated Bubble Study?
Last patient height? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date in
comment):
|
-- STAT priority is for *CLINICAL EMERGENCY* use
only --
A page will automatically send to the Pediatric
Cardiologist upon signing if a STAT Priority is
selected.
Please have a CD of the echocardiogram made.
Consult Cardiology (Inpatient) [CON0012] ONCE
Intent: Consult and Recommend (No Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): To evaluate for
cardiac procurement
Non-Categorized Patient Care Orders [113122]
Measure Height [NURMON0052] ONCE For 1 Occurrences, Routine
Measure Weight [NURMON0015] ONCE For 1 Occurrences, Routine
Weigh With?
Weigh when?
Maintain Arterial Line [NURVAD0001] CONTINUOUS, Routine
Device Status:
Flush Solution:
Site:
Maintain Central Venous Access [NURVAD0023] CONTINUOUS, Routine
Device Status:
Leave All Lines and Catheters Provided They Are
Not Causing Discomfort for the Patient
[NURCOM0022]
CONTINUOUS
RN to Verify Consent for Organ Donation Has
Been Obtained [NURCOM0022]
CONTINUOUS
Contingency Parameters [113124]
Page 6 of 18
Printed by O'BRIEN, RYLEY P [RPO249] at 9/12/2017 2:49:28 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Notify Primary Team [NURCOM0001] Provider to Notify: Other (Comment)
If systolic blood pressure > (mmHg): 100
If systolic blood pressure < (mmHg): 78
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38
If temperature < (C): 36.5
If heart rate > (bpm): 180
If heart rate < (bpm): 90
If respiratory rate >: 50
If respiratory rate <: 25
If blood glucose > (mg/dL): 200 milligrams/deciliter if
patient not on an insulin drip
If blood glucose < (mg/dL): 80
If pain score >:
Pulse Oximetry < (%): 95
If urine output < (mL): 1 mL/kg/hr or greater than 4
mL/kg/hr for 2 consecutive hours
Other: Central venous pressure less than 4 mmHg or
grater than 14 mmHg,Systemic vascular resistance
less than 800 or greater than 1300 dyne-
seconds/contimeter,Hematocrit less than 8
gram/deciliter,Platelet Count less than
50,000/microliter,Sodium greater than 150
millimole/liter,Potassium greater than 5 millimole/liter
Contingency Parameters [113125]
Notify Primary Team [NURCOM0001] Provider to Notify: Other (Comment)
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
If temperature < (C): 36.5
If heart rate > (bpm): 160
If heart rate < (bpm): 80
If respiratory rate >: 40
If respiratory rate <: 20
If blood glucose > (mg/dL): 200 milligrams/deciliter if
patient not on an insulin drip
If blood glucose < (mg/dL): 80
If pain score >:
Pulse Oximetry < (%): 95
If urine output < (mL): 1 mL/kg/hr or greater than 4
mL/kg/hr for 2 consecutive hours
Other: Central venous pressure less than 4 mmHg or
grater than 14 mmHg,Systemic vascular resistance
less than 800 or greater than 1300 dyne-
seconds/contimeter,Hematocrit less than 8
gram/deciliter,Platelet Count less than
50,000/microliter,Sodium greater than 150
millimole/liter,Potassium greater than 5 millimole/liter
Contingency Parameters [113126]
Page 7 of 18
Printed by O'BRIEN, RYLEY P [RPO249] at 9/12/2017 2:49:28 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Notify Primary Team [NURCOM0001] Provider to Notify: Other (Comment)
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
If temperature < (C): 36.5
If heart rate > (bpm): 140
If heart rate < (bpm): 75
If respiratory rate >: 30
If respiratory rate <: 18
If blood glucose > (mg/dL): 200 milligrams/deciliter if
patient not on an insulin drip
If blood glucose < (mg/dL): 80
If pain score >:
Pulse Oximetry < (%): 95
If urine output < (mL): 1 mL/kg/hr or greater than 4
mL/kg/hr for 2 consecutive hours
Other: Central venous pressure less than 4 mmHg or
grater than 14 mmHg,Systemic vascular resistance
less than 800 or greater than 1300 dyne-
seconds/contimeter,Hematocrit less than 8
gram/deciliter,Platelet Count less than
50,000/microliter,Sodium greater than 150
millimole/liter,Potassium greater than 5 millimole/liter
Contingency Parameters [113128]
Notify Primary Team [NURCOM0001] Provider to Notify: Other (Comment)
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
If temperature < (C): 36.5
If heart rate > (bpm): 120
If heart rate < (bpm): 70
If respiratory rate >: 24
If respiratory rate <: 14
If blood glucose > (mg/dL): 200 milligrams/deciliter if
patient not on an insulin drip
If blood glucose < (mg/dL): 80
If pain score >:
Pulse Oximetry < (%): 95
If urine output < (mL): 1 mL/kg/hr or greater than 4
mL/kg/hr for 2 consecutive hours
Other: Central venous pressure less than 4 mmHg or
grater than 14 mmHg,Systemic vascular resistance
less than 800 or greater than 1300 dyne-
seconds/contimeter,Hematocrit less than 8
gram/deciliter,Platelet Count less than
50,000/microliter,Sodium greater than 150
millimole/liter,Potassium greater than 5 millimole/liter
Contingency Parameters [113129]
Page 8 of 18
Printed by O'BRIEN, RYLEY P [RPO249] at 9/12/2017 2:49:28 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Notify Primary Team [NURCOM0001] Provider to Notify: Other (Comment)
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
If temperature < (C): 36.5
If heart rate > (bpm): 110
If heart rate < (bpm): 60
If respiratory rate >: 22
If respiratory rate <: 12
If blood glucose > (mg/dL): 200 milligrams/deciliter if
patient not on an insulin drip
If blood glucose < (mg/dL): 80
If pain score >:
Pulse Oximetry < (%): 95
If urine output < (mL): 1 mL/kg/hr or greater than 4
mL/kg/hr for 2 consecutive hours
Other: Central venous pressure less than 4 mmHg or
grater than 14 mmHg,Systemic vascular resistance
less than 800 or greater than 1300 dyne-
seconds/contimeter,Hematocrit less than 8
gram/deciliter,Platelet Count less than
50,000/microliter,Sodium greater than 150
millimole/liter,Potassium greater than 5 millimole/liter
Intravenous Therapy
IV Fluids [191629]
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS
Run at maintenance fluid rate
Medications
Antihypertensives - PRN [113063]
labetalol (NORMODYNE;TRANDATE) injection
RANGE - NOTE: Maximum Dose = 20 mg
[750053]
0.2-0.5 mg/kg, Intravenous, EVERY 1 HOUR PRN,
hypertension
Call OPO Coordinator prior to administering
medication to receive instructions on medication
selection
for 2 Minutes
hydrALAZINE (APRESOLINE) injection RANGE -
NOTE: Maximum Dose = 20 mg [750049]
0.1-0.2 mg/kg, Intravenous, EVERY 1 HOUR PRN,
hypertension
Call OPO Coordinator prior to administering
medication to receive instructions on medication
selection
Diabetes Insipidus [114122]
(PEDS DI) vasopressin (PITRESSIN) infusion
[800169]
0.5 milli-units/kg/hr, Intravenous, CONTINUOUS
Diuretics [113065]
furosemide (LASIX) intraVENOUS - NOTE:
Maximum Dose = 20 mg [800046]
0.5 mg/kg, Intravenous, EVERY 6 HOURS PRN,
edema, CVP greater than 12 mmHg
Call OPO Coordinator prior to medication
administration
IV push rate 10 mg/minute. IV infusion rate 4
mg/minute
Electrolyte Supplements (Single Response) [113066]
Electrolyte Supplements - Central Line [230429]
Page 9 of 18
Printed by O'BRIEN, RYLEY P [RPO249] at 9/12/2017 2:49:28 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

potassium chloride intraVENOUS PEDS
CENTRAL - Note: Maximum Dose = 20 mEq
[800209]
0.5 mEq/kg, Intravenous, PRN, For potassium less
than 3.5 mmol/liter
calcium GLUConate intraVENOUS - Note:
Maximum Dose = 2 g [800105]
50 mg/kg, Intravenous, PRN, For ionized calcium
less than 4.6 mg/dL
magnesium sulfate intraVENOUS (PEDS) - Note:
Maximum Dose = 2 g [800194]
50 mg/kg, Intravenous, PRN, For magnesium less
than 1.8 mg/dL
phosphate SODIUM intraVENOUS PEDS
CENTRAL - Note: Maximum Dose = 15 mmol
[800216]
0.36 mmol/kg, Intravenous, PRN, For phosphate
less than 3 mg/dL
Electrolyte Supplements - Peripheral Line
[230430]
potassium chloride intraVENOUS PEDS
PERIPHERAL - Note: Maximum Dose = 10 mEq
[800208]
0.5 mEq/kg, Intravenous, PRN, For potassium less
than 3.5 mmol/liter
calcium GLUConate intraVENOUS - Note:
Maximum Dose = 2 g [800105]
50 mg/kg, Intravenous, PRN, For ionized calcium
less than 4.6 mg/dL
magnesium sulfate intraVENOUS (PEDS) - Note:
Maximum Dose = 2 g [800194]
50 mg/kg, Intravenous, PRN, For magnesium less
than 1.8 mg/dL
phosphate SODIUM intraVENOUS PEDS
PERIPHERAL - Note: Maximum Dose = 7.5
mmol [800215]
0.36 mmol/kg, Intravenous, PRN, For phosphate
less than 3 mg/dL
Levothyroxine [13538]
levothyroxine injection [760146] 0.7 mcg/kg, Intravenous, ONCE For 1 Doses, for 1
Minutes
levothyroxine infusion PEDS [800151] Intravenous, CONTINUOUS
Initiate at 1 mcg/kg/hr. Increase by 0.1 mcg/kg/hr
every 30 minutes to maintain systolic blood pressure
greater than *** mmHg and mean arterial pressure
greater than ***
Vasopressors [113064]
DOPamine (INTROPIN) infusion PEDS [800137] Intravenous, CONTINUOUS
Initiate at ***. Further rate changes will be directed by
the physician
Central line preferred, however,
peripheral/intraosseous access may be used when
benefit outweighs risks
phenylEPHRINE (NEO-SYNEPHRINE) infusion
PEDS [800164]
Intravenous, CONTINUOUS
Initiate at ***. Further rate changes will be directed by
the physician
Central line preferred, however,
peripheral/intraosseous access may be used when
benefit outweighs risks
Non-Categorized [191505]
albuterol HFA (VENTOLIN HFA) 90 mcg/act
inhaler [53730]
4 puff, Inhalation, EVERY 2 HOURS PRN, dyspnea
May give through ventilator circuit
methylprednisolone sodium succ. (SOLU-
MEDROL) intraVENOUS - NOTE: Maximum
Dose = 1000 mg [800058]
15 mg/kg, Intravenous, EVERY 12 HOURS
Administer over 30 minutes
Dilute with 50-100 mL dextrose 5%
For Lung Donors [114603]
rocuronium (ZEMURON) injection [800213] 1 mg/kg, Intravenous, ONCE For 1 Doses
Administer 5 minutes prior to giving naloxone to
prevent spinal reflexes due to naloxone administration
naloxone (NARCAN) injection - NOTE: Maximum
Dose = 8 mg [800199]
0.1 mg/kg, Intravenous, ONCE For 1 Doses
Insulin Infusion
Page 10 of 18
Printed by O'BRIEN, RYLEY P [RPO249] at 9/12/2017 2:49:28 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Non-Categorized Patient Care Orders [113141]
Glucose, POC [IPGLUCOSE] SEE COMMENTS For 7 Days, Routine, Glucose,
POC should always be ordered in conjunction with
orders for hypoglycemia management and monitoring
as indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
Every hour until within target range (90-180 mg/dL.
NOTE: Pilot target range is 110-150 mg/dL) for 3
hours (3 readings in a row), then decrease frequency
to every 2 hours. Hourly monitoring must be resumed
if blood glucose deviates from target range.
After Priming IV Tubing with Insulin, Waste 20 mL
Insulin Drip to Saturate all IV Tubing Binding Sites
[NURCOM0022]
CONTINUOUS
Contingency Parameters [113142]
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): 180
If blood glucose < (mg/dL): 90
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Infusion rate is less than 1 unit/hour with
glucose value less than Target Range (90-180
milligrams/deciliter)
Insulin [113073]
insulin regular (human) infusion PEDS [800147] 0.05 Units/kg/hr, Intravenous, CONTINUOUS
Initiate at blood glucose greater than 180 mg/dL.
Hypoglycemia [113074]
dextrose injection [800233] 0.5 g/kg, Intravenous, PRN, For blood glucose less
than or equal to 69 mg/dL AND patient is unable to
eat/swallow safely, NPO or unconscious AND has IV
access
Repeat every 15 minutes until blood glucose greater
than 70 mg/dL
Laboratory
Draw Now [116877]
Page 11 of 18
Printed by O'BRIEN, RYLEY P [RPO249] at 9/12/2017 2:49:28 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

TYPE AND SCREEN [HCTS] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT, As good clinical practice and for
patient safety, the Transfusion Service will
automatically crossmatch 2 packed RBCs on all
patients with antibodies to ensure blood would be
available in the event it is needed. If you would like to
opt out of this automatic order for this patient please
contact the UWHC Blood Bank at (608) 263-8367 or
The American Center Lab at (608) 234-6600 as
appropriate.
BLOOD GASES [HCBGAS] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If source is OTHER, indicate here:
Indicate FIO2: Per DCD Protocol
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CBC WITH DIFFERENTIAL [CBC] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTHROMBIN TIME/INR [PT] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PTT [PTT] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALKALINE PHOSPHATASE [ALKP] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALT/SGPT [ALT] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
AMYLASE [AMYL] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
AST/SGOT [AST] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BILIRUBIN, DIRECT [DBIL] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 12 of 18
Printed by O'BRIEN, RYLEY P [RPO249] at 9/12/2017 2:49:28 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

BILIRUBIN, TOTAL [TBIL] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BUN [BUN] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CALCIUM, IONIZED [XICAL] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CK, TOTAL [CPK] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CKMB AND INDEX [MBI] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATININE [CRET] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
GLUCOSE [GLU] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
GGT [GGT] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
LD, TOTAL [LDH] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
LIPASE [LIPS] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 13 of 18
Printed by O'BRIEN, RYLEY P [RPO249] at 9/12/2017 2:49:28 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

MAGNESIUM [MAG] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTEIN, TOTAL [TP] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
TROPONIN [GM2447] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEMOGLOBIN A1C [HA1C] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CULTURE, BLOOD, BACTERIA/YEAST (2
SITES) [116728]
.Practices for Blood Culturing Best This order equals 2 sites (4 bottles). See link below for
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?
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?
CULTURE, SPUTUM WITH GRAM STAIN
[HCSPUCS]
ONCE, Starting today For 1 Occurrences, Routine,
For patients with an ET tube or tracheostomy,
quantitative mini-BAL by RT or bronchoscopic BAL are
the preferred methods of specimen collection.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CULTURE, URINE [URC] 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?
Page 14 of 18
Printed by O'BRIEN, RYLEY P [RPO249] at 9/12/2017 2:49:28 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

ALBUMIN [ALB] 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?
URINALYSIS WITH MICROSCOPY [UA] 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?
Labs [191660]
PHOSPHATE [PHOS] CONDITIONAL - RN COLLECT For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw 1 hour after IV
replacement
Conditional Orders [105866]
BLOOD GASES [HCBGAS] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If source is OTHER, indicate here:
Indicate FIO2: Per DCD Protocol
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
CBC WITH DIFFERENTIAL [CBC] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
PROTHROMBIN TIME/INR [PT] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
PTT [PTT] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
ALKALINE PHOSPHATASE [ALKP] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
ALT/SGPT [ALT] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
Page 15 of 18
Printed by O'BRIEN, RYLEY P [RPO249] at 9/12/2017 2:49:28 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

AMYLASE [AMYL] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
AST/SGOT [AST] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
BILIRUBIN, DIRECT [DBIL] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
BILIRUBIN, TOTAL [TBIL] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
BUN [BUN] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
CALCIUM, IONIZED [XICAL] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
CK, TOTAL [CPK] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
CKMB AND INDEX [MBI] CONDITIONAL - RN COLLECT, Starting today For 3
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
CREATININE [CRET] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
Page 16 of 18
Printed by O'BRIEN, RYLEY P [RPO249] at 9/12/2017 2:49:28 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

ELECTROLYTES [LYTE] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
GLUCOSE [GLU] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
GGT [GGT] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
LD, TOTAL [LDH] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
LIPASE [LIPS] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
MAGNESIUM [MAG] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
PROTEIN, TOTAL [TP] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
TROPONIN [GM2447] CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw per OPO
request. For potential Organ Donation.
ALBUMIN [ALB] 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 per OPO
request. For potential Organ Donation.
Consults
Consults [113143]
Page 17 of 18
Printed by O'BRIEN, RYLEY P [RPO249] at 9/12/2017 2:49:28 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Consult Spiritual Care (Inpatient) [CON0056] ONCE, Routine
Reason for Consult: End of Life and organ donation
Consult Palliative Care - Pediatric (Inpatient)
[CON0172]
ONCE, Routine
Reason For Consult: End of Life Care/Comfort Care
Page 18 of 18
Printed by O'BRIEN, RYLEY P [RPO249] at 9/12/2017 2:49:28 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org