/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-98195-en.cckm

201706156

page

100

UWHC,UWMF,

Tools,

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

IP – Diabetes Management with Pump – Pediatric – Supplemental [2187]

IP – Diabetes Management with Pump – Pediatric – Supplemental [2187] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Diabetes Management With Pump - Pediatric - Supplemental [2187]
Patient Care Orders
Nutrition [103830]
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Non-Categorized Patient Care Orders [31179]
Glucose, POC [IPGLUCOSE] BEFORE MEALS AND BEDTIME, Starting today For
Until specified, 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?
15 to 30 minutes before meals and at bedtime.
Glucose, POC - For NPO Status [IPGLUCOSE] CONDITIONAL, Starting today For Until specified,
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 4 Hours When
NPO or Continuous Tube Feeding
Glucose, POC [IPGLUCOSE] SUPPLEMENTAL CHECK AT 0200, Starting today,
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?
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting today For Until specified,
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?
Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA TREATMENT
For Until specified, 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?
Contingency Parameters [31180]
Page 1 of 9
Printed by SPENCER, LINDSEY M [LMS033] at 5/26/2017 5:16:48 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] CONTINUOUS
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): 400
If blood glucose < (mg/dL): 70
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: 2 consecutive blood glucose results greater
than 400 mg/dL,Mental status changes
Medications - Continuous Subcutaneous Insulin Infusion
Continuous Subcutaneous Insulin Infusion [30289]
UWHC Agreement to Use Patient's Own
Medication Delivery Device
URL: https://uconnect.wisc.edu/clinical/tools-
resources/med-
records/consentsagreements/resources/name-
36522-en.file
Patient/caregiver to change Insulin pump
catheter every 2-3 days or per home regimen
[NURVAD0053]
CONTINUOUS, Starting today
Page 2 of 9
Printed by SPENCER, LINDSEY M [LMS033] at 5/26/2017 5:16:48 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Insulin pump subcutaneous patient's own
[950042]
4 X DAILY (NOTE ACKNOWLEDGE)
Patient may use own insulin and pump to self
administer insulin. The attached "Agreement to Use
Medication Delivery Device (301503-DT)” form
MUST be completed with every admission.
Document all boluses and daily doses on IV/IV MAR.
Document carbohydrate grams eaten in Doc
Flowsheet.
Subcutaneous pump insulin type:
{aspart;lispro:2000130}
Basal rate:
Starting at midnight give at *** units/hr.
{Subsequent rate changes:2000131}
Insulin-to-carbohydrate ratio:
Starting at midnight give 1 unit of insulin per *** g of
carbohydrate
{Subsequent insulin to carbohydrate ratio
changes:2000132}
Target blood glucose goal *** mg/dL.
{Subsequent target glucose:2000442}
Active insulin *** hours.
Sensitivity (correction factor):
Starting at midnight give 1 unit of insulin for every ***
mg/dL above glucose goal.
{Subsequent sensitivity settings:2000133}
Subcutaneous Insulin Pump (patient's own)
Documentation Requirements [NURCOM0022]
SEE COMMENTS, The nurse must document the
following in the IV/IV MAR or MAR:
1) Once Daily on day shift: Total Daily Dose (TDD)
administered from the previous day. (This is the total
amount administered in 24 hours. The patient should
be able to retrieve this amount from the "Utilities" or
"History" menu or "Home/My records" section
depending on the brand of pump.)
2) All bolus doses given by the patient for meal
coverage and/or for correction of hyperglycemia.
3) Document carbohydrate grams eaten in Doc
Flowsheet.
"Agreement to Use Medication Delivery Device
(301503-DT)" form MUST be completed with every
admission.
Note: Self Administered Medication Program
Documentation [950000]
ONCE
Nursing Communication - Catheter:
Subcutaneous Insulin Pump (Patient's Own)
[NURVAD0053]
SEE COMMENTS, Add Lines/Drains/Airway (LDA) for
Catheter: Subcutaneous Insulin Pump (Patient's
Own).
Document site condition twice daily and PRN.
Document site change as often as needed (usually
every 2-3 days)
Page 3 of 9
Printed by SPENCER, LINDSEY M [LMS033] at 5/26/2017 5:16:48 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Nursing Communication - Insulin Pump
Competency Documentation [NURCOM0022]
ONCE For 1 Occurrences, Complete documentation
of insulin pump self-administration competency when
pump orders given. Update if competency changes.
Chart within Patient Education activity using Title:
Diabetes, Therapeutic Regimen Management,
Ineffective, Topic: Insulin Pump (Patient's Own).
Medications - Hypoglycemia Treatment
Pediatric Hypoglycemia Algorithm URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/diabetes-and-
endocrinology/related/name-97515-en.cckm
Patient Unable to Eat/Swallow Safely and No IV Access (Single Response) [143430]
glucagon 1 mg injection kit - NOTE: Maximum
Dose = 1 mg [107799]
0.03 mg/kg, Subcutaneous, 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
NO IV access.
Reconstituted concentration equals 1 mg/mL. If no
weight entered and patient 3 years or younger, give
0.5 mg. If no weight entered and patient older than 3
years, give 1 mg.
Patient Unable to Eat/Swallow Safely and Has IV Access [143431]
dextrose injection - NOTE: Maximum Dose = 25
g [800233]
0.5-1 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
Oral Treatment [26524]
Hypoglycemia Treatment for blood glucose less
than 40 mg/dL and patient able to eat/swallow
safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? For blood glucose
less than 40 mg/dL and patient able to eat/swallow
safely
Give 30 grams of carbohydrate (6-8 oz. of fruit juice).
Repeat treatment every 15 minutes until glucose is 70
mg/dL or greater. Give 15 gram carbohydrate and
protein snack if meal or snack is not scheduled within
1 hour of hypoglycemic episode.
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today
If Conditional, What Condition? For blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely
Give 15 grams of carbohydrate (3-4 oz. of fruit juice).
Repeat treatment every 15 minutes until glucose is 70
mg/dL or greater. Give 15 gram carbohydrate and
protein snack if meal or snack is not scheduled within
1 hour of hypoglycemic episode.
glucose-vitamin C chew tab [50690] 16 g, Oral, EVERY 15 MINUTES PRN, hypoglycemia,
For blood glucose 40-69 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater
Page 4 of 9
Printed by SPENCER, LINDSEY M [LMS033] at 5/26/2017 5:16:48 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

glucose-vitamin C chew tab [50690] 32 g, Oral, EVERY 15 MINUTES PRN, hypoglycemia,
For blood glucose less than 40 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater
Laboratory
Conditional Labs [144856]
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL - RN COLLECT, Starting today For 7
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if blood glucose
is less than 40 mg/dL or greater than 400 mg/dL
Conditional Labs - Hyperglycemia [30244]
URINALYSIS, NO MICROSCOPY (includes
Ketones) [UACHEM]
CONDITIONAL - RN COLLECT, Starting today For 7
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Obtain if >2 POC
glucose values in a row > 300 mg/dL
Obtain if Not Done Within Last 90 Days [19217]
HEMOGLOBIN A1C [HA1C] NEXT DRAW, 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?
Consults
Consults [31174]
Consult Learning Center - Diabetes Education
(Pediatric) [CON0127]
ONCE, Starting today For 1 Occurrences, Routine, - If
patient is newly diagnosed or is new to insulin,
provide 24 hours notice to allow adequate time for
education,
- Indicate diabetes medication/treatment plan if
known.
- Consults requested after 1600 on Fridays may not
be seen until following Monday. Learning Center
available Mon-Sat 0800-1630 (only 1 RN available on
Saturday for CSC and AFCH).
- Staff may be contacted by Pager 7927 on weekdays
and Pager 3276 on weekends.
- Learning Center staff are not available on holidays.
Type of Education: Diabetes Self-Management
Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Page 5 of 9
Printed by SPENCER, LINDSEY M [LMS033] at 5/26/2017 5:16:48 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Consult Diabetes Education - Nutrition (Inpatient)
[CON0126]
ONCE, Starting today For 1 Occurrences, Routine, ·
If your patient is newly diagnosed and/or is new to
insulin therapy, provide 24 hours notice to allow
adequate time for nutrition education.
· Indicate diabetes medication/treatment plan if
known.
· Consults requested after 1300 on Friday may not
be completed until the following Monday.
· If you are placing a consult on a weekend day for a
patient who will be discharging that weekend, please
have the Paging Center contact the on-call dietitian to
help you facilitate the diabetes nutrition education
session prior to the patient's discharge.
Type of Education: Diabetes Self-Management
Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
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:
Can this consult be done via video?
Consult Child Life Specialist (Inpatient)
[CON0014]
ONCE, Routine
Activity Level: ABLE TO ATTEND PLAY
ROOM/TEEN ROOM
Reason for Consult: ADAPTING TO
HOSP/ILLNESS/TX
Comfort with new diagnosis. Introduce patient to
pediatric diabetes website
http://www.uwhealthkids.org/type1diabetes
Follow-up Appointments - Required Documentation
Schedule Appointment - Diabetes Follow-up [149023]
Schedule Appointment with Provider to Manage
Diabetes [NURCOM0026]
Reason for Hospital Follow Up Appointment: Diabetes
management
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty:
Follow Up Appointments - Diabetes (Single Response) [149021]
Joint Commission Requirement: Patients must have an appointment scheduled WITHIN 30
DAYS of discharge with a provider who will manage their diabetes care. Exclusions are allowed
based upon patient situation (e.g., discharge to skilled nursing facility, patient refusal, etc.).
Schedule Appointment with Provider to Manage
Diabetes [221272]
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Diabetes management
Which Provider:
Page 6 of 9
Printed by SPENCER, LINDSEY M [LMS033] at 5/26/2017 5:16:48 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Appointment scheduled (with provider who can
manage diabetes) [COR0064]
ONCE For 1 Occurrences, Routine
Documentation (required): Appointment scheduled
(with provider who can manage diabetes)
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge
with a provider who will manage a patient's
diabetes care (e.g., primary care physician,
endocrinologist, etc.) is a Joint Commission
requirement. Exclusions are allowed based upon
patient situation (e.g., patient discharging to a
skilled nursing facility, patient refusal, etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed
to request assistance in scheduling an
appointment.
Appointment scheduled per patient report
(ENTER DATE IN COMMENTS) [COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Appointment scheduled
per patient report (ENTER DATE)
Date of appointment (Month/Year):
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Appointment pending: patient discharged on
weekend; follow-up information provided
[COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Appointment pending:
patient discharged on weekend; follow-up information
provided
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Page 7 of 9
Printed by SPENCER, LINDSEY M [LMS033] at 5/26/2017 5:16:48 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Free clinic information provided [COR0064] ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Free clinic information
provided
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
No appointment: Patient discharging to a facility
(e.g., skilled nursing facility, correctional facility,
etc.) [COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
discharging to a facility (e.g., skilled nursing facility,
correctional facility, etc.)
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
No appointment: Patient refusal [COR0064] ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
refusal
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Page 8 of 9
Printed by SPENCER, LINDSEY M [LMS033] at 5/26/2017 5:16:48 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

No appointment: Patient does not have diabetes
[COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
does not have diabetes
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Page 9 of 9
Printed by SPENCER, LINDSEY M [LMS033] at 5/26/2017 5:16:48 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org