/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-98200-en.cckm

201606170

page

100

UWHC,UWMF,

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

IP - Donation After Circulatory Death (DCD) - Pediatric - Supplemental [4227]

IP - Donation After Circulatory Death (DCD) - Pediatric - Supplemental [4227] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Donation After Circulatory Death (DCD) - Pediatric - Supplemental [4227]
Consent for organ procurement must have been obtained prior to use of this order set.
Do NOT use on patients with paralytics actively present at the time this protocol is enacted.
A note must be written that documents the rationale for comfort care, discussions with attending and discussion with
family in order to proceed with this order set.
Educate family regarding tachypnea not being equal to dyspnea, secretion build-up in airways and snoring, changes in
skin color, bowel/bladder control, unpredictability in the timing of death, etc.
Post-mortem examination must be requested per hospital Policy.
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 [113118]
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
Measure Respiratory Rate [NURMON0028] SEE COMMENTS, Routine, 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:
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.
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority


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
Details: To Dependent Drainage
Irrigate With:
Irrigation Frequency:
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
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority


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 8/13/15 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 8/14/15 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 8/15/15 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
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority


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.
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 [113126]
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
Intravenous Therapy
IV Fluids [191629]
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS
Run at maintenance fluid rate
Medications
Antihypertensives - PRN [191630]
labetalol (NORMODYNE;TRANDATE) injection RANGE
[750053]
0.2-0.5 mg/kg, Intravenous, EVERY 1 HOUR PRN,
hypertension
Call physician prior to administering medication to receive
instructions on medication selection.
for 2 Minutes
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority


hydrALAZINE (APRESOLINE) injection RANGE
[750049]
0.1-0.2 mg/kg, Intravenous, EVERY 1 HOUR PRN,
hypertension
Call physician 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 [191631]
furosemide (LASIX) intraVENOUS [800046] 0.5 mg/kg, Intravenous, EVERY 6 HOURS PRN, edema,
CVP greater than 12 mmHg
Call physician 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 [191632]
potassium chloride intraVENOUS PEDS CENTRAL
[800209]
0.5 mEq/kg, Intravenous, PRN, For potassium less than
3.5 mmol/liter
calcium GLUConate intraVENOUS [800105] 50 mg/kg, Intravenous, PRN, For ionized calcium less than
4.6 mg/dL
magnesium sulfate intraVENOUS (PEDS) [800194] 50 mg/kg, Intravenous, PRN, For magnesium less than 1.8
mg/dL
phosphate SODIUM intraVENOUS PEDS CENTRAL
[800216]
0.35 mmol/kg, Intravenous, PRN, For phosphate less than
3 mg/dL
Electrolyte Supplements - Peripheral Line [191633]
potassium chloride intraVENOUS PEDS PERIPHERAL
[800208]
0.5 mEq/kg, Intravenous, PRN, For potassium less than
3.5 mmol/liter
calcium GLUConate intraVENOUS [800105] 50 mg/kg, Intravenous, PRN, For ionized calcium less than
4.6 mg/dL
magnesium sulfate intraVENOUS (PEDS) [800194] 50 mg/kg, Intravenous, PRN, For magnesium less than 1.8
mg/dL
phosphate SODIUM intraVENOUS PEDS PERIPHERAL
[800215]
0.35 mmol/kg, Intravenous, PRN, For phosphate less than
3 mg/dL
Sedatives [113067]
midazolam (VERSED) injection RANGE - NOTE: Use
ONLY with infusion order [750056]
0.05-0.1 mg/kg, Intravenous, EVERY 2 HOURS PRN,
agitation
Use ONLY with infusion order
Use ONLY with infusion order
midazolam (VERSED) infusion PEDS [800154] 0.05-0.1 mg/kg/hr, Intravenous, CONTINUOUS
Initiate at 0.05 mg/kg/hr or current rate. Titrate rate by 20%
of current rate every 4 hours to maintain sedation score of 2.
Bolus by dose equal to current hourly infusion rate every 2
hours if patient exhibits signs or symptoms of discomfort.
Contact MD with any questions
Analgesics (Single Response) [113069]
FENTanyl (SUBLIMAZE) infusion PEDS [800143] 0.5-2 mcg/kg/hr, Intravenous, CONTINUOUS
Initiate at 0.5 mcg/kg/hr or current rate. Increase infusion rate
by 20% every 4 hours if patient exhibits signs or symptoms of
discomfort - see CNPI non-verbal pain discomfort indicators.
Contact MD with any questions
MORPHine infusion PEDS [800156] 0.05-0.1 mg/kg/hr, Intravenous, CONTINUOUS
Initiate at 0.05 mg/kg/hr or current rate. Increase infusion
rate by 20% every 4 hours if patient exhibits signs or
symptoms of discomfort - see CNPI non-verbal pain
discomfort indicators. Contact MD with any questions
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
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority


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 [113062]
acetylcysteine 20% soln(ORAL) CUSTOM [780005] 140 mg/kg, Nasogastric Tube, ONCE For 1 Doses
albuterol HFA (VENTOLIN HFA) 90 mcg/act inhaler
[53730]
4 puff, Inhalation, EVERY 2 HOURS PRN, dyspnea
May give through ventilator circuit
methylprednisolone sod succ. in sodium chloride 0.9%
(SOLU-MEDROL) injection CUSTOM [755013]
15 mg/kg, Intravenous, EVERY 12 HOURS
Dilute with 50-100 mL dextrose 5%
for 30 Minutes
tocopherol (VITAMIN E) soln [800228] 15 Units/kg, Nasogastric Tube, ONCE For 1 Doses
ursodiol (ACTIGALL) susp CUSTOM [780143] 5 mg/kg, Nasogastric Tube, ONCE For 1 Doses
Insulin Infusion
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] 0.05-0.1 Units/kg/hr, Intravenous, CONTINUOUS
Initiate at blood glucose greater than 180 mg/dL. Administer
insulin drip at ***
Hypoglycemia [113074]
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority


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]
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?
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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?
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?
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?
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?
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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]
This order equals 2 sites (4 bottles). See link below for Best Practices for Blood Culturing.
Best Practices for Blood Culturing URL: https://uconnect.wisc.edu/clinical/references/clinical-
laboratories/blood/
Lab Test Directory URL: https://uconnect.wisc.edu/clinical/tools-resources/lab-test
-directory/microbiology/name-67798-en.labtest
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?
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?
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority


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.
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.
Page 10 of 12
Pr i nt ed by O'BRIEN, RYLEY P [RPO249] at 8/11/2015 3:34:34 PM
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority


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.
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.
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.
Page 11 of 12
Pr i nt ed by O'BRIEN, RYLEY P [RPO249] at 8/11/2015 3:34:34 PM
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority


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]
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 12 of 12
Pr i nt ed by O'BRIEN, RYLEY P [RPO249] at 8/11/2015 3:34:34 PM
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority