/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-98202-en.cckm

20170494

page

100

UWHC,UWMF,

Tools,

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

IP - ECMO - Adult - Post-Cannulation [2459]

IP - ECMO - Adult - Post-Cannulation [2459] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - ECMO - Adult - Post-Cannulation [2459]
for Adult Patients OnlyIntended
Extracorporeal Membrane Oxygenation (ECMO) Type
Extracorporeal Membrane Oxygenation (ECMO) Type [31437]
Venoarterial (VA) [NURCOM0022] ONCE, Starting today For 1 Occurrences
Venovenous (VV) [NURCOM0022] ONCE, Starting today For 1 Occurrences
Patient Care Orders
Activity [102173]
Range of Motion Exercises [NURACT0011] SEE COMMENTS, Starting today For Until specified,
Every 8 hours
Carefully Rotate Patient With Assistance From
ECMO Specialist. Any movement of the patient's
affected limbs warrants an ECMO Specialist to
assist to ensure no issues occur with the
cannulas. [NURACT0011]
CONTINUOUS, Starting today
Patient Monitoring [80160]
Assess Neurologic Status [NURMON0006] SEE COMMENTS, Starting today, Routine, Every 1
hour times 8, then every 2 hours times 16, then every
4 hours.
Respiratory [80161]
Respiratory Therapy Communication [RT0065] ONCE, Routine, Discuss lung protection strategies
with ECMO team to consider resetting mechanical
ventilation settings as follows:
Tidal volume: 3-5 mL/kg of Ideal Body Weight
Pressure Control: Maximum PIP of 24-28
Nutrition [80162]
Supplemental" -Adult -Total Parenteral Nutrition -total parenteral nutrition, refer to "IP For
Order Set.
NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: Strict NPO
Bedside Meal Instructions:
Room Service Class:
Wound/Procedure Site Care [109068]
Do Not Change Surgical Incision Dressing for 48
Hours, Unless Heavily Blood Stained
[NURWND0018]
CONTINUOUS, Starting today For 48 Hours
Page 1 of 13
Printed by LIND, JANNA S [JSL237] at 4/4/2017 10:27:10 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Wound Care - Closed Incision (Adult)
[NURWND0055]
CONTINUOUS, Routine
Wound Site:
Wound Location:
Assess Frequency: EVERY 8 HOURS
Incision Closed With: Sutures
Maintain OR Dressing: Minimum of 48 hours
Remove OR Dressing after 48 hours: Yes
Removal of OR Dressing performed by: RN
Cleansing with Removal of OR Dressing: CHG
Primary Dressing (after 48 hours): Other (Comment)
(tegaderm with biopatch)
Incision Care (after 48 hours): Other (Comment)
(change every 6 days or if saturated)
If dressing becomes saturated in 48 hours, sterile
dressing change? Yes - Notify provider
Biopatch can be placed at cannula exit site
If Patient's Chest Open, MD Must Clean Cannula
Site [NURWND0015]
CONTINUOUS, Starting today, Routine
Wound Type:
Wound Site:
Wound Location:
Assess Frequency:
Care Frequency:
Wash With:
Irrigate/Rinse With:
Apply (Must also enter separate medication order to
obtain drug):
Primary Dressing:
Secondary Dressing:
Hemofiltration [80177]
Hemofiltration Parameters [NURCOM0022] CONTINUOUS, Starting today, Hemofilter (HF) line to
be placed and primed in circuit by Perfusionist.
Ultrafiltrate (UF) line to IV infusion pump and
urimeter.
Maintain blood flow through hemofilter at 50-100
mL/minute.
Maintain ultrafiltration rate at *** mL/hour or to
achieve an overall patient hourly balance of ***
mL/hour.
Non-Categorized Patient Care Orders [80178]
Do Not Insert Tubes Nasally [NURTAD0046] CONTINUOUS, Starting today
No Intramuscular Medications, No
Venipunctures, No Heelsticks, No Spinal Taps
[NURCOM0022]
CONTINUOUS, Starting today
No Infusions into the ECMO Centrifugal Circuit
[NURCOM0022]
CONTINUOUS, Starting today, No Infusions into the
ECMO Centrifugal Circuit
Do Not Insert Rectal Thermometer
[NURMON0060]
CONTINUOUS, Starting today
Medications
General [80360]
hydrALAZINE (APRESOLINE) injection RANGE
[750049]
10-20 mg, Intravenous, EVERY 2 HOURS PRN,
mean arterial pressure greater than 65 mmHg
calcium CHLOride injection [35486] 1 g, Intravenous, EVERY 4 HOURS PRN, ionized
calcium less than 4.8 mg/dL
albumin human 5% infusion [44038] 12.5 g, Intravenous, PRN, If ECMO flow < 10% of
ordered flow for 5 minutes, give 5% albumin with a
maximum dose of 250 mL
Page 2 of 13
Printed by LIND, JANNA S [JSL237] at 4/4/2017 10:27:10 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Laboratory
Laboratory (If Not Drawn in the Last 4 Hours) [80189]
CBC WITHOUT DIFFERENTIAL [HEMO] CONDITIONAL - RN COLLECT, Starting today,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Hemodynamic issues
or evidence of bleeding
ELECTROLYTES [LYTE] 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?
GLUCOSE [GLU] 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?
BUN [BUN] 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?
CREATININE [CRET] 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?
CALCIUM [CA] 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?
FIBRINOGEN [GM1320] 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?
LACTATE [GM2255] NEXT DRAW, 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?
Draw Every 4 Hours Times 6, Then Every 6 Hours Times 4, Then Every 8 Hours [80712]
CBC WITHOUT DIFFERENTIAL [HEMO] EVERY 4 HOURS, Starting today For 6 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CBC WITHOUT DIFFERENTIAL [HEMO] EVERY 6 HOURS, Starting tomorrow For 4
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 3 of 13
Printed by LIND, JANNA S [JSL237] at 4/4/2017 10:27:10 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL [HEMO] EVERY 8 HOURS, Starting 4/6/17 For 7 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PLATELET COUNT [PLT] EVERY 4 HOURS, Starting today For 6 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PLATELET COUNT [PLT] EVERY 6 HOURS, Starting tomorrow For 4
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PLATELET COUNT [PLT] EVERY 8 HOURS, Starting 4/6/17 For 7 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] EVERY 4 HOURS, Starting today For 6 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] EVERY 6 HOURS, Starting tomorrow For 4
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] EVERY 8 HOURS, Starting 4/6/17 For 7 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
FIBRINOGEN [GM1320] EVERY 4 HOURS, Starting today For 6 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
FIBRINOGEN [GM1320] EVERY 6 HOURS, Starting tomorrow For 4
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
FIBRINOGEN [GM1320] EVERY 8 HOURS, Starting 4/6/17 For 7 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BLOOD GASES AND O2 SATURATION - ECMO
Circuit, Post-Membrane [HCBGASOS]
EVERY 4 HOURS, Starting today For 6 Occurrences,
STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ECMO Circuit. Patient, post membrane.
Page 4 of 13
Printed by LIND, JANNA S [JSL237] at 4/4/2017 10:27:10 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

BLOOD GASES AND O2 SATURATION - ECMO
Circuit, Post-Membrane [HCBGASOS]
EVERY 6 HOURS, Starting tomorrow For 4
Occurrences, STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ECMO Circuit. Patient, post membrane.
BLOOD GASES AND O2 SATURATION - ECMO
Circuit, Post-Membrane [HCBGASOS]
EVERY 8 HOURS, Starting 4/6/17 For 7 Days, STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ECMO Circuit. Patient, post membrane.
BLOOD GASES AND O2 SATURATION -
ECMO Circuit, Pre-Membrane [HCBGASOS]
EVERY 4 HOURS, Starting today For 6 Occurrences,
STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ECMO Circuit. Patient, pre membrane.
BLOOD GASES AND O2 SATURATION - ECMO
Circuit, Pre-Membrane [HCBGASOS]
EVERY 6 HOURS, Starting tomorrow For 4
Occurrences, STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ECMO Circuit. Patient, pre membrane.
BLOOD GASES AND O2 SATURATION - ECMO
Circuit, Pre-Membrane [HCBGASOS]
EVERY 8 HOURS, Starting 4/6/17 For 7 Days, STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ECMO Circuit. Patient, pre membrane.
Every 8 Hours [106376]
CBC WITH DIFFERENTIAL [CBC] EVERY 8 HOURS, Starting today For 24 Hours,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] NEXT AM, Starting tomorrow For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PLATELET COUNT [PLT] EVERY 8 HOURS For 24 Hours, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
SPECIFIC GRAVITY, URINE, POC [HCSGPOC] EVERY 8 HOURS For 7 Days, Routine
If Conditional, What Condition?
Draw After Every Bowel Movement [106377]
Page 5 of 13
Printed by LIND, JANNA S [JSL237] at 4/4/2017 10:27:10 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

OCCULT BLOOD (IMMUNOASSAY),
DIAGNOSTIC, STOOL [IFOBTM]
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? Draw after every
bowel movement
Draw Daily After Day 3 [80191]
BUN [BUN] NEXT AM, Starting today For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CALCIUM [CA] NEXT AM, Starting today For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CBC WITHOUT DIFFERENTIAL [HEMO] NEXT AM, Starting today For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATININE [CRET] NEXT AM, Starting today For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] NEXT AM, Starting tomorrow For 7 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEMOGLOBIN [HGB] NEXT AM, Starting today For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PLATELET COUNT [PLT] NEXT AM, Starting tomorrow For 7 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
AST/SGOT [AST] NEXT AM, Starting today For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALT/SGPT [ALT] NEXT AM, Starting today For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BILIRUBIN, TOTAL [TBIL] NEXT AM, Starting today For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CBC WITH DIFFERENTIAL [CBC] NEXT AM, Starting tomorrow For 7 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 6 of 13
Printed by LIND, JANNA S [JSL237] at 4/4/2017 10:27:10 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

FIBRINOGEN [GM1320] NEXT AM, Starting tomorrow For 7 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CBC WITH DIFFERENTIAL [CBC] CONDITIONAL - RN COLLECT, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Concern for bleeding
GLUCOSE [GLU] NEXT AM, Starting today For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
MAGNESIUM [MAG] NEXT AM, Starting today For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PHOSPHATE [PHOS] NEXT AM, Starting today For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PLATELET COUNT [PLT] CONDITIONAL - RN COLLECT, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Concern for bleeding
Draw Once Every 24 Hours for Temperature Greater than 38.5 Degrees Celsius [31568]
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT, Starting today For 7
Days, 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 once every 24
hours for temperature greater than 38.5 degrees
Celsius
CULTURE, URINE [URC] CONDITIONAL - RN COLLECT, Starting today For 7
Days, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw once every 24
hours for temperature greater than 38.5 degrees
Celsius
Page 7 of 13
Printed by LIND, JANNA S [JSL237] at 4/4/2017 10:27:10 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

CULTURE, SPUTUM WITH GRAM STAIN
[HCSPUCS]
CONDITIONAL - RN COLLECT, Starting today For 7
Days, 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? Draw once every 24
hours for temperature greater than 38.5 degrees
Celsius
Draw Postprocedure Day 1 [31569]
CULTURE, SPUTUM WITH GRAM STAIN
[HCSPUCS]
ONCE, Starting tomorrow 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?
Blood Bank
Tests [145005]
TYPE AND SCREEN [HCTS] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, 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.
TYPE AND SCREEN [HCTS] EVERY 72 HOURS, Starting today, Routine, 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.
Analgesics [81358]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Oral, ONCE For 1 Doses
Premedication for blood product
Blood Products [12026]
Page 8 of 13
Printed by LIND, JANNA S [JSL237] at 4/4/2017 10:27:10 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@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):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Plasma (Adult) [BLB0003] Starting today, 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:
Consent Status:
Platelets (Adult) [BLB0004] 1 SINGLE, 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:
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):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Cryoprecipitate (Adult) [BLB0005] Starting today, 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:
Consent Status:
Fibrin Glue, mLs Needed:
Blood Product [12027]
Page 9 of 13
Printed by LIND, JANNA S [JSL237] at 4/4/2017 10:27:10 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@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):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Plasma (Pediatric) [BLB0010] Starting today, 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:
Consent Status:
Platelets (Pediatric) [BLB0011] Starting today, 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:
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):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Cryoprecipitate (Pediatric) [BLB0012] Starting today, 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:
Consent Status:
Page 10 of 13
Printed by LIND, JANNA S [JSL237] at 4/4/2017 10:27:10 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Transfusion [12028]
been ordered.ordering to transfuse a product, make sure the product is or has already If
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT, Starting today For 1
Occurrences, Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
Transfuse Plasma (Adult) [NURTRT0031] Starting today, Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at (608)
234-6600 as appropriate 30-60 minutes before
transfusion to prepare products.
Run Each Unit Over:
Transfuse Platelets (Adult) [NURTRT0030] TRANSFUSE 1 SINGLE, Starting today For 1
Occurrences, Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Call Blood Bank at 263-8367
30-60 minutes before transfusion to prepare products.
Run Each Unit Over:
Transfuse Cryoprecipitate (Adult) [NURTRT0032] Starting today, Routine, Patient Weight
No data found for Wt
Cryoprecipitate is stored frozen as 5 pooled units
(approx 120mL). Standard adult dose = 10 units.
Suggested dose = 1 unit/10 kg.
Individual cryoprecipitate units are also available for
fibrin glue (approx 10-15 mL each).
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at (608)
234-6600 as appropriate 30-60 minutes before
transfusion to prepare products.
Run Each Unit Over:
Fibrin Glue, mLs Needed:
Transfusion [12029]
been ordered.ordering to transfuse a product, make sure the product is or has already If
Page 11 of 13
Printed by LIND, JANNA S [JSL237] at 4/4/2017 10:27:10 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT, Starting today For 1
Occurrences, Routine, 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.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Transfuse Plasma (Pediatric) [NURTRT0037] Starting today, Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at (608)
234-6600 as appropriate 30-60 minutes before
transfusion to prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Transfuse Platelets (Pediatric) [NURTRT0036] Starting today, Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested dose
= 10-20 mL/kg body weight for neonatal and pediatric
patients. For patients greater than 60 kg, suggested
dose is 1 Single Donor Unit.
NURSING REMINDER: Call Blood Bank at 263-8367
30-60 minutes before transfusion to prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Transfuse Cryoprecipitate (Pediatric)
[NURTRT0038]
Starting today, Routine, Patient Weight
No data found for Wt
1 Cryoprecipitate Unit ~ 10-20 mL. Suggested dose: 1
Unit/10 kg body weight. If patient weighs less than 10
kg give 1 unit.
NURSING REMINDER: Call Blood Bank at 263-8367
30-60 minutes before transfusion to prepare products.
Run Over:
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [80193]
Page 12 of 13
Printed by LIND, JANNA S [JSL237] at 4/4/2017 10:27:10 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

ECG - 12 Lead [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
Position patient requires the assistance of an ECMO
Specialist
X-RAY CHEST AP VIEW [R71010] CONDITIONAL, Starting today, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Transport Method: Floor Determined/Entered
If Conditional, What Condition? Obtain daily at 0600
and as needed while patient is on ECMO
Position patient requires the assistance of an ECMO
Specialist
Position patient requires the assistane of an
ECMO Specialist [NURCOM0055]
CONTINUOUS, Starting today, Routine
Consults
Consults [31577]
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult: LE
ROM/Strengthening,Mobility Training
For ECMO patient. Check with ECMO Specialist and
nursing staff to verify which limb(s) can have ROM
done.
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE For 1 Occurrences, Routine
Reason for Occupational Therapy Consult: UE
ROM/Strengthening,ADL Training
Page 13 of 13
Printed by LIND, JANNA S [JSL237] at 4/4/2017 10:27:10 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org