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/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98225-en.cckm

201709263

page

100

UWHC,UWMF,

Tools,

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

IP - Paracentesis - Bedside - Adult - Pre/Postprocedure [2469]

IP - Paracentesis - Bedside - Adult - Pre/Postprocedure [2469] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Paracentesis - Bedside - Adult - Pre/Postprocedure [2469]
for Adult Patients OnlyIntended
Paracentesis - The New England Journal of
Medicine 2006;355:e21 (November 9, 2006)
URL: http://content.nejm.org/cgi/reprint/355/19/e21.pdf
Patient Care Orders - Preprocedure
Vital Signs - Preprocedure [80288]
Vital Signs [NURMON0013] ONCE, Starting today For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Prior to procedure.
Non-Categorized Patient Care Orders [80289]
Void Prior to Procedure [NURELM0061] ONCE, Starting today For 1 Occurrences
Confirm Signed Consent on Chart
[NURCOM0022]
ONCE, Starting today For 1 Occurrences
PARACENTESIS (PERFORMED BY BEDSIDE
PROCEDURE SERVICE) [NWIP0010]
ONCE
Reason for Exam:
Diagnostic, Therapeutic or Both:
Provider Call-back Number:
To be performed at bedside.
ABDOMINAL PARACENTESIS W GUIDANCE
(PERFORMED IN INTERVENTIONAL
RADIOLOGY) [R49083]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Is this Diagnostic, Therapeutic, or Both?
Radiology Specialty Area: ULTRASOUND
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
For Scheduling purposes, is the patient claustrophobic
or require any form of sedation? Note: ordering
provider is responsible for prescribing oral anxiolytic or
ordering sedation services.
Is patient on anticoagulation therapy? If yes, specify
coagulation disorder and current medications in
comments box at bottom.
Transport Method: Floor Determined/Entered
To be performed at bedside.
Pre-procedure Medications
Preprocedure Medications [148238]
lidocaine 1 % vial [39034] ONCE For 1 Doses
Laboratory - Preprocedure
Laboratory [80273]
Page 1 of 6
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

PROTHROMBIN TIME/INR [PT] 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?
HEMATOCRIT [HCT] 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?
PLATELET COUNT [PLT] 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?
Patient Care Orders - Postprocedure
Vital Signs [80295]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Once after procedure and as needed.
Activity [80296]
Bed Rest for 1 Hour, Then Ad Lib [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: other (comment)
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
For 1 hour, then ad lib.
Site Care [80297]
Inspect Puncture Site [NURWND0018] SEE COMMENTS, Starting today, Once after
procedure, then every 8 hours times 24 hours.
Contingency Parameters [80298]
Page 2 of 6
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

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):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Pain not controlled with ordered analgesics or
ordered interventions
Medications - Postprocedure
Albumin [103471]
(approximately 6 g/L of 25% dose is determined by the volume of ascites fluid removed Albumin
fluid removed).
3.9 liters are removed, follow the instructions of the ordering provider to determine need for -If 2
albumin (approximately 6 g/L fluid removed). The instructions are located in the paracentesis
procedure orders.
albumin human 25% infusion - NOTE: Maximum
Dose = 100 g [44037]
Intravenous, ONCE For 1 Doses
Hang to gravity. Albumin tubing needed.
Document lot number of all doses given in comments
section of MAR
Laboratory - Postprocedure-Common Ascitic Fluid Labs
Laboratory [80789]
Paracentesis URL: http://content.nejm.org/cgi/reprint/355/19/e21.pdf
Fluid Volume Removed
(liters)
Albumin 25% Dose
(grams)
0-1.9 Do not administer
albumin
2-3.9 Follow instructions of
ordering provider to
determine the need for
albumin
4-4.9 25
5-6.9 37.5
7-8.9 50
9-10.9 62.5
11-12.9 75
13-14.9 87.5
Greater than or equal to 15 100
Page 3 of 6
Printed by O'BRIEN, RYLEY P [RPO249] at 9/19/2017 9:53:11 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Nursing Communication - Lab [NURCOM0055] ONCE, Starting today For 1 Occurrences, Routine,
Peritoneal fluid specimens to be labeled STAT &
immediately hand-carried to the lab. Follow Policy
#5.06 Acceptance Policy for Specimen Identification.
Routine - Peritoneal Fluid [80790]
CELL COUNT, PERITONEAL FLUID [HCPECC] ONCE, Starting today For 1 Occurrences, Routine
Indicate specimen source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CULTURE, BODY FLUID, AER/ANA WITH
GRAM STAIN [HCWABF]
ONCE, Starting today For 1 Occurrences, Routine,
UWHC Only: Use blood culture bottles for peritoneal,
pericardial, pleural, synovial and dialysate fluids.
Indicate source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Laboratory - Postprocedure - Serum Labs
Simultaneous Draw - Peritoneal Fluid/Serum [80792]
ALBUMIN, PERITONEAL FLUID [HCPEALB] ONCE, Starting today For 1 Occurrences, Routine
Indicate specimen source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
To calculate serum-ascites albumin gradient.
ALBUMIN [ALB] ONCE, 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?
To calculate serum-ascites albumin gradient.
LD, TOTAL, PERITONEAL FLUID [HCPELD] ONCE, Starting today For 1 Occurrences, Routine
Indicate specimen source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Laboratory - Postprocedure - Optional Peritoneal Fluid Labs
Optional - Peritoneal Fluid [80793]
ADENOSINE DEAMINASE, PERITONEAL FLUID
[HCADEPERI]
ONCE, 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?
BILIRUBIN, TOTAL, PERITONEAL FLUID
[HCPETBIL]
ONCE, Starting today For 1 Occurrences, Routine
Indicate specimen source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTEIN, PERITONEAL FLUID [HCPEP] ONCE, Starting today For 1 Occurrences, Routine
Indicate specimen source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
AMYLASE, PERITONEAL FLUID [HCPEAMYL] ONCE, Starting today For 1 Occurrences, Routine
Indicate specimen source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 4 of 6
Printed by O'BRIEN, RYLEY P [RPO249] at 9/19/2017 9:53:11 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

GLUCOSE, PERITONEAL FLUID [HCPEGLUC] ONCE, Starting today For 1 Occurrences, Routine
Indicate specimen source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CULTURE, FUNGAL, WITH SMEAR
[HCFCULTS]
ONCE, Starting today For 1 Occurrences, Routine,
Smears not routinely performed on CSF. If CSF,
order Culture, Fungal.
Indicate source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
TRIGLYCERIDE, PERITONEAL FLUID
[HCPETRIG]
ONCE, Starting today For 1 Occurrences, Routine
Indicate specimen source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CYTOLOGY, PERITONEAL FLUID [HCPATHM] ONCE, For any questions please refer to U-Connect
Test Directory or contact UWHC Cytology at (608)263-
3205.
Specimen Source Description/Laterality: Peritoneal
Fliud
Please indicate laterality if appropriate:
Method of Collection - Urine specimens only:
Other cytology tests not related to malignancy:
Clinical History:
CHOLESTEROL, PERITONEAL FLUID
[HCPECHOL]
ONCE, Starting today For 1 Occurrences, Routine
Indicate specimen source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATININE, PERITONEAL FLUID
[HCPECRET]
ONCE, Starting today For 1 Occurrences, Routine
Indicate specimen source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
UREA, PERITONEAL FLUID [HCPEUREA] ONCE, Starting today For 1 Occurrences, Routine
Indicate specimen source if other: Peritoneal Fluid
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
AFB SMEAR AND CULTURE [130496]
AFB SMEAR [AFBSMR] ONCE 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 5 of 6
Printed by O'BRIEN, RYLEY P [RPO249] at 9/19/2017 9:53:11 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

AFB CULTURE [AFBCX] ONCE For 1 Occurrences, Routine, Smear and
culture should be ordered for diagnostic specimens.
M. avium complex PCR is performed on the first
smear positive respiratory specimen from patients
not previously diagosed with tuberculosis.
Susceptibility testing is performed automatically on
all initial M. tuberculosis isolates. Susceptibility
testing for some non-tuberculous mycobacteria is
available.
The initial M. tuberculosis isolate from each patient is
also genotyped as part of the CDC Universal
Genotyping Program.
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
Airborne Isolation - Measles [ISO0327] What is the Reason for the Isolation?
Page 6 of 6
Printed by O'BRIEN, RYLEY P [RPO249] at 9/19/2017 9:53:11 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org