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201707209

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IP - Surgical Bowel Preparation - Pediatric - Supplemental [1426]

IP - Surgical Bowel Preparation - Pediatric - Supplemental [1426] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Surgical Bowel Preparation - Pediatric - Supplemental [1426]
Patient Care Orders
Nutrition [19753]
Clear Liquid Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: Diet Modifications
Diet Modifications: Liquid
Liquid: Clear Liquid
No Red or Purple Dye:
Liquid Thickness:
Bedside Meal Instructions:
Room Service Class:
NPO [NUT9999] EFFECTIVE MIDNIGHT, Starting tomorrow at 12:01
AM, Routine
Patient Type: Pediatric
Diet Type: NPO
NPO Diet: Strict NPO
Bedside Meal Instructions:
Room Service Class:
Non-Categorized Patient Care Orders [19754]
NG Tube Placement - Pediatric [121658]
Insert and Maintain Nasogastric Tube
[NURTAD0014]
CONTINUOUS, Routine
Options:
Flush with:
Flush Frequency: EVERY 8 HOURS
Clamp NG Tube:
Check Residual:
Does this need to be inserted/placed?
Device Status:
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 3
Printed by O'BRIEN, RYLEY P [RPO249] at 7/28/2017 8:17:03 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@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
Feeding Tube Placement Request [NURDIE0015] ONCE, Starting today For 1 Occurrences, Routine
Feeding Tube Placement Reason: Medication
Administration
Feeding Tube Placement: Gastric
Insertion Point: Nasal
Allow removal of existing orogastric or nasograstric
tube?
Insert nasogastric feeding tube for patient unable or
unwilling to drink fluids.
Contigency Parameters [19755]
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: Bowel effluent not clear after GI lavage
(GOLYTELY) completed.,Persistent
emesis,Abdominal distention,Respiratory distress.
Stop bowel prep if persistent emesis, abdominal
distention or respiratory distress.
Intravenous Therapy
IV Fluids [19946]
dextrose 5%-NaCl 0.2% with KCl 20 mEq/L
infusion [44909]
Intravenous, CONTINUOUS
Start with initiation of bowel prep
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L
infusion - NOTE: Order for patients 10 kg or
greater and having urologic procedure [44910]
Intravenous, CONTINUOUS
Start with initiation of bowel prep
NOTE: Order for patients 10 kg or greater and having
urologic procedure
Page 2 of 3
Printed by O'BRIEN, RYLEY P [RPO249] at 7/28/2017 8:17:03 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
07/2017CCKM@uwhealth.org

Medications - Bowel Prep
Bowel Prep (Single Response) [19948]
G.I. lavage (GOLYTELY) soln - NOTE: Order for
patients 7.6-10 kg [103976]
1,100 mL, Oral, ONCE For 1 Doses
Give 80 mL orally every 10 minutes for a total dose up
to 1100 mL
NOTE: Order for patients 7.6-10 kg
G.I. lavage (GOLYTELY) soln - NOTE: Order for
patients 10.1-20 kg [103976]
1,600 mL, Oral, ONCE For 1 Doses
Give 100 mL orally every 10 minutes for a total dose
up to 1600 mL
NOTE: Order for patients 10.1-20 kg
G.I. lavage (GOLYTELY) soln - NOTE: Order for
patients 20.1-30 kg [103976]
2,200 mL, Oral, ONCE For 1 Doses
Give 140 mL orally every 10 minutes for a total dose
up to 2200 mL
NOTE: Order for patients 20.1-30 kg
G.I. lavage (GOLYTELY) soln - NOTE: Order for
patients 30.1-40 kg [103976]
2,900 mL, Oral, ONCE For 1 Doses
Give 180 mL orally every 10 minutes for a total dose
up to 2900 mL
NOTE: Order for patients 30.1-40 kg
G.I. lavage (GOLYTELY) soln - NOTE: Order for
patients 40.1-50 kg [103976]
3,200 mL, Oral, ONCE For 1 Doses
Give 200 mL orally every 10 minutes for a total dose
up to 3200 mL
NOTE: Order for patients 40.1-50 kg
G.I. lavage (GOLYTELY) soln - NOTE: Order for
patients greater than 50 kg [103976]
4,000 mL, Oral, ONCE For 1 Doses
Give 240 mL orally every 10 minutes for a total dose
up to 4000 mL
NOTE: Order for patients greater than 50 kg
Note: GI Lavage (GOLYTELY) By Feeding Tube
For Patients Less Than 7.5 Kg [950018]
ONCE For 1 Doses
GI lavage (GOLYTLELY) *** mL/hr (Suggested dose
12.5 mL/kg/hr) by feeding tube times 4 hours.
Administer by enteral pump
Note: GI lavage (GOLYTLELY) By Gravity for
Patients Less Than 7.5 Kg [950018]
ONCE For 1 Doses
GI lavage (GOLYTLELY) *** mL/hr (Suggested dose
12.5 mL/kg/hr) by feeding tube times 4 hours.
Administer by gravity
Bowel Sterilization [19949]
erythromycin ethylsuccinate (EES) 200 MG/5ML
susp - NOTE: Suggested dose 20 mg/kg/dose
(max 1g/dose) [37239]
20 mg/kg, Oral, EVERY 2 HOURS For 3 Doses
Begin after GI lavage completed
neomycin 25 mg/mL soln - NOTE: Suggested
dose 20 mg/kg/dose (max 1g/dose) [780249]
20 mg/kg, Oral, EVERY 2 HOURS For 3 Doses
Begin after GI lavage completed
Enemas [19951]
Sodium chloride 0.9% enema 10 mL/kg
(Maximum 500 mL) rectally once until clear.
Administer after GI lavage complete
[NURTRT0048]
ONCE
Sodium chloride 0.9% enema 10 mL/kg
(Maximum 500 mL) per ostomy once until clear.
Administer after GI lavage complete
[NURTRT0048]
ONCE, Starting today For 1 Occurrences
BestPractice
No Hospital Problems have yet been identified. [107035]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing.
Page 3 of 3
Printed by O'BRIEN, RYLEY P [RPO249] at 7/28/2017 8:17:03 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
07/2017CCKM@uwhealth.org