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IP – Tube Feeding – Pediatric – Supplemental [4293]

IP – Tube Feeding – Pediatric – Supplemental [4293] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


SmartSet: IP - TUBE FEEDING - PEDIATRIC - SUPPLEMENTAL (ID:4293)
General Information
Display name: IP - Tube Feeding - Pediatric - Supplemental
Type: General
Merge priority: 0
Version comment:
Content source:
Synonyms: 1. TUBE FEEDING
2. .OTHER
3. .SUPPLEMENTAL
4. .PEDS
SmartSet notes:
Description:
Web information:
Title URL
1. Pediatric Enteral Nutrition Guidelines for
Tube Feeding
https://uconnect.wisc.edu/clinical/references/clinical-
nutrition-resources/nutrition-guidelines-and-enteral-
formularies/resources/name-33916-en.file
Questionnaire:
Configuration
Patient Care Orders
Patient Monitoring - General
Glucose, POC AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Routine
If Conditional, What Condition?
Patient Monitoring - Cotinuous Tube Feeding
Glucose, POC EVERY 6 HRS IF NPO/ CONT. TUBE FEEDING/ OR TPN,
Starting S For 48 Hours, Routine
If Conditional, What Condition?
Patient Monitoring - Tube Feeding Bolus
Glucose, POC 30 MINUTES BEFORE CYCLIC TUBE FEEDING, Starting S
For 48 Hours, Routine
If Conditional, What Condition?
Patient Monitoring - Gastric Feedings
For Gastric Feedings SEE COMMENTS, Starting S, - Measure and document
residual every 4 hours for 48 hours
- Hold tube feeding for 1 hour if residual greater than 250
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison


milliliters
- Recheck residual after 1 hour and restart tube feeding at
previous rate if residual is less than 250 milliliters
- Restart tube feeding at previous rate if residual is less than
250 milliliters
- Notify Physician if tube feeding residual is still greater than
250 milliliters
Patient Monitoring - Small Bowel Feeding
For Small Bowel Feeding SEE COMMENTS, Starting S, - Monitor GI tolerance closely
- Hold tube feeding if there are sudden changes in abdominal
exam, GI function, or hemodynamic status
Notify Provider
Notify Provider 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): 150 during the first 48 hours of
tube feeding administration
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other:
Nutrition
Diet
Tube Feeding With Tray EFFECTIVE NOW, Starting S, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison


Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail): TUBE FEEDING WITH TRAY;
Tube Feeding Management:
Room Service Class:
Tube Feeding No Tray EFFECTIVE NOW, Starting S, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail): TUBE FEEDING NO TRAY;
Tube Feeding Management:
Room Service Class: RS3-ROOM SERVICE NON-SELECT
Tube Feeding With PN EFFECTIVE NOW, Starting S, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison


Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail): TUBE FEEDING WITH TNA;
Tube Feeding Management:
Room Service Class:
Tube Feeding Strict NPO EFFECTIVE NOW, Starting S, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail): TUBE FEEDING STRICT NPO
Tube Feeding Management:
Room Service Class:
Tube Feeding NPO Except Medications EFFECTIVE NOW, Starting S, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison


Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail): TUBE FEEDING NPO EXCEPT MEDICATIONS
Tube Feeding Management:
Room Service Class:
Tube Feeding NPO With Ice Chips EFFECTIVE NOW, Starting S, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail): TUBE FEEDING NPO WITH ICE CHIPS
Tube Feeding Management:
Room Service Class:
Tube Feeding NPO With Sips of Water EFFECTIVE NOW, Starting S, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison


Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail): TUBE FEEDING NPO WITH SIPS OF WATER
Tube Feeding Management:
Room Service Class:
Tube, Nasojejunal, J-tube (DOBHOFF or JEJUNOSTOMY)
Tube Feeding, Continuous EFFECTIVE NOW, Starting S, Routine
Products (Adult / Adolescent / Pediatric):
Products (Infant):
Continuous Start Rate: *** mL/hr
Advance Rate by: *** mL/hr
Advance Rate Frequency: ***
Continuous Goal Rate: *** mL/hr
Flush With: ***
Flush Volume: *** mL
Flush Frequency: ***
Tube Feeding, Cyclic EFFECTIVE NOW, Starting S, Routine
Products (Adult / Adolescent / Pediatric):
Products (Infant):
Rate: *** mL/hr
Start Time: ***
End Time: ***
Flush With: ***
Flush Volume: *** mL
Flush Frequency: ***
Tube, Nasogastric, Gastrostomy, Percutaneous Endoscopic Gastrostomy, (PEG-Tube)
Tube Feeding, Continuous EFFECTIVE NOW, Starting S, Routine
Products (Adult / Adolescent / Pediatric):
Products (Infant):
Continuous Start Rate: *** mL/hr
Advance Rate by: *** mL/hr
Advance Rate Frequency: ***
Continuous Goal Rate: *** mL/hr
Flush With: ***
Flush Volume: *** mL
Flush Frequency: ***
Tube Feeding, Cyclic EFFECTIVE NOW, Starting S, Routine
Products (Adult / Adolescent / Pediatric):
Products (Infant):
Rate: *** mL/hr
Start Time: ***
End Time: ***
Flush With: ***
Flush Volume: *** mL
Flush Frequency: ***
Tube Feeding, Bolus EFFECTIVE NOW, Starting S, Routine
Products (Adult / Adolescent / Pediatric):
Products (Infant):
Initial Bolus Volume: *** mL
Advance Volume By: *** mL
Bolus Frequency: ***
Goal Bolus Volume: *** mL
Free Water: ***/day
Special Instructions: ***
Laboratory
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison


Laboratory
ELECTROLYTES NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
ELECTROLYTES EVERY MONDAY AND THURSDAY, Starting S with First
Occurrence As Scheduled For 4 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Consults
Consults
Consult Nutrition (Inpatient) ONCE, Starting S For 1 Occurrences, Routine
Reason for Consult:
Delegate to Initiate and Manage Tube Feeding:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
Initiation of tube feeding
Consult Surgical Nutrition Support (Inpatient) ONCE
Intent: Consult and Recommend (Write Orders)
Reason for Consult:
Initiation of tube feeding.
Consult Diabetes Management (Inpatient) ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Initiation of tube feeding for
patients being followed by diabetes management
Criteria
Suggestions: UWIP C LOGIN DEPT IP PEDIATRICS[3001746]
Filter: UWIP ORDER SET RESTRICTION - HOSPITAL ENCOUNTERS EXCEPT ED - NOT IP DC
[3000400]
Restrict SmartSet:
Settings
Discontinue action:
Deselect sections for
Pended/Held orders:
Pended/Held orders display:
Release date: Use System Definitions Setting
Disallow user override:
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison