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IP - Venous Access Team - PICC Placement Request - Pediatric - Supplemental [1429]

IP - Venous Access Team - PICC Placement Request - Pediatric - Supplemental [1429] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Venous Access Team - PICC Placement Request - Pediatric - Supplemental
[1429]
PICC Placement Request
PICC Placement Request [17753]
PICC Placement Request [NURVAD0051] ONCE, Starting today For 1 Occurrences, Routine
PICC Line Placement Reason:
PICC Line Placement Duration:
Mastectomy? No
Dialysis Graft/Shunt?
Thrombosis?
Existing Venous Access Device(s)?
Number of Lumens:
Do Not Use:
Do Not Use Reason:
Medications - Premedications
Premedications [19892]
lidocaine (LMX 4) 4% cream - NOTE: Order for
patients weighing 5 kg or less [59741]
Topical, ONCE For 1 Doses
Apply to single site. Do NOT apply to area greater
than 100 square centimeters (Maximum 1 g/site;
maximum 1 site)
lidocaine (LMX 4) 4% cream - NOTE: Order for
patients weighing 5.1 - 10 kg [59741]
Topical, ONCE For 1 Doses
Apply to each site. Do NOT apply to area greater than
100 square centimeters (Maximum 1 g/site; maximum
2 sites)
lidocaine (LMX 4) 4% cream - NOTE: Order for
patients weighing more than 10 kg [59741]
Topical, ONCE For 1 Doses
Apply to each site. Do NOT apply to area greater than
200 square centimeters (Maximum 2.5 g/site;
maximum 4 sites)
lidocaine 1 % vial - NOTE: Do not use if history of
allergy to lidocaine [39034]
Subcutaneous, ONCE For 1 Doses
Sucrose for Oral Analgesia [110669]
sucrose (SWEET-EASE) 24% buccal soln
[794009]
Oral, PRN, pain, mild pain or potentially painful
procedures. See Admin Instructions
Patient Care Orders - Post PICC Placement
Catheter Care [19806]
Replace All IV Tubing Before Connecting to New
PICC [NURVAD0053]
ONCE, Starting today For 1 Occurrences
Maintain PICC [NURVAD0050] CONTINUOUS, Starting today, Routine
Device Status: Not Ready For Use
Site:
PICC Secured With: Statlock (Change with Routine
Dressing Changes)
Flush With(Must also enter separate medication order
to obtain drug):
Site Assessment Frequency: EVERY 4 HOURS
Provide Patient Education "Preparing and Caring
for Your Midline or PICC Catheter" (HFFY#5093)
[NURCOM0025]
ONCE, Starting today For 1 Occurrences, Routine
Contingency Parameters [17755]
Notify Venous Access Team (pager # 5151)
[NURCOM0022]
ONCE, Notify venous access team for catheter
migration and/or malposition of catheter noted on
x-ray
Medications - Post PICC Placement
Page 1 of 2
Printed by WILLIAMS, HEATHER R [HRS0] at 7/28/2017 9:41:28 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Flushes - NOTE: Order saline flush for heparin-induced thrombocytopenia or heparin allergy (Single
Response) [19893]
sodium chloride 0.9% flush 10 mL injection
[785055]
Flush, PRN, flush/line care
Flush per VAD guidelines
NOTE: Order saline flush for heparin-induced
thrombocytopenia or heparin allergy. Suggested dose
3-5 mL/dose
heparin lock flush 10 units/mL 5 mL injection
[75031]
1-150 units, Flush, PRN, flush/line care
Heparin/lock per VAD guidelines
NOTE: Suggested dose 30-50 units/dose
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [17759]
X-RAY CHEST AP VIEW [R71010] CONDITIONAL, Starting today For 3 Days, Routine
Current signs and symptoms? s/p PICC line
placement
What specific question(s) would you like answered by
this exam? Evaluate PICC Tip Termination and/or for
retained guidewire
Relevant recent/past history? s/p PICC line placement
Is patient pregnant?
If being performed remotely, where? Bedside
Transport Method: Floor Determined/Entered
If Conditional, What Condition? Evaluate PICC Tip
Termination and/or for retained guidewire
Last patient weight? (will auto pull in value and date in
comment):
Consults
Consults [24621]
Consult Venous Access Team (Inpatient)
[CON0124]
ONCE, Starting today For 1 Occurrences, Routine
Reason for consult: PICC Placement
Consult Child Life Specialist (Inpatient)
[CON0014]
ONCE, Starting today For 1 Occurrences, Routine
Activity Level:
Reason for Consult:
Can this consult be done via video?
Page 2 of 2
Printed by WILLIAMS, HEATHER R [HRS0] at 7/28/2017 9:41:28 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org