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IP – Bronchiolitis – Pediatric – Admission [3902]

IP – Bronchiolitis – Pediatric – Admission [3902] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Bronchiolitis - Pediatric - Admission [3902]
Admission Status
Level of Care (Single Response) [186484]
*An admit patient order has already been written, but the level of care at which the patient
should be placed still needs to be identified.
Place Patient on General Care [ADT0018] General Care, has already been signed. This order
will ensure that the patient is placed at the
appropriate level of care.
Place Patient on Intermediate Care (IMC)
[ADT0018]
Intermediate Care, has already been signed. This
order will ensure that the patient is placed at the
appropriate level of care.
Place Patient on Intensive Care (ICU) [ADT0018] Intensive Care, has already been signed. This order
will ensure that the patient is placed at the
appropriate level of care.
Admit to Inpatient (Single Response) [188296]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically
necessary because of either an anticipated LOS >2
midnights, complexity and/or severity of illness, an
inpatient-only surgery, or a previously-authorized
inpatient stay. Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status (Single Response) [82665]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-only
surgery, or a previously-authorized inpatient stay.
Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Page 1 of 6
Printed by STRAKA, KEVIN F [KFS1] at 3/16/2017 4:53:52 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status (Single Response) [109203]
Admit To Inpatient Status [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-only
surgery, or a previously-authorized inpatient stay.
Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit To Observation Status [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Isolation Status
Respiratory Isolation [109204]
Isolation - Contact and Droplet - Respiratory
Infection - Acute, Infant/Child [ISO0045]
CONTINUOUS
Patient Care Orders
Vital Signs [109205]
Vital Signs [NURMON0013] SEE COMMENTS, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 2 hours X 2, then every 4 hours and PRN
Activity [109207]
Page 2 of 6
Printed by STRAKA, KEVIN F [KFS1] at 3/16/2017 4:53:52 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

Activity [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB: ad lib
AMBULATE:
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Nutrition [109208]
NPO except Medications [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: NPO
NPO Diet: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
Breast Feeding Mom [DIE0008] Please Provide Tray for Breast Feeding Mom: Yes
Routine, CONTINUOUS, Starting today
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Respiratory [109209]
Pulse Oximetry [NURMON0009] SEE COMMENTS, Starting today, Routine, Every 2
hours X 2, then every 4 hours and PRN
Respiratory Care Protocol - Bronchiolitis
[RT0067]
CONTINUOUS, Starting today, Routine
Nasal Cannula or Oxygen Therapy (Single Response) [218740]
Pediatric Bronchiolitis High Flow Nasal Cannula
(HFNC) Management- Emergency Dept./General
Care
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/respiratory/related/name-
113133-en.cckm
Oxygen Therapy [RT0032] CONTINUOUS, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Initiate oxygen therapy for SpO2 consistency less
than or equal to 90%. Titrate oxygen by 1/4 L to keep
SpO2 between 91-94%. Discontinue for oxygen
saturation greater than or equal to 94%.
High Flow Nasal Cannula [RT0071] CONTINUOUS, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 90 (and
flow)
Attempt to Wean Off Oxygen?
Intake and Output [109210]
Measure Intake And Output [NURMON0005] EVERY 4 HOURS, Routine
Non-Categorized Patient Care Orders [109211]
Measure Height - On Admission [NURMON0052] ONCE, Starting today For 1 Occurrences, Routine
Page 3 of 6
Printed by STRAKA, KEVIN F [KFS1] at 3/16/2017 4:53:52 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

Measure Weight - On Admission
[NURMON0015]
ONCE, Starting today For 1 Occurrences, Routine
Weigh With?
Weigh when?
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With?
Weigh when? AM
Supply - Little Sucker [SUP0001] Details
Perform nasal suction as needed and before
feedings [NURCOM0022]
CONTINUOUS
Contingency Paramaters for Patients Less than 7 Months of Age [109880]
Notify Provider [NURCOM0001] CONTINUOUS
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):
Pulse Oximetry < (%):
Other:
Contingency Parameters for Patients 7 Months to 3 Years of Age [109881]
Notify Provider [NURCOM0001] CONTINUOUS
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):
Pulse Oximetry < (%):
Other:
Contingency Parameters for Patients 3 to 7 Years of Age [188870]
Page 4 of 6
Printed by STRAKA, KEVIN F [KFS1] at 3/16/2017 4:53:52 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] CONTINUOUS
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):
Pulse Oximetry < (%):
Other:
Contingency Parameters for Patients 7 to 11 Years of Age [188871]
Notify Provider [NURCOM0001] CONTINUOUS
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):
Pulse Oximetry < (%):
Other:
Contingency Parameters for Patients 11 Years of Age and Older [188872]
Notify Provider [NURCOM0001] CONTINUOUS
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):
Pulse Oximetry < (%):
Other:
Intravenous Therapy
Premedication for Needle Insertion [30232]
Lidocaine [152737]
Page 5 of 6
Printed by STRAKA, KEVIN F [KFS1] at 3/16/2017 4:53:52 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, prior to needle
sticks to reduce pain. See "LMX Use Instructions"
order in Active Orders report or the Admin
Instructions for application details
FOR PATIENTS 5 Kg OR LESS: Do NOT apply to
area greater than 100 square centimeters.
(maximum 1 g/site; maximum 1 site per hour, 6
times per day).
FOR PATIENTS 5.1-10 Kg: Do NOT apply to area
greater than 100 square centimeters. (maximum 1
g/site; maximum 2 sites per hour, 6 times per day).
FOR PATIENTS GREATER THAN 10 Kg: Do NOT
apply to area greater than 200 square centimeters.
(maximum 2.5 g/site; maximum 4 sites per hour, 6
times per day).
For patients less than 1 year old do NOT leave on
longer than 1 hour. For patients 1 year or older do
NOT leave on longer than 2 hours
LMX Use Instructions for Premedication Prior to
Needle Insertion [NURCOM0095]
Details
IV Fluids [18098]
Consider NG tube placement for poor oral intake or dehydration.
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L
infusion [44910]
Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.9% infusion [51641] Intravenous, CONTINUOUS
dextrose 5%- NaCl 0.9% with KCl 20 mEq/L
infusion [44904]
Intravenous, CONTINUOUS
sodium chloride 0.9% BOLUS - NOTE:
Suggested dose 10-20 mL/kg [730003]
Intravenous, ONCE For 1 Doses
NOTE: Suggested dose 10-20 mL/kg
Medications
Analgesics/Antipyretics [108750]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 10-15
mg/kg/dose (Maximum 650 mg/dose) [800005]
Oral, EVERY 4 HOURS PRN, pain/fever
NOTE: Suggested dose 10-15 mg/kg/dose (Maximum
650 mg/dose)
acetaMINOPHEN (TYLENOL) suppository -
NOTE: Suggested dose 10-15 mg/kg /dose
(Maximum 650 mg/dose) [43994]
Rectal, EVERY 4 HOURS PRN, pain/fever
NOTE: Suggested dose 10-15 mg/kg/dose (Maximum
650 mg/dose)
Non-Categorized [108746]
sodium chloride (SALINE) 0.65% nasal spray
[41865]
1 spray, Nostril (Each), EVERY 1 HOUR PRN, Before
feedings, for increased work of breathing or before
inhalation therapy
Page 6 of 6
Printed by STRAKA, KEVIN F [KFS1] at 3/16/2017 4:53:52 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org