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/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98265-en.cckm

201710275

page

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UWHC,UWMF,

Tools,

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

IP – Basic – Intensive Care – Pediatric – Admission [5395]

IP – Basic – Intensive Care – Pediatric – Admission [5395] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Basic - Intensive Care - Pediatric - Admission [5395]
Admission Status
Level of Care (Single Response) [226553]
*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) [109515]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: CRITICAL CARE
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: Critical Care
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Page 1 of 10
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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

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) [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:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Isolation Status
Isolation Status [152666]
Isolation - Contact And Droplet - Respiratory
Infection - Acute - Panel [116343]
Isolation - Contact and Droplet - Respiratory
Infection - Acute [ISO0045]
CONTINUOUS
Isolation Cart [EQP0016] CONTINUOUS, Routine
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [154455]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
Sequential Compression Device (SCD) Panel
(TREATMENT AND SUPPLY) [206111]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral (Unless
contraindicated. Use nursing judgement.)
Use venous foot pumps if SCDs are too big.
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type:
Use venous foot pumps if SCDs are too big
Patient Care Orders
Vital Signs [152883]
Page 2 of 10
Printed by WILLIAMS, HEATHER R [HRS0] at 9/29/2017 2:27:31 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Vital Signs [NURMON0013] EVERY 1 HOUR, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Patient Monitoring [152884]
Cardio-Respiratory Monitor - Pediatric - With
Rhythm [227558]
Cardio-Respiratory Monitor - Pediatric - With
Rhythm [NURMON0014]
CONTINUOUS, Routine, Most pediatric patients do
NOT require rhythm analysis. Please complete the
Notify Provider order below, including specification
for apnea > *** seconds. If indicated, order pulse
oximetry separately.
Device Present:
Device Mode:
Device Low Rate Limit (BPM):
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Notify [NURCOM0001] Provider to Notify: Provider
Notify based on:
Notify provider for apnea > 20 seconds
Measure Central Venous Pressure
[NURMON0002]
CONTINUOUS, Starting today For Until specified,
Routine
Measure Cerebral and Somatic Oximetry
[NURMON0060]
CONTINUOUS, Starting today For Until specified
Measure Intracranial Pressure [NURMON0040] CONTINUOUS, Starting today For Until specified,
Routine
Assess Neurologic Status - Every 1 Hour
[NURMON0006]
EVERY 1 HOUR, Starting today For Until specified,
Routine
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today, Routine
Measure Height - On Admission [NURMON0052] ONCE For 1 Occurrences, Routine, On Admission
Measure Weight - Daily [NURMON0015] 1X DAILY, Starting today at 4:00 AM, Routine
Weigh With?
Weigh when? AM (4am)
Measure weight daily for: Infants under the age of 6
months or less than 5 kilograms; patients on diuretics
to achieve a negative fluid balance; patients with acute
renal; cardiac or pulmonary disease, patients on
dialysis or hemofiltration; patients with vomiting,
diarrhea, DI, SIADH.
Note: If nursing staff does not feel performing a
weight on a patient can be done safely or poses a risk
to a patient, they should communicate this direcly with
the attending physician.
Activity [19358]
Page 3 of 10
Printed by WILLIAMS, HEATHER R [HRS0] at 9/29/2017 2:27:31 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Bedrest [NURACT0008] CONTINUOUS, Starting today For Until specified,
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:
Elevate Head Of Bed [NURACT0002] Equal to (degrees):
Greater than (degrees):
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting today
Nutrition [152885]
Tube Feeding Management - Refer to "Tube Feeding - Supplemental Order Set"
Parenteral Nutrition Management - Refer to "Parenteral Nutrition - Supplemental Order Set"
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 Milk Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: Bottle Feeding
Products (Infant): Human milk
Caloric Density:
Bottle Feed Diet: Bottle Feeding with Breastfeeding
Nipple Type:
Bedside Meal Instructions:
Room Service Class:
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Respiratory [152886]
Provide Manual Resuscitator at Bedside [RT0039] CONTINUOUS, Starting today For Until specified,
Routine
Oxygen Therapy [RT0032] CONTINUOUS, Starting today For Until specified,
Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%: 93
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Page 4 of 10
Printed by WILLIAMS, HEATHER R [HRS0] at 9/29/2017 2:27:31 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

High Flow Nasal Cannula [RT0071] CONTINUOUS, Starting today For Until specified,
Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%: 93
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
Attempt to Wean Off Oxygen? Yes
Incentive Spirometry [NURTRT0018] EVERY 2 HOURS, Routine, Instruct patient to do on
their own every 10 minutes while awake.
Intake and Output [19371]
Measure Intake And Output [NURMON0005] EVERY 1 HOUR For Until specified, Routine
Non-Categorized Patient Care Orders [152905]
Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, Routine, To discontinue this order,
enter a new order for "Discontinue Urinary Catheter".
To modify this order, enter a new order for "Maintain
Urinary Catheter" and make the necessary changes in
the new order.
Type: Indwelling Single Lumen
Indication for Placement: Monitor Volume in ICU
Patient and Unable to Use Alternative Methods
Initiate Urinary Catheter Removal Protocol? (NP/PA
Must Select "No"):
Details: To Dependent Drainage
Does this need to be inserted/placed?
NG Tube Placement - Pediatric [226565]
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 5 of 10
Printed by WILLIAMS, HEATHER R [HRS0] at 9/29/2017 2:27:31 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

X-RAY ABDOMEN AP VIEW (KUB) [R74000] CONDITIONAL For 3 Days, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? New NG placement,
ICU patient
What specific question(s) would you like answered
by this exam? Evaluate nasogastric tube placement
Relevant recent/past history? ICU patient with new
NG
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
Maintain Gastrostomy Tube For Decompression
[NURTAD0007]
CONTINUOUS, Routine
Tube Indications:
Flush With:
Flush Volume (mL):
Flush Frequency:
Site Assessment Frequency:
Care Frequency:
Wash With:
Primary Dressing:
Secondary Dressing:
Contingency Parameters [152887]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 100
If systolic blood pressure < (mmHg): 65
If diastolic blood pressure > (mmHg): 65
If diastolic blood pressure < (mmHg): 45
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 180
If heart rate < (bpm): 90
If respiratory rate >: 50
If respiratory rate <: 25
If blood glucose > (mg/dL): 200
If blood glucose < (mg/dL): 80
Pulse Oximetry < (%): 95
Other: Chest tube output is greater than *** mL/hour
Contingency Parameters [152888]
Page 6 of 10
Printed by WILLIAMS, HEATHER R [HRS0] at 9/29/2017 2:27:31 PM
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): 118
If systolic blood pressure < (mmHg): 85
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If temperature < (C):
If heart rate > (bpm): 160
If heart rate < (bpm): 80
If respiratory rate >: 40
If respiratory rate <: 20
If blood glucose > (mg/dL): 200
If blood glucose < (mg/dL): 80
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other: Chest tube output is greater than *** mL/hour
Contigency Parameters [152889]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 118
If systolic blood pressure < (mmHg): 87
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If temperature < (C):
If heart rate > (bpm): 140
If heart rate < (bpm): 75
If respiratory rate >: 30
If respiratory rate <: 18
If blood glucose > (mg/dL): 200
If blood glucose < (mg/dL): 80
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other: Chest tube output is greater than *** mL/hour
Contingency Parameters [152890]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 125
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 120
If heart rate < (bpm): 70
If respiratory rate >: 24
If respiratory rate <: 14
Pulse Oximetry < (%): 93
Other: Chest tube output is greater than *** mL/hour
If temperature < (C):
If blood glucose > (mg/dL): 200
If blood glucose < (mg/dL): 80
If pain score >:
If urine output < (mL):
Contingency Parameters for Patients [152891]
Page 7 of 10
Printed by WILLIAMS, HEATHER R [HRS0] at 9/29/2017 2:27:31 PM
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): 140
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If temperature < (C):
If heart rate > (bpm): 110
If heart rate < (bpm): 60
If respiratory rate >: 22
If respiratory rate <: 12
If blood glucose > (mg/dL): 200
If blood glucose < (mg/dL): 80
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other: Chest tube output is greater than *** mL/hour
Intravenous Therapy
IV Fluids [154509]
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% with KCl 20 mEq/L
infusion [44910]
Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.9% infusion [51641] Intravenous, CONTINUOUS
sodium chloride 0.9% infusion [64367] Intravenous, CONTINUOUS
Premedication for Needle Insertion [226572]
Lidocaine [152737]
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
Medications
Analgesics - Acetaminophen - PRN (Single Response) [152894]
Page 8 of 10
Printed by WILLIAMS, HEATHER R [HRS0] at 9/29/2017 2:27:31 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 10-15
mg/kg/dose (Maximum 650 mg/dose) [800005]
10 mg/kg, Oral, EVERY 4 HOURS PRN, pain/fever,
Temp greater than 38.5C or mild to moderate pain
Temperature greater than 38.5 C or pain
NOTE: Suggested dose 10-15 mg/kg/dose (Maximum
650 mg/dose)
acetaMINOPHEN (TYLENOL) tab [34149] Oral, EVERY 4 HOURS PRN, pain, Temp greater than
38.5C or mild to moderate pain
acetaMINOPHEN (TYLENOL) suppository
[43994]
Rectal, EVERY 6 HOURS PRN, pain/fever, Temp
greater than 38.5C or mild to moderate pain
Sucrose for Oral Analgesia [152896]
sucrose (SWEET-EASE) 24% buccal soln
[794009]
Oral, PRN, pain, mild pain or potentially painful
procedures. See Admin Instructions
Laboratory
Conditional Labs [190962]
Lab Schedule [NURCOM0022] CONTINUOUS
BLOOD GASES AND O2 SATURATION
[HCBGASOS]
CONDITIONAL, STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? per lab schedule
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? per lab schedule
ELECTROLYTES, WHOLE BLOOD
[HCWBLYTS]
CONDITIONAL, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? per lab schedule
CALCIUM, IONIZED, WHOLE BLOOD
[HCWBICA]
CONDITIONAL, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? per lab schedule
HEMOGLOBIN, WHOLE BLOOD [HCWBHGB] CONDITIONAL, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? per lab schedule
LACTATE [GM2255] CONDITIONAL, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? per lab schedule
Diagnostic Tests and Imaging
Studies [19381]
X-RAY CHEST AP VIEW - STAT [R71010] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, STAT
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Transport Method: Floor Determined/Entered
BestPractice
No Hospital Problems Have Yet Been Identified. [107035]
Page 9 of 10
Printed by WILLIAMS, HEATHER R [HRS0] at 9/29/2017 2:27:31 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing.
Page 10 of 10
Printed by WILLIAMS, HEATHER R [HRS0] at 9/29/2017 2:27:31 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org