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/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98266-en.cckm

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

IP – Advanced – Intensive Care – Pediatric – Admission [5408]

IP – Advanced – Intensive Care – Pediatric – Admission [5408] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Advanced - Intensive Care - Pediatric - Admission [5408]
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) [151587]
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: Critical Care
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Page 1 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 9/25/2017 1:36:50 PM
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 [152659]
Page 2 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 9/25/2017 1:36:50 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 [152647]
Cardio-Respiratory Monitor - Pediatric - With
Rhythm [139419]
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 Arterial Blood Pressure [NURMON0019] CONTINUOUS, Routine
BP Source:
BP Location: Arterial
BP Position:
BP Restrictions:
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 [152660]
Page 3 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 9/25/2017 1:36:50 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
Spinal Precautions [151599]
Thoracic/Lumbar Spine Precautions
[PRECAU0009]
CONTINUOUS, Starting today For Until specified,
Routine, Thoracic/Lumbar Spine Precautions:
Head of bed less than 30 degrees unless otherwise
stated.
Head of bed flat for log rolling side to side., Position
Patient - Reverse Trendelenberg.
Cervical Spine Precautions [PRECAU0005] CONTINUOUS, Starting today For Until specified,
Routine, Cervical Spine Precautions:
Cervical collar at all times.
No pillow behind head.
No lifting anything greater than 10 pounds.
No lifting of arms over head., Inspect skin under collar
and change pads every 24 hours and as needed
Use log roll for turning patient
Nutrition [152661]
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:
Page 4 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 9/25/2017 1:36:50 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Respiratory [152650]
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 ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
High Flow Nasal Cannula [RT0071] CONTINUOUS, Starting today For Until specified,
Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
Attempt to Wean Off Oxygen? Yes
CPAP Continuous [RT0009] Routine
PEEP (cmH2O):
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Titrate oxygen to maintain O2 sat at (%):
Self Administered (Only RT may document in this box
after patient assessment): RT Approval Required
Biphasic Positive Airway Pressure (BIPAP)
[RT0004]
Routine
Mode:
IPAP (cm H2O):
EPAP (cm H2O):
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Set Rate/Min:
Titrate oxygen to maintain O2 sat at (%):
Self Administered (Only RT may document in this box
after patient assessment): RT Approval Required
Mechanical Ventilation - Pediatric [147629]
Chlorhexidine.patients 1 year of age and older SELECT the order for For
chlorhexidine (PERIDEX) 0.12 % soln
MULTIDOSE - NOTE: For Patients 1 year of age
or older [792004]
15 mL, Mouth/Throat, 2 X DAILY
Use to swab oral cavity. D/C when patient no longer
on ventilation.
Provide Manual Resuscitator at Bedside
[RT0039]
CONTINUOUS, Routine
Page 5 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 9/25/2017 1:36:50 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Mechanical Ventilation - Peds [RT0090] Routine, For patients 6 years and older order
chlorihexidene gluconate (PERIDEX) 0.12% soln 15
mL to swab oral cavity 2x daily while on ventilation.
Ventilator Management: Per MD
Wean Peds: Per MD
Mode:
Set Rate/Min:
Tidal Volume Multiplier: 7 (ml/kg)
PEEP (cmH2O):
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Pressure Support:
Pressure Control:
P High (cmH20):
P Low (PEEP) (cmH20):
T High (sec):
T Low (T PEEP) (sec):
PS above P High (cmH2O):
PS above PEEP (cmH2O):
NAVA Level (µV):
artificial tears PF ophthalmic ointment [157764] Eyes (Each), PRN, Irritation
Adminster to each eye every 2-4 hours as needed.
For use while patient is mechanically ventilated and
sedated. Please refer to ocular care algorithm.
Ventilator Associated Peneumonia (VAP
Precautions) [NURCOM0022]
SEE COMMENTS, Ventilator Associated Pneumonia
Precautions
Suction Airway [NURTAD0017] PRN, Routine
Location: Tracheal
ETCO2 Monitoring [RT0006] CONTINUOUS, Routine
Mechanical Ventilation - Neonatal [RT0080] Routine, For ADULT patients order chlorihexidene
gluconate (PERIDEX) 0.12% soln 15 mL to swab oral
cavity 2x daily while on ventilation.
Ventilator Management:
Mode:
Volume Guarantee:
Set Rate/Min:
Tidal Volume (mL) (4-6 mL/kg of Ideal Body Weight for
neonatal):
PEEP (cmH2O):
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Pressure Support:
PIP (Pressure Control + PEEP):
Inspiratory Time:
NAVA Level (µV):
Ventilator Associated Event (VAE) Precautions
[NURCOM0022]
SEE COMMENTS, Ventilator Associated Events
Precautions.
Suction Airway [NURTAD0017] PRN, Starting today For Until specified, Routine
Location: Tracheal
Respiratory Therapy per Protocol [RT0035] Routine
Protocol Type: Neuromuscular
Neuromuscular Disorder Protocol
Intake and Output [152662]
Measure Intake And Output [NURMON0005] EVERY 1 HOUR For Until specified, Routine
Non-Categorized Patient Care Orders [152649]
Page 6 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 9/25/2017 1:36:50 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

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:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Maintain Arterial Line [NURVAD0001] CONTINUOUS, Routine
Device Status:
Flush Solution:
Site:
Check and document patency, tubing change, site
assessment, and dressing change per policy.
NG Tube Placement - PICU [226007]
Insert and Maintain Nasogastric Tube - PICU
[NURTAD0014]
CONTINUOUS, Routine
Options:
Flush with:
Flush Frequency:
Clamp NG Tube:
Check Residual:
Does this need to be inserted/placed?
Device Status:
X-RAY ABDOMEN AP VIEW (KUB) [R74000] ONCE-RAD NEXT AVAILABLE, Routine
Radiology Specialty Area:
Current signs and symptoms? New enteral tube
placement in PICU patient
What specific question(s) would you like answered
by this exam? Verify new enteral tube placement in
PICU patient
Relevant recent/past history? New enteral tube
placement in PICU patient
If being performed remotely, where?
Last patient weight? (will auto pull in value and date
in comment):
Transport Method:
If Conditional, What Condition?
Is patient pregnant?
Maintain Gastrostomy Tube For Decompression -
Closed [NURTAD0007]
CONTINUOUS, Starting today, Routine
Drainage Options: None
Flush With: Water
Flush Volume (mL):
Flush Frequency:
Site Assessment Frequency:
Care Frequency:
Wash With:
Primary Dressing:
Secondary Dressing:
Feeding Tube Placement Request [NURDIE0015] ONCE, Starting today, Routine
Feeding Tube Placement Reason:
Feeding Tube Placement:
Insertion Point:
Allow removal of existing orogastric or nasograstric
tube?
Page 7 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 9/25/2017 1:36:50 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Maintain Chest Tube [NURTAD0001] CONTINUOUS, Starting today For Until specified,
Routine
Location:
Position: N/A - Single Location
Drainage Options:
Site Assessment Frequency:
Care Frequency:
Wash With:
Primary Dressing:
Secondary Dressing:
Contingency Parameters [151617]
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 [152663]
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
Contingency Parameters [152664]
Page 8 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 9/25/2017 1:36:50 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): 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 [151621]
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 [152665]
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
Page 9 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 9/25/2017 1:36:50 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

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
IV Fluids - Special [152667]
this listContact unit pharmacist for assistance in ordering fluids not found on NOTE:
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS
dextrose 5%- NaCl 0.9% with KCl 20 mEq/L
infusion [44904]
Intravenous, CONTINUOUS
dextrose 10%-NaCl 0.2% with KCl 20 mEq/L
infusion [710000]
Intravenous, CONTINUOUS
NOTE: Equivalent to dextrose 10%-NaCl 0.2% with
KCl 20 mEq/L infusion
dextrose 10%-NaCl 0.45% infusion [710000] Intravenous, CONTINUOUS
Equivalent to dextrose 10%-NaCl 0.45% infusion
dextrose 10%-NaCl 0.45% with KCl 20 mEq/L
infusion [710000]
Intravenous, CONTINUOUS
NOTE: Equivalent to dextrose 10%-NaCl 0.45% with
KCl 20 mEq/L infusion
dextrose 10%-NaCl 0.9% infusion [700590] Intravenous, CONTINUOUS
dextrose 10%- NaCl 0.9% with KCl 20 mEq/L
infusion [710000]
Intravenous, CONTINUOUS
CUSTOM maintenance fluid [710000] Intravenous, CONTINUOUS
Flushes [152668]
patency line fluid in 0.9 % sodium chloride 50mL
syringe PEDS - Arterial Line Flush [700923]
Intraarterial, CONTINUOUS
Infusion rate: 1 mL/hr for patients weighing 10kg and
under
3 mL/hr for patients weighing greater than 10kg
patency line fluid in 0.9 % sodium chloride 50mL
syringe PEDS - Central Venous Pressure Line
Flush [700923]
Intravenous, CONTINUOUS
Infusion rate: 1 mL/hr for patients weighing 10kg and
under
3 mL/hr for patients weighing greater than 10kg
Premedication for Needle Insertion [30232]
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
Page 10 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 9/25/2017 1:36:50 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

LMX Use Instructions for Premedication Prior to
Needle Insertion [NURCOM0095]
Details
Medications
Analgesics/Antipyretics (Single Response) [151614]
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
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg
First Line for temperature greater than 38.5 C or pain
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
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg
Temperature greater than 38.5 C or pain - If unable to
tolerate PO
NOTE: Suggested dose 10-15 mg/kg/dose (Maximum
650 mg/dose)
Non-categorized [154499]
artificial tears PF ophthalmic ointment [157764] Eyes (Each), EVERY 4 HOURS
Sucrose for Oral Analgesia [110384]
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 - RN COLLECT, 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 - RN COLLECT, 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 - RN COLLECT, 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 - RN COLLECT, 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 - RN COLLECT, 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 - RN COLLECT, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? per lab schedule
Laboratory [152648]
URINALYSIS WITH MICROSCOPY [UA] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 11 of 13
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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

CULTURE, BLOOD, BACTERIA/YEAST (2
SITES) [116728]
.Practices for Blood Culturing Best This order equals 2 sites (4 bottles). See link below for
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
ONCE For 1 Occurrences, Routine, For optimum
diagnosis of sepsis, sample 3-4 sites only on the first
day of a septic episode. Cultures on subsequent
days are of minimal diagnostic value. Culture
detects bacteria, Candida and Cryptococcus. If
filamentous fungi are suspected see Culture, Blood,
Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition?
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
ONCE For 1 Occurrences, Routine, For optimum
diagnosis of sepsis, sample 3-4 sites only on the first
day of a septic episode. Cultures on subsequent
days are of minimal diagnostic value. Culture
detects bacteria, Candida and Cryptococcus. If
filamentous fungi are suspected see Culture, Blood,
Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition?
CULTURE, URINE [URC] ONCE For 1 Occurrences, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CULTURE, SPUTUM WITH GRAM STAIN
[HCSPUCS]
ONCE For 1 Occurrences, Routine, For patients with
an ET tube or tracheostomy, quantitative mini-BAL by
RT or bronchoscopic BAL are the preferred methods
of specimen collection.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Diagnostic Tests and Imaging
Studies [152669]
X-RAY CHEST AP VIEW AM BEDSIDE [R71010] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
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
Page 12 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 9/25/2017 1:36:50 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Routine
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?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
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 13 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 9/25/2017 1:36:50 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org