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IP – Whole Body Cooling-Therapeutic Hypothermia – Neonatal – Admission [4746]

IP – Whole Body Cooling-Therapeutic Hypothermia – Neonatal – Admission [4746] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Neonatal


SmartSet: IP - WHOLE BODY COOLING/THERAPEUTIC HYPOTHERMIA - NICU -
ADMISSION (ID:4746)
General Information
Display name: IP - Whole Body Cooling/Therapeutic Hypothermia - Neonatal - Admission
Type: General
Merge priority:
Version comment:
Content source:
Synonyms: 1. NICU
2. Neonate
3. Neonatal
4. Temp
5. Cooling
6. Admit
7. Admission
8. .NICU
9. .NEONATE
SmartSet notes:
Description:
Web information: Title URL
1. Policy 4.24P - Neonatal Whole Body
Cooling (Pediatric)
https://uconnect.wisc.edu/policies/clinical/uwhc-
clinical/department-specific/nursing-patient-
care/integumentary/424-p.policy
Questionnaire:
Configuration
Admission Status
Level of Care
Place Patient on General Care 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) 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) 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)
Admit To Inpatient Attending:
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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)
Admit To Observation Attending:
Admitting Resident:
Requested Floor:
Service:
Admit to Outpatient Short Stay (Single Response)
Admit To Outpatient Short Stay Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status
Admit To Inpatient 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 Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status
Admit To Inpatient Attending:
Admitting Resident:
Requested Floor:
Service: NEONATAL INTENSIVE 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:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit To Observation Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay Attending:
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Admitting Resident:
Requested Floor:
Service:
Isolation Status
Patient Care Orders
Vital Signs
Vital Signs SEE COMMENTS, Routine
Temperature Measurement Method: Other (Comment)
(Axillary, skin, and esophageal)
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 15 minutes times 2, then every 1 hour times 4, then
every 2 hours for duration of cooling (72 hours).
Assess Physiologic Systems ONCE, Once upon admission, then every 30 minutes times 2,
then every 3 hours and PRN.
Patient Monitoring
Cardio-Respiratory Monitor - Pediatric - With Rhythm
Cardio-Respiratory Monitor - Pediatric - With Rhythm 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 Provider to Notify: Provider
Notify based on:
Notify provider for apnea > 20 seconds
HeRO Monitoring CONTINUOUS, Routine
Notify Provider:
Functional Cardiac Defibrillator Present:
Pulse Oximetry - Pre Ductal Monitoring CONTINUOUS, Routine
High saturation limit:
Low saturation limit:
Measure pre ductal saturation on right upper extremity.
Pulse Oximetry - Post Ductal Monitoring CONTINUOUS, Routine
High saturation limit:
Low saturation limit:
Measure post ductal saturation on either lower extremity or
left upper extremity.
Measure Cerebral And Somatic Oximetry CONTINUOUS, Routine
Measure Length EVERY SUNDAY, Routine
Measure With? Length Board
Measure when?
Upon Admission
Measure Length EVERY 7 DAYS, Starting S+1, Routine
Measure With? Length Board
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Measure when? Other (Comment) (Every Sunday)
Measure Weight ONCE For 1 Occurrences, Routine
Weigh With?
Weigh when?
Upon Admission
Measure Weight - Daily 1X DAILY, Routine
Weigh With?
Weigh when?
Measure Head Circumference ONCE For 1 Occurrences, Routine, Upon Admission
Measure Head Circumference EVERY SUNDAY, Routine
Body Cooling/Re-Warming
Initiate Body Cooling CONTINUOUS For 72 Hours, Cool patient to 33.5 degrees C
for 72 hours. Rewarm at 72 hours. Record blanket water
temperature readings with every vital sign documentation.
Hyper/Hypothermia Machine CONTINUOUS, Routine
Activity
Elevate Head Of Bed Equal to (degrees):
Greater than (degrees):
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting S, Ventilator-Associated
Pneumonia Bundle elevate HOB 30 degrees for patients who
are endotracheally intubated
Reposition Patient Type:
Routine, SEE COMMENTS, Reposition patient every 3 hours
and PRN as tolerated to avoid skin break down
Nutrition
Diet - Neonatal - Strict NPO EFFECTIVE NOW, Starting S, Routine
NPO: STRICT NPO
Infant Nutrition Primary:
Infant Nutrition Secondary:
Fortification:
Calories per Ounce:
Route:
Route (Comments):
Frequency:
Frequency (Comments):
Total Volume per Feeding (mL):
Enteral Tube Placement - Neonatal
Insert and Maintain Orogastric/Nasogastric Tube CONTINUOUS, Routine
Check Residual:
Does this need to be inserted/placed? Yes
For tubes with 30 day dwell time, recheck for growth 2
weeks after placement.
X-RAY ABDOMEN AP VIEW (KUB) CONDITIONAL For 3 Days, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered by this
exam? Evaluate orogastric tube placement
Relevant recent/past history?
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 orogastric tube
placement. The location of orogastric 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
Is patient pregnant?
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Drain/Tube Care
Insert and Maintain Gastric Tube - Neonatal
Insert and Maintain Neonatal Tube for Gastric
Decompression
CONTINUOUS, Routine
Options:
Flush with: Sterile Water
Flush Frequency: PRN
Check Residual:
Does this need to be inserted/placed?
X-RAY ABDOMEN AP VIEW (KUB) ONCE-RAD NEXT AVAILABLE, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? Decompression tube
What specific question(s) would you like answered by this
exam? Placement
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
Respiratory
Provide Manual Resuscitator at Bedside CONTINUOUS, Routine
Respiratory Therapy - Neonatal
Suction Airway - Neonatal PRN, Starting S, Routine
Location: Other (Comment)
Per RN/RT discretion.
Oxygen Therapy - Neonatal CONTINUOUS, Starting S For Until specified, Routine
FiO2 (%):
Liter Flow:
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
High Flow Nasal Cannula - Neonatal CONTINUOUS, Starting S For Until specified, Routine
FiO2 (%):
Liter Flow:
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Non-Invasive Ventilation - Neonatal CONTINUOUS, Starting S, Routine, HOB 15 degrees
Ventilator Management: Per MD
Mode:
Set Rate/Min: 40
PEEP (cmH2O): 5
FiO2 (%):
Pressure Support:
PIP (Pressure Control + PEEP): 20
Peak Inspiratory Pressure:
Inspiratory Time: 0.5
Mechanical Ventilation - Neonatal CONTINUOUS, Starting S, 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 (%):
Pressure Support:
PIP (Pressure Control + PEEP):
Inspiratory Time:
High Frequency Oscillatory Ventilation (HFOV) CONTINUOUS, Starting S, Routine
FiO2 (%):
I-Time (%):
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MAP (cmH2O):
Hertz:
Delta P (cmH2O):
Intake and Output
Measure Intake EVERY 1 HOUR, Routine
Weigh Diapers CONTINUOUS, Routine, After each elimination
Non-Categorized Patient Care Orders
Insert and Maintain Urinary Catheter 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:
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Newborn Hearing Screen ONCE, Routine, Notify Care Team Leader to perform hearing
screen.
Complete order when screen has been performed.
Notify Provider if patient refers twice on Newborn Hearing
Screen. Provider to order Outpatient Audiology Screening.
Contingency Parameters
Notify 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): 200
If heart rate < (bpm): 60
If respiratory rate >: 85
If respiratory rate <: 20
If blood glucose > (mg/dL):
If blood glucose < (mg/dL): 50
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL): 1 mL/kg/hr
Other: Symptomatic for hypoglycemia,Unable to maintain
saturation within target range,If saturation outside of target
range,If mean arterial pressure > ***,If mean arterial pressure
< ***,If blood glucose < 50 mg/dL or > 200 mg/dL or if patient
is symptomatic for hypoglycemia
Intravenous Therapy
IV Fluids
Insert and Maintain Peripheral IV CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
heparin in sodium chloride 0.9 % 50 mL patency line Intraarterial, CONTINUOUS
neonatal arterial solution Intraarterial, CONTINUOUS
neonatal arterial trophamine 3% - heparin Intraarterial, CONTINUOUS
neonatal venous maintenance solution Intravenous, CONTINUOUS
dextrose 10 % infusion Intravenous, CONTINUOUS
sodium chloride 0.9 % infusion Intravenous, CONTINUOUS
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Medications
Medications
MORPHine PF injection Intravenous
phenobarbital injection - Not to exceed 1 mg/kg/minute.
Max of 30 mg/min for infants
Intravenous
Anti-Infectives
ampicillin (OMNIPEN) intraVENOUS 100 mg/kg, Intravenous
cefotaxime (CLAFORAN) intraVENOUS 50 mg/kg, Intravenous
gentamicin (GARAMYCIN) intraVENOUS Intravenous
Continuous Infusions
DOBUTamine (DOBUTREX) infusion PEDS Intravenous, CONTINUOUS
DOPamine (INTROPIN) infusion PEDS Intravenous, CONTINUOUS
epiNEPHrine infusion PEDS Intravenous, CONTINUOUS
FENTanyl (SUBLIMAZE) infusion PEDS Intravenous, CONTINUOUS
midazolam (VERSED) infusion PEDS Intravenous, CONTINUOUS
MORPHine infusion PEDS 0.01 mg/kg/hr, Intravenous, CONTINUOUS
Birth Medications
erythromycin (ROMYCIN) ophthalmic ointment Eyes (Each)
phytonadione (VITAMIN K1) injection - For infants < 1.5
kg
0.3 mg/kg, Intramuscular, ONCE For 1 Doses
phytonadione (VITAMIN K1) injection - For infants 1.5
kg or more
1 mg, Intramuscular, ONCE For 1 Doses
Immunizations and Immunoglobulins
hepatitis B vaccine (ENGERIX-B) 10 mcg/0.5 mL vial
SUSP - For HEP B positive mothers
10 mcg, Intramuscular, ONCE For 1 Doses
If mother is HepBSAg positive = Hepatitis B Immune Globulin
give by age 8 hours. If mother's HBsAg status is unknown
AND baby is less than 2000 g, give by age 12 hours.
Oral Analgesia
sucrose (SWEET-EASE) 24% buccal soln Oral, PRN, pain, mild pain or potentially painful procedures.
See Admin Instructions
Breast Milk for Painful Procedure Reason for Breast Milk: Pain
Other Medications
vitamin A (AQUASOL A) 50000 UNIT/ML injection 5,000 units, Intramuscular, EVERY MON, WED, FRI For 12
Doses
poractant alfa (CUROSURF) neb susp Endotracheal, ONCE For 1 Doses
sodium chloride flush 0.9% 2.5 mL injection Flush, PRN, flush/line care
sodium chloride flush 0.9% 10 mL injection Flush, PRN, flush/line care
heparin lock flush 1 UNIT/ML injection 1-5 units, Flush, EVERY 8 HOURS PRN, flush/line care
Laboratory
Whole Blood Testing on Unit
Glucose, POC SEE COMMENTS, Routine, Glucose, POC should always be
ordered in conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition?
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Obtain with every lab draw and signs/symptoms of
hypo/hyperglycemia. May result on Nova meter or ABL90.
GLUCOSE, WHOLE BLOOD CONDITIONAL - RN COLLECT For 7 Days, STAT
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
With every Whole Blood lab draw
BLOOD GASES AND O2 SATURATION STAT - RN COLLECT For 1 Occurrences, STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
ELECTROLYTES, WHOLE BLOOD 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?
CALCIUM, IONIZED, WHOLE BLOOD STAT - RN COLLECT For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
HEMOGLOBIN, WHOLE BLOOD STAT - RN COLLECT For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
LACTATE STAT - RN COLLECT For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
BILIRUBIN, TOTAL, WHOLE BLOOD 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?
Must send tube to core lab
NICU Nutrition Lab Panel
NICU Nutrition Lab Panel
BUN NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
CREATININE NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
CALCIUM NEXT AM 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 NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
AST/SGOT NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
GLUCOSE NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
ALT/SGPT NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
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BILIRUBIN, TOTAL NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
BILIRUBIN, DIRECT NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
ALBUMIN NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
ALKALINE PHOSPHATASE NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
TRIGLYCERIDE NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
GGT NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
C REACTIVE PROTEIN NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
MAGNESIUM NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
PHOSPHATE NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Labs
BUN 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?
CREATININE 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?
MAGNESIUM 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?
PHOSPHATE 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?
ALBUMIN 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?
PROTEIN, TOTAL 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?
AMMONIA STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
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previous specimen?
If Conditional, What Condition?
Transport specimen to laboratory immediately. Whole blood
specimen must arrive in the Core Lab within 30 minutes of
collection if not on ice pack. If in question, transport on ice
pack. Transport frozen plasma on dry ice if coming from
outreach location.
TROPONIN 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?
BILIRUBIN, TOTAL 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?
BILIRUBIN, DIRECT 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?
AST/SGOT 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?
ALT/SGPT 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?
ALKALINE PHOSPHATASE 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?
C REACTIVE PROTEIN 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?
NEONATAL SCREEN STAT - RN COLLECT For 1 Occurrences, Routine, This test
is to be used for a complete Wisconsin State Newborn
Screen. Do not use to order other testing to be collected
using dried blood spots.
Last patient weight? (will auto pull in value and date in
comment):
Has pt EVER been transfused? (If YES enter date of last
transufsion below):
Date of Last Transfusion:
Date of last newborn screen:
Timing of Collection (See WSLH Collection Info reference link
below):
CBC WITH DIFFERENTIAL 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?
URINALYSIS WITH MICROSCOPY 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?
ORGANIC ACIDS, URINE STAT - RN COLLECT For 1 Occurrences, Routine
Clinical History/ Reason for Testing:
Is infant on formula?
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Cultures
CULTURE, BLOOD, BACTERIA AND YEAST STAT - RN COLLECT For 1 Occurrences, Routine, For
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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, SPUTUM WITH GRAM STAIN 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?
CULTURE, URINE WITH GRAM STAIN ONCE For 1 Occurrences, Routine
Indication:
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
MRSA BY PCR CONDITIONAL - RN COLLECT For 7 Days, Nares, L and R,
Routine, There is no need to obtain repeated surveillance
tests to clear patients from MRSA isolation. Once a patient is
flagged as MRSA positive it will remain in the HealthLink
header indefinitely.
For NICU patients: left and right nares only.
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Perform on all patients. Patient must be 48 hours of age for
initial screen.
Cerebral Spinal Fluid
CELL COUNT, CSF STAT - RN COLLECT For 1 Occurrences, Routine, Please
indicate if specimen source is CSF, lumbar puncture, or
ventricular shunt fluid.
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
CULTURE, CSF, AER WITH GRAM STAIN 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?
PROTEIN, CSF 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?
GLUCOSE, CSF 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?
LACTATE, CSF STAT - RN COLLECT For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Coagulation
PROTHROMBIN TIME/INR 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?
PTT STAT - RN COLLECT For 1 Occurrences, Routine
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If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
FIBRINOGEN 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?
D-DIMER, QUANT 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?
FIBRIN MONOMER 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?
Blood Bank
Tests
TYPE AND SCREEN, NEONATAL 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?
Blood Products
Red Blood Cells (Neonatal) < 1 UNIT For 1 Occurrences, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to 60
minutes from the time nursing notifies the Blood Bank to
prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Uncrossmatched **WARNING** Requesting MD verifies that
the clinical situation is sufficiently urgent to require release of
blood before completion of compatibility testing and agrees to
hold UWHC harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be pre-
selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during the first four
months of life
CMV Negative (Heart/Lung Transplant and Neonates up to 4
Months Only) (May be pre-selected based on history): Yes
Volume-Reduced (May be pre-selected based on history):
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV safe).
1 Red Blood Cell Unit ~ 350 mL.
Plasma (Neonatal) < 1 UNIT For 1 Occurrences, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to 60
minutes from the time nursing notifies the Blood Bank to
prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Patient Weight
No data found for Wt
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REMINDER: Call Blood Bank at 263-8367 30-60 minutes
before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Platelets (Neonatal) < 1 SINGLE DONOR UNIT For 1 Occurrences, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to 60
minutes from the time nursing notifies the Blood Bank to
prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be pre-
selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during the first four
months of life
CMV Negative (Heart/Lung Transplant and Neonates up to 4
Months Only) (May be pre-selected based on history): Yes
Volume-Reduced (May be pre-selected based on history):
Patient Weight
No data found for Wt
For refractory patients, call UWHC Blood Back at (608) 263-
8307 or The American Center Lab at (608) 234-6600 as
appropriate 30-60 minutes (at UWHC) or 2-3 hours (at The
American Center) before transfusion to prepare products.
Suggested dose = 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 40 kg, suggested
dose is 1 Single Donor Unit. 1 Single Donor Unit = 200-250
mL. All platelet products are leukocyte-reduced (CMV safe).
NURSING REMINDER: Call UWHC Blood Bank at (608) 263-
8367 or The American Center Lab at (608) 234-6600 as
appropriate 30-60 minutes (at UWHC) or 2-3 hours (at The
American Center) before transfusion to prepare products.
Cryoprecipitate (Neonatal) 1 UNIT For 1 Occurrences, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to 60
minutes from the time nursing notifies the Blood Bank to
prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60 minutes
before transfusion to prepare products.
Cryoprecipitate is stored frozen as individual units
(approximately 10-15mL) or as 5 pooled units (approximately
120mL). Suggested guideline = 1 unit/10 kg.
Transfusion
Transfuse Red Blood Cells (Neonatal) ONCE, Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
Total Volume to be transfused (mL):
Transfuse Plasma (Neonatal) ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60 minutes
before transfusion to prepare products.
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1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
Transfuse Platelets (Neonatal) ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60 minutes
before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
Transfuse Cryoprecipitate (Neonatal) ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60 minutes
before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging
X-RAY CHEST AP VIEW ONCE-RAD NEXT AVAILABLE 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?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
X-RAY ABDOMEN AP VIEW (KUB) ONCE-RAD NEXT AVAILABLE For 1 Occurrences, Routine
Radiology Specialty Area: GENERAL IMAGING
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
X-RAY BABYGRAM (PEDS CHEST/ABD COMBINED-
LESS THAN 2 YEARS)
ONCE-RAD NEXT AVAILABLE For 1 Occurrences, Routine
Radiology Specialty Area: GENERAL IMAGING
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
aEEG ONCE For 1 Occurrences, Routine
Reason for Monitoring: Background and Seizures
aEEG/CEEG/Video EEG ONCE For 1 Occurrences, Routine
Reason for Monitoring:
Sleep deprived?
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Duration:
Has a Neurology Consult been obtained? (If no, obtain a
Neurology Consult prior to ordering the procedure):
Transthoracic Resting Echocardiogram (PEDS) ONCE For 1 Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by this
exam?
Relevant recent/past history?
To whom can we send the results of the study? (include
clinician and location):
Last patient height? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date in
comment):
US INTRACRANIAL ONCE-RAD NEXT AVAILABLE, Routine
Current signs and symptoms?
What specific question(s) would you like answered by this
exam?
Relevant recent/past history?
For scheduling purposes, does the patient require general
anesthesia, sedation or anxiolytics? Note: ordering provider is
responsible for prescribing oral anxiolytics or arranging peds
anesthesia / sedation services. See reference link above.
If being performed remotely, where?
Transport Method: Floor Determined/Entered
MR SPECTROSCOPY SINGLE VOXEL ONCE-RAD NEXT AVAILABLE 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?
Study Needed Within:
Does patient have a pacemaker or defibrillator?
Allergy to Gadolinium (MRI) contrast?
For Scheduling purposes, is the patient claustrophobic or
require any form of sedation? Note: ordering provider is
responsible for prescribing oral anxiolytic or ordering sedation
services.
For scheduling purposes, does the patient require general
anesthesia, sedation or anxiolytics? Note: ordering provider is
responsible for prescribing oral anxiolytics or arranging peds
anesthesia / sedation services. See reference link above.
Relevant Surgical History (Select all applicable or None):
Implanted Devices? (Select all applicable or None):
History of Metal in Body? (Select all applicable or None):
Has patient had a colonoscopy/endoscopy in the last 8
weeks?
Last creatinine value? (will auto pull in date and value in
comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date in
comment):
Last patient height? (will auto pull in value and date in
comment):
Transport Method:
Consults
Consults
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Consult Social Work (Inpatient) ONCE For 1 Occurrences, Routine
Reason for Consult: OTHER (Evaluate and treat)
Consult Lactation Consultant ONCE For 1 Occurrences, Routine, Patient's assigned RN is
to arrange for the Lactation Consultant or designee to
complete the consult.
Reason for Consult: Other (Evaluate and treat)
Consult Speech Therapy ONCE For 1 Occurrences, Routine
Reason for Consult: Evaluate and treat
Consult Physical Therapy ONCE For 1 Occurrences, Routine
Reason for Consult: Other (comment) (Evaluate and treat)
Consult Occupational Therapy ONCE For 1 Occurrences, Routine
Reason for Consult: Other (comment) (Evaluate and treat)
Consult Case Management (Inpatient) ONCE For 1 Occurrences, Routine
Reason for Consult: OTHER (Evaluate and treat)
Consult Pediatric Health Psychology (Inpatient) ONCE, Routine, Please notify consulting provider if patient
needs to be seen same day (Monday-Friday) or if special
assessment needs.
Reason for Consult: Evaluate and treat
Consult Spiritual Care (Inpatient) ONCE For 1 Occurrences, Routine
Reason for Consult: Evaluate and treat
Consult Neonatal Ophthalmology (Inpatient) ONCE
Reason for Consult:
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Consult Infectious Disease (Inpatient) ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): For HIV exposed infants or
mothers who receive no antepartum antiretroviral prophylaxis
Consult Angle Tolerance Test (Inpatient) ONCE For 1 Occurrences, Routine
Reasons / indications for test: Physiologic immaturity (i.e.,
hypotonia, cardio-respiratory complications, Down's
syndrome, congenital neuromuscular disorders, craniofacial
anomalies, or congenital heart defects)
Provider to Notify: Provider
If heart rate < (bpm): 80
Pulse Oximetry < (%): 90
If bradycardia >= (sec): 10
If desaturation >= (sec): 10
If apnea >= (sec): 20
Consult Pediatric Nutrition Support (Inpatient) ONCE
Intent: Consult and Recommend (Write Orders)
Reason for Consult: Initiate Parenteral Nutrition
Consult Pediatric Neurology (Inpatient) ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Call back number:
Best Practice
No Hospital Problems Have Yet Been Identified.
Specify Hospital Problem(s) You will be prompted to specify a hospital problem on signing.
Criteria
Suggestions: UWIP C LOGIN DEPT IPPED NEONATAL INTENSIVE CARE[3001764]
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Filter: UWIP ORDER SET RESTRICTOR - IP AND PEDS - NOT IP DC[3000404]
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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