/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/inpatient/,/clinical/cckm-tools/content/order-sets/inpatient/neurosciences/,

/clinical/cckm-tools/content/order-sets/inpatient/neurosciences/name-98140-en.cckm

201606170

page

100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Neurosciences

IP - Ketogenic Diet Admission - Pediatric [3313]

IP - Ketogenic Diet Admission - Pediatric [3313] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Neurosciences


IP - Ketogenic Diet Initiation - Pediatric - Admission [3313]
Admission Status
Admission Status (Single Response) [7248]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
Expected Discharge Date:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Expected Discharge Date:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Expected Discharge Date:
Isolation Status
If patient requires Isolation, please search for isolation in the additional orders section below.
Patient Care Orders
Vital Signs [99989]
Vital Signs [NURMON0013] EVERY 4 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Pediatric Early Warning Signs [NURMON0060] SEE COMMENTS, Starting today, Every 4 Hours.
Activity [99992]
Ad Lib [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:
Activity [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE: ad lib
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Bed Rest [NURACT0008] CONTINUOUS, Starting today, Routine
Page 1 of 7
Pr i nted by STRAKA, KEVIN F [KFS1] at 9/5/2013 10:57:49 AM
Copyright © 2013 University of Wisconsin Hospital and Clinics Authority


AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: strict bedrest
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Activity [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR: ad lib
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Nutrition [99993]
Refer to "Parenteral Nutrition - Pediatric - Supplemental" Order Set
Refer to "Tube Feeding - Supplemental" Order Set
Ketogenic Diet [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic: KETOGENIC;
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail):
Tube Feeding Management:
Room Service Class:
Respiratory [99995]
Pulse Oximetry [NURMON0009] EVERY 4 HOURS, Starting today, Routine, With vital signs.
Page 2 of 7
Pr i nted by STRAKA, KEVIN F [KFS1] at 9/5/2013 10:57:49 AM
Copyright © 2013 University of Wisconsin Hospital and Clinics Authority


Pulse Oximetry Continuous [NURMON0009] CONTINUOUS, Starting today, Routine
Intake and Output [99996]
Measure Intake And Output [NURMON0005] EVERY 4 HOURS, Starting today, Routine
Patient Monitoring [99991]
Measure Height [NURMON0052] ONCE, Starting today For 1 Occurrences, Routine, On
admission.
Measure Weight [NURMON0015] ONCE, Starting today For 1 Occurrences, Routine
Weigh With?
Weigh when?
On admission.
Assess Neurologic Status [NURMON0006] EVERY 4 HOURS, Starting today, Routine
Cardio-Respiratory Monitor - Pediatric - Without Rhythm
[139420]
Cardio-Respiratory Monitor - Pediatric - Without Rhythm
[NURMON0074]
CONTINUOUS, Starting today, Routine
Device Present:
Device Mode:
Device Low Rate Limit (BPM):
Notify Provider:
Notify [NURCOM0001] 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):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other:
Notify provider for apnea > 20 seconds
Seizure Precautions [PRECAU0002] CONTINUOUS, Starting today, Routine
Glucose Point of Care Orders [100677]
Glucose, POC [IPGLUCOSE] SEE COMMENTS, Starting today, Routine
If Conditional, What Condition?
Every 2 hours if less than 1 year of age; Every 4 hours if
greater than 1 year of age
Non-Categorized Patient Care Orders [99997]
Urinary Catheterization-Intermittent [NURELM0018] PRN, Starting today, Routine
URINALYSIS, MICROSCOPY ONLY, POC
[HCUAMPOC]
AFTER EACH VOID, Starting today, Routine
If Conditional, What Condition?
Ketones
SPECIFIC GRAVITY, URINE, POC [HCSGPOC] PRN, Starting today, Routine
If Conditional, What Condition?
With every void.
Contingency Parameters [99998]
Notify Provider [NURCOM0001] 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): 38.2 degrees Celsius OR 38.0 degrees
Celsius if sustained for over one hour
If temperature < (C):
If heart rate > (bpm): ***
Page 3 of 7
Pr i nted by STRAKA, KEVIN F [KFS1] at 9/5/2013 10:57:49 AM
Copyright © 2013 University of Wisconsin Hospital and Clinics Authority


If heart rate < (bpm): ***
If respiratory rate >: ***
If respiratory rate <: ***
If blood glucose > (mg/dL):
If blood glucose < (mg/dL): 50
If pain score >:
Pulse Oximetry < (%): 95
If urine output < (mL):
Other: Patient has more than 3 diarrheal stools per day
Notify Unit Dietitian of Patient's Arrival [NURCOM0022] ONCE, Starting today For 1 Occurrences
Notify Pharmacy of Patient's Arrival [NURCOM0022] ONCE, Starting today For 1 Occurrences
Intravenous Therapy
IV Fluids [100496]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today, Routine
Peripheral IV Device:
Peripheral IV Location:
Peripheral IV Size:
Peripheral IV Status:
Does this need to be inserted/placed?
sodium chloride 0.9% infusion [64367] Intravenous, CONTINUOUS
Note: IV Fluids [950018] EVERY 8 HOURS
All IV fluids should be in sodium chloride 0.9%. May use
lactated ringers as well. Dextrose solutions should be
avoiding unless fasting for more than 12 hours and blood
glucose levels are less than 50 mg/dL when it may be
necessary to maintain stable glucose. Check last registered
dietitian/nutritionst note for daily carbohydrates allow if
fasting.
Medications
General [100497]
Note: All medications should be in lowest carbohydrate
form possible. May use home medications. [950018]
CONTINUOUS
Seizure Treatment [100499]
diazepam (VALIUM) injection CUSTOM - NOTE:
Suggested dose 0.5 mg/kg (Maximum dose 20 mg)
[760073]
0.5 mg/kg, Rectal, EVERY 4 HOURS PRN, seizures lasting
more than 3 minutes
NOTE: Suggested dose 0.5 mg/kg (Maximum dose 20 mg)
lorazepam (ATIVAN) injection [800053] 0.05 mg/kg, Intravenous, PRN, other, Seizure
Please contact physician before administering. May repeat
after 10 - 15 minutes.
midazolam (VERSED) injection - NOTE: Order for
patients without IV access [760167]
Nasal, PRN, sedation
Use nasal mucosal atomization device. Split dose equally
between nostrils. Maximum dose per nostril = 5 mg
Maximum combined dose = 10 mg. Please contact physician
before administering. May repeat after 10 - 15 minutes.
Hypoglycemia Treatment [100583]
Hypoglycemia Treatment If Able to Take PO
[NURCOM0022]
SEE COMMENTS, Starting today, If glucose less than 50
mg/dL, give 15 mL apple juice and re-check in 1 hour.
dextrose 50% 25g/50mL vial [36634] 2.5 g, Intravenous, EVERY 1 HOUR PRN, hypoglycemia less
than 50 mg/dL and patient NPO
Recheck glucose in 1 hour. Each 10 mL delivers 5 g
dextrose
for 60 Minutes
Bowel Management - Scheduled [16420]
polyethylene glycol (MIRALAX) oral powder [61353] Oral
Page 4 of 7
Pr i nted by STRAKA, KEVIN F [KFS1] at 9/5/2013 10:57:49 AM
Copyright © 2013 University of Wisconsin Hospital and Clinics Authority


Dissolve in *** ounces of liquid. Hold for loose stools
Bowel Management - As Needed - First Line [16422]
magnesium hydroxide (MILK OF MAGNESIA) susp -
NOTE: Suggested dose 0.5 mL/kg (Maximum dose 30
mL) [780092]
0.5 mL/kg, Oral, 1 X DAILY PRN, constipation
senna-docusate (SENOKOT-S) 8.6-50 mg per tab
[60530]
Oral
Bowel Management - As Needed - Second Line [16423]
bisacodyl (DULCOLAX) rectal suppository [35231] 10 mg, Rectal
Administer if first line agent fails
glycerin (CHILD) rectal suppository [37955] 1 suppository, Rectal, 1 X DAILY PRN, constipation
Administer if first line agent fails.
phosphate (FLEET PEDIATRIC) enema - NOTE: Order
for children 2-11 years [37522]
1 enema, Rectal, 1 X DAILY PRN, constipation
Administer if first line agent fails
phosphate (FLEET) enema - NOTE: Order for children
12 years or older [37517]
1 enema, Rectal, 1 X DAILY PRN, constipation
Administer if first line agent fails
Non-categorized [100502]
acetaMINOPHEN (TYLENOL) tab - NOTE: Suggested
dose 10-15 mg/kg (Maximum 650 mg/dose) [34149]
Oral, EVERY 4 HOURS PRN, pain/fever
Patient to use home supply
NOTE: Suggested dose 10-15 mg/kg (Maximum 650
mg/dose)
acetaMINOPHEN (TYLENOL) suppository - NOTE:
Suggested dose 10-15 mg/kg (Maximum 650 mg/dose)
[43994]
Rectal, EVERY 4 HOURS PRN, pain/fever
NOTE: Suggested dose 10-15 mg/kg (Maximum 650
mg/dose)
Laboratory
Draw on Admission [99999]
ELECTROLYTES [LYTE] NEXT DRAW, Starting today 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 [GLU] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
BUN [BUN] NEXT DRAW, Starting today 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 [CRET] NEXT DRAW, Starting today 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 [CA] NEXT DRAW, Starting today 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 [ALB] NEXT DRAW, Starting today 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 [TP] NEXT DRAW, Starting today 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 [TBIL] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
Page 5 of 7
Pr i nted by STRAKA, KEVIN F [KFS1] at 9/5/2013 10:57:49 AM
Copyright © 2013 University of Wisconsin Hospital and Clinics Authority


If Conditional, What Condition?
AST/SGOT [AST] NEXT DRAW, Starting today 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 [ALT] NEXT DRAW, Starting today 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 [ALKP] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
CBC WITH DIFFERENTIAL [CBC] NEXT DRAW, Starting today 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 GASES [HCBGAS] NEXT DRAW, Starting today 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?
VALPROATE [DEP] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
TOPIRAMATE [XTOPIR] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
PHENOBARBITAL [PHEN] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
LAMOTRIGINE [XLAMO] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
FELBAMATE [XFELB] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
CARBAMAZEPINE [TEG] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
LEVETIRACETAM [HCKEPPRA] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
PHENYTOIN [DIL] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
PRIMIDONE AND METABOLITE [XPRIM] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
ZONISAMIDE [HCZONIS] NEXT DRAW, Starting today For 1 Occurrences, Routine
Page 6 of 7
Pr i nted by STRAKA, KEVIN F [KFS1] at 9/5/2013 10:57:49 AM
Copyright © 2013 University of Wisconsin Hospital and Clinics Authority


If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Draw Daily [100000]
BLOOD GASES [HCBGAS] NEXT AM, Starting today 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 [LYTE] NEXT AM, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
BETA-HYDROXYBUTYRATE [XBOH] NEXT AM, Starting 9/7/13 For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Consults
Consults [100001]
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Consult Pediatric Health Psychology (Inpatient)
[CON0202]
ONCE, Starting today, Routine
Reason for Consult:
Consult Child Life Specialist (Inpatient) [CON0014] ONCE, Starting today For 1 Occurrences, Routine
Activity Level:
Reason for Consult:
Consult School [CON0153] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Consult Nutrition (Inpatient) [CON0043] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Delegate to Initiate and Manage Tube Feeding:
Delegate to Initiate Feeding Tube Placement Order Set:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
Consult Learning Center - Pediatric (Inpatient)
[CON0137]
ONCE, Starting today, Routine
Reason for Consult: Blood Glucose Testing Teaching
BestPractice
No Hospital Problems have yet been identified. [107035]
Specify Hospital Problem(s) [COR0018] Details
Page 7 of 7
Pr i nted by STRAKA, KEVIN F [KFS1] at 9/5/2013 10:57:49 AM
Copyright © 2013 University of Wisconsin Hospital and Clinics Authority