/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/orthopedicsrehab/,

/clinical/cckm-tools/content/order-sets/inpatient/orthopedicsrehab/name-98106-en.cckm

20170233

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Orthopedics/Rehab

IP - Rehabilitation - General - Pediatric - Admission [4539]

IP - Rehabilitation - General - Pediatric - Admission [4539] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Orthopedics/Rehab


IP - Rehabilitation - General - Pediatric - Admission [4539]
Admission Status
Level of Care (Single Response) [187515]
*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) [121999]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: PEDIATRIC REHAB MEDICINE
Rationale for LOS greater than 2 midnights:
Patient Care Orders
Vital Signs [124403]
Page 1 of 8
Printed by O'BRIEN, RYLEY P [RPO249] at 2/2/2017 3:24:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Vital Signs [NURMON0013] 2X DAILY, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Vital Signs [NURMON0013] DAILY, Starting today with First Occurrence As
Scheduled, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Vital Signs [NURMON0013] EVERY 8 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Activity [7779]
Chair Twice Daily With Assistance
[NURACT0008]
CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR: 2x daily,other (comment)
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Ambulate Per Physical Therapy
Recommendations [NURACT0008]
CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE: other (comment)
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Reposition [NURCOM0022] SEE COMMENTS, Starting today with First
Occurrence As Scheduled, Every 2 hours while in
bed.
Weight Bearing Status [NURACT0008] CONTINUOUS, Starting today, Routine
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Apply Brace, Spine [NURTRT0014] CONTINUOUS, Starting today, Routine
Type:
Wearing schedule:
Page 2 of 8
Printed by O'BRIEN, RYLEY P [RPO249] at 2/2/2017 3:24:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

Apply Brace/Splint, Lower Body [NURTRT0009] CONTINUOUS, Starting today, Routine, If ordering a
Bledsoe Boot or Hip Abduction Brace, please contact
the cast room technician at 265-0746.
Type:
Left/Right/Bilateral?
Wearing schedule:
Apply Brace/Splint, Upper Body [NURTRT0015] CONTINUOUS, Starting today, Routine, If ordering a
Sarmiento Humeral Fracture Orthosis, please contact
the cast room technician at 265-0746.
Type:
Left/Right/Bilateral?
Wearing schedule:
Cervical Spine Precautions [PRECAU0005] CONTINUOUS, Starting today, 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.
Sternal Precautions [PRECAU0010] CONTINUOUS, Starting today, Routine, Sternal
Precautions:
No lifting greater than 8 pounds.
No pushing/pulling with arms during transfers.
No shoulder elevation past 90 degrees.
Total Hip Precautions [PRECAU0006] CONTINUOUS, Starting today, Routine
Nutrition [122000]
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Wound Care [7782]
Dry Dressing to Surgical Incision Site
[NURWND0015]
CONTINUOUS, Starting today For Until specified,
Routine
Wound Type:
Wound Site:
Wound Location:
Assess Frequency:
Care Frequency:
Wash With:
Irrigate/Rinse With:
Apply (Must also enter separate medication order to
obtain drug):
Primary Dressing:
Secondary Dressing:
Intake and Output [7783]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today For Until specified,
Routine
Non-Categorized Patient Care Orders [122001]
Measure Weight [NURMON0015] ONCE For 1 Occurrences, Routine
Weigh With?
Weigh when?
On admission
Page 3 of 8
Printed by O'BRIEN, RYLEY P [RPO249] at 2/2/2017 3:24:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

Measure Weight [NURMON0015] EVERY 7 DAYS, Routine
Weigh With?
Weigh when?
Medications
Analgesics - Acetaminophen - PRN (Single Response) [152612]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - Maximum dose 650 mg [800005]
15 mg/kg, Oral, EVERY 4 HOURS PRN, pain
Administer for mild to moderate pain and/or
multimodal therapy.
Maximum dose 650 mg
acetaMINOPHEN (TYLENOL) tab - Maximum
dose 650 mg [34149]
325 mg, Oral, EVERY 4 HOURS PRN, pain
Administer for mild to moderate pain and/or
multimodal therapy.
Maximum dose 650 mg
acetaMINOPHEN (TYLENOL) disintegrating tab
[64412]
Oral, EVERY 4 HOURS PRN, pain
Administer for mild to moderate pain and/or
multimodal therapy.
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg
Analgesics - NSAIDS - PRN (Single Response) [152617]
ibuprofen (MOTRIN) susp [45376] 10 mg/kg, Oral, EVERY 6 HOURS PRN, pain, For
pain and inflammation
Administer for pain and inflammation and/or
multimodal therapy.
ibuprofen (MOTRIN) tab [38353] 200 mg, Oral, EVERY 6 HOURS PRN, pain, For pain
and inflammation.
Administer for pain and inflammation and/or
multimodal therapy.
ibuprofen (MOTRIN) tab [38353] 400 mg, Oral, EVERY 6 HOURS PRN, pain, For pain
and inflammation
Administer for pain and inflammation and/or
multimodal therapy.
ibuprofen (MOTRIN) chew tab [49626] Oral, EVERY 6 HOURS PRN, pain, For pain and
inflammation
Administer for pain and inflammation and/or
multimodal therapy
Analgesics - Opioids - PRN (Single Response) [152616]
oxycodone 5 MG/5ML soln [45975] 0.1 mg/kg, Oral, EVERY 6 HOURS PRN, pain
Administer for severe pain
oxycodone tab RANGE [750032] 5-10 mg, Oral, EVERY 6 HOURS PRN, pain
Administer for severe pain
Analgesics - Other (Single Response) [152611]
gabapentin (NEURONTIN) soln [65814] 10 mg/kg, Oral, 3 X DAILY
gabapentin (NEURONTIN) cap [54258] 100 mg, Oral, 3 X DAILY
gabapentin (NEURONTIN) cap [54258] 200 mg, Oral, 3 X DAILY
Bowel Management - Scheduled [152619]
senna-docusate (SENOKOT S) 8.6-50 MG per
tab [60530]
1 tab, Oral, 2 X DAILY
polyethylene glycol (MIRALAX) oral powder -
Suggested dose - Start at 8.5 - 17 g daily.
[61829]
Oral, 1 X DAILY
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal, 1 X DAILY
Bowel Management - As Needed - First Line (Single Response) [152621]
polyethylene glycol (MIRALAX) oral powder -
Start at 8.5 - 17 g daily. [61829]
Oral, 1 X DAILY PRN, constipation
Dissolve in 240 mL of liquid. First line therapy.
Page 4 of 8
Printed by O'BRIEN, RYLEY P [RPO249] at 2/2/2017 3:24:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

bisacodyl (DULCOLAX) EC tab [49076] 10 mg, Oral, 1 X DAILY PRN, constipation
First line therapy.
magnesium hydroxide (MILK OF MAGNESIA)
susp - NOTE: order for patients less than 2 years
old [65443]
0.5 mL/kg, Oral, 1 X DAILY (HS) PRN, constipation
First line therapy.
magnesium hydroxide (MILK OF MAGNESIA)
susp - NOTE: order for patients 2-5 years old
[65443]
5-15 mL/kg, Oral, 1 X DAILY (HS) PRN, constipation
First line therapy.
magnesium hydroxide (MILK OF MAGNESIA)
susp - NOTE: order for patients 6-11 years old
[65443]
15 mL/kg, Oral, 1 X DAILY (HS) PRN, constipation
First line therapy.
Bowel Management - As Needed - Second Line (Single Response) [122145]
polyethylene glycol (MIRALAX) oral powder -
Start at 8.5 - 17 g daily. [61829]
Oral, 1 X DAILY PRN, constipation
Dissolve in 240 mL of liquid. Second line therapy if no
response to first line therapy within 8 hours.
bisacodyl (DULCOLAX) EC tab [49076] 10 mg, Oral, 1 X DAILY PRN, constipation
Second line therapy if no response to first line therapy
within 8 hours.
magnesium hydroxide (MILK OF MAGNESIA)
susp - NOTE: order for patients less than 2 years
old [65443]
0.5 mL/kg, Oral, 1 X DAILY (HS) PRN, constipation
Second line therapy if no response to first line therapy
within 8 hours.
magnesium hydroxide (MILK OF MAGNESIA)
susp - NOTE: order for patients 2-5 years old
[65443]
5-15 mL/kg, Oral, 1 X DAILY (HS) PRN, constipation
Second line therapy if no response to first line therapy
within 8 hours.
magnesium hydroxide (MILK OF MAGNESIA)
susp - NOTE: order for patients 6-11 years old
[65443]
15 mL/kg, Oral, 1 X DAILY (HS) PRN, constipation
Second line therapy if no response to first line therapy
within 8 hours.
Bowel Management - As Needed -Third Line (Single Response) [152620]
polyethylene glycol (MIRALAX) oral powder -
Start at 8.5 - 17 g daily. [61829]
Oral, 1 X DAILY PRN, constipation
Dissolve in 240 mL of liquid. Third line therapy if no
response to second line therapy within 8 hours.
bisacodyl (DULCOLAX) EC tab [49076] 10 mg, Oral, 1 X DAILY PRN, constipation
Third line therapy if no response to first line therapy
within 8 hours.
magnesium hydroxide (MILK OF MAGNESIA)
susp - NOTE: order for patients less than 2 years
old [65443]
0.5 mL/kg, Oral, 1 X DAILY (HS) PRN, constipation
Third line therapy if no response to first line therapy
within 8 hours.
magnesium hydroxide (MILK OF MAGNESIA)
susp - NOTE: order for patients 2-5 years old
[65443]
5-15 mL/kg, Oral, 1 X DAILY (HS) PRN, constipation
Third line therapy if no response to first line therapy
within 8 hours.
magnesium hydroxide (MILK OF MAGNESIA)
susp - NOTE: order for patients 6-11 years old
[65443]
15 mL/kg, Oral, 1 X DAILY (HS) PRN, constipation
Third line therapy if no response to first line therapy
within 8 hours.
Bowel Management - Rectal Agents (Single Response) [152622]
phosphate (FLEET PEDIATRIC) enema [37522] 1 enema, Rectal, 1 X DAILY PRN, constipation
Administer if unable to take or unresponsive to other
laxatives
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal, 1 X DAILY PRN, constipation
Administer if unable to take or unresponsive to other
laxatives
Laboratory
Draw on Admission [152618]
CBC WITH DIFFERENTIAL [CBC] NEXT AM, 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?
Page 5 of 8
Printed by O'BRIEN, RYLEY P [RPO249] at 2/2/2017 3:24:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

PROTHROMBIN TIME/INR [PT] NEXT AM, 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?
ELECTROLYTES [LYTE] NEXT AM, 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 AM, 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 AM, 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 AM, 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 AM, 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 AM, 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 AM, 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 AM, 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 AM, 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?
AST/SGOT [AST] NEXT AM, 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 AM, 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?
PREALBUMIN [XPRALB] NEXT AM, 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?
Consults
Consults [122002]
Page 6 of 8
Printed by O'BRIEN, RYLEY P [RPO249] at 2/2/2017 3:24:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult: Mobility
Training
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Occupational Therapy Consult: ADL
Training
Consult Speech Therapy (Inpatient) Eval and
Treat [CON0077]
ONCE, Starting today For 1 Occurrences, Routine
Patient Type: Pediatric
Reason for Speech Therapy Consult: Other (Please
provide evaluation and treatment for communication,
cognition and dysphagia as indicated)
Consult Pediatric Health Psychology (Inpatient)
[CON0202]
ONCE, Routine, Please notify consulting provider if
patient needs to be seen same day (Monday-Friday)
or if special assessment needs.
Reason for Consult: depression/adjustment
Consult Vocational Services (Inpatient)
[CON0085]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Other (Comment)
Evaluate and treat.
Consult Orthotics (Inpatient) [CON0051] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Can this consult be done via video?
Consult Child Life Specialist (Inpatient)
[CON0014]
ONCE, Starting today For 1 Occurrences, Routine
Activity Level:
Reason for Consult:
Can this consult be done via video?
Pet Pals Therapy [NURTRT0045] PRN, Routine
Consult Orthopedics (Inpatient) [CON0050] 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:
Consult Pediatric Neurology (Inpatient)
[CON0097]
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:
Consult Neurosurgery (Inpatient) [CON0042] 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:
Consult Respiratory Therapy (Inpatient)
[CON0071]
ONCE, Routine
Reason for Consult:
Can this consult be done via video?
Consult Pediatric Urology (Inpatient) [CON0108] 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:
Page 7 of 8
Printed by O'BRIEN, RYLEY P [RPO249] at 2/2/2017 3:24:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

Consult Child Psychiatry (Inpatient) [CON0170] 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:
Page 8 of 8
Printed by O'BRIEN, RYLEY P [RPO249] at 2/2/2017 3:24:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org