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/clinical/cckm-tools/content/order-sets/inpatient/orthopedicsrehab/name-98118-en.cckm

20170117

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IP - Orthopedics - General - Pediatric - Admission [5589]

IP - Orthopedics - General - Pediatric - Admission [5589] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Orthopedics/Rehab


IP - Orthopedics - General - Pediatric - Admission [5589]
Admission Status
Admission Status [187463]
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:
Patient Care Orders
Vital Signs [187464]
Vital Signs [NURMON0013] EVERY 4 HOURS, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Neurovascular Checks [NURMON0045] EVERY 4 HOURS, Starting today, Routine
Activity [187465]
Activity [NURACT0008] CONTINUOUS, Starting today, Routine
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:
Nutrition [187466]
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:
Page 1 of 5
Printed by O'BRIEN, RYLEY P [RPO249] at 1/9/2017 4:35:01 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

Strict NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: NPO
NPO Diet: Strict NPO
Bedside Meal Instructions:
Room Service Class:
General [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Respiratory [187471]
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today For Until specified,
Routine
Intake and Output [187472]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today, Routine
Non-Categorized Patient Care Orders [187475]
Measure Height [NURMON0052] ONCE For 1 Occurrences, Routine
Measure Weight [NURMON0015] ONCE For 1 Occurrences, Routine
Weigh With?
Weigh when?
Contingency Parameters for Patients 3 through 6 Years Old [135342]
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): 38.5
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):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other:
Intravenous Therapy
IV Fluids (Single Response) [189581]
dose:Suggested
4weight less than 10 kg suggested dose (mL/hr) = weight in kg x For
2020 kg suggested dose (mL/hr) = (weight in kg x 2) + -weight 10For
40)weight greater than 20 kg suggested dose (mL/hr) = weight in kg + For
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS
Suggested dose: For weight less than 10 kg
suggested dose (mL/hr) = weight in kg x 4 For weight
10-20 kg suggested dose (mL/hr) = (weight in kg x 2)
+ 20 For weight greater than 20 kg suggested dose
(mL/hr) = weight in kg + 40)
Page 2 of 5
Printed by O'BRIEN, RYLEY P [RPO249] at 1/9/2017 4:35:01 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

dextrose 5%-NaCl 0.45% with KCl 20 mEq/L
infusion [44910]
Intravenous, CONTINUOUS
Suggested dose: For weight less than 10 kg
suggested dose (mL/hr) = weight in kg x 4 For weight
10-20 kg suggested dose (mL/hr) = (weight in kg x 2)
+ 20 For weight greater than 20 kg suggested dose
(mL/hr) = weight in kg + 40)
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
LMX Use Instructions for Premedication Prior to
Needle Insertion [NURCOM0095]
Details
General Medications
Analgesics - Acetaminophen - Scheduled (Single Response) [131815]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 15 mg/kg
(Maximum 650 mg/dose) [800005]
15 mg/kg, Oral, EVERY 6 HOURS For 72 Hours,
Post-Op/Phase II
acetaMINOPHEN (TYLENOL) tab [34149] Oral, EVERY 6 HOURS For 72 Hours, Post-
Op/Phase II
acetaMINOPHEN (TYLENOL) suppository -
NOTE: Suggested dose 20 mg/kg. Must order in
whole suppository size (maximum 650 mg/dose)
[43994]
Rectal, Post-Op/Phase II
Analgesics - Acetaminophen - PRN (Starting in 72 hours) (Single Response) [187907]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 15 mg/kg
(Maximum 650 mg/dose) [800005]
15 mg/kg, Oral, EVERY 4 HOURS PRN Starting
1/12/17, pain, Mild pain or multimodal therapy., Post-
Op/Phase II
acetaMINOPHEN (TYLENOL) tab - NOTE:
Suggested dose 15 mg/kg (maximum 650
mg/dose) [34149]
Oral, EVERY 4 HOURS PRN Starting 1/12/17, pain,
Mild pain or multimodal therapy, Post-Op/Phase II
acetaMINOPHEN (TYLENOL) suppository -
NOTE: Suggested dose 20 mg/kg. Must order in
whole suppository size (Maximum 650 mg/dose)
[43994]
Rectal, EVERY 6 HOURS PRN Starting 1/12/17,
pain, Mild pain or multimodal therapy, Post-Op/Phase
II
Analgesics - NSAID - Scheduled (Single Response) [187906]
ketOROLAC (TORODOL) injection - NOTE:
Suggested dose 0.5 mg/kg (Maximum 15
mg/dose) [800050]
0.5 mg/kg, Intravenous, EVERY 6 HOURS For 72
Hours, Post-Op/Phase II
Page 3 of 5
Printed by O'BRIEN, RYLEY P [RPO249] at 1/9/2017 4:35:01 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

ibuprofen (MOTRIN) susp - NOTE: Suggested
dose 10 mg/kg (Maximum 600 mg/dose) [45376]
10 mg/kg, Oral, EVERY 6 HOURS For 72 Hours,
Post-Op/Phase II
Analgesics - NSAID - PRN (Starting in 72 hours) [187870]
ibuprofen (MOTRIN) susp - NOTE: Suggested
dose 10 mg/kg (Maximum 600 mg/dose) [45376]
10 mg/kg, Oral, EVERY 6 HOURS PRN Starting
1/12/17, pain, Mild to Moderate Pain or Multimodal
therapy, Post-Op/Phase II
Analgesics - Opioids (Oral) - PRN (Single Response) [187909]
oxycodone 5 MG/5ML soln RANGE – (Maximum
20 mg/dose) [750031]
0.1-0.2 mg/kg, Oral, EVERY 4 HOURS PRN, pain,
Moderate/Severe Pain, Post-Op/Phase II
oxycodone tab RANGE – NOTE: Suggested
dose 0.1-0.2 mg/kg (Maximum 20mg/dose)
[750032]
Oral, EVERY 4 HOURS PRN, pain, Moderate/Severe
Pain, Post-Op/Phase II
Analgesics - Opioids (Intravenous) - PRN (Single Response) [187910]
morphine PF injection – NOTE: suggested dose
0.05 – 0.1 mg/kg (Maximum 2 mg/dose) [800122]
0.05-0.1 mg/kg, Intravenous, EVERY 2 HOURS PRN,
pain, Moderate/Severe Pain and unable to take oral
opiod, Post-Op/Phase II
HYDROmorphone PF (DILAUDID) injection -
NOTE: suggested dose 0.01-0.02 mg/kg
(Maximum 0.4 [800120]
0.01-0.02 mg/kg, Intravenous, EVERY 2 HOURS
PRN, pain, Moderate/Severe Pain and unable to take
oral opiod, Post-Op/Phase II
Bowel Management (Single Response) [131817]
docusate sodium (COLACE) cap [36859] 100 mg, Oral, 2 X DAILY, Post-Op/Phase II
polyethylene glycol (MIRALAX) oral powder -
NOTE: suggested dose 0.01-0.02 mg/kg
(Maximum 0.4 [61829]
3.4 g, Oral, 1 X DAILY, Post-Op/Phase II
polyethylene glycol (MIRALAX) oral powder -
NOTE: For patients 10 - 25 kg [61829]
8.5 g, Oral, 1 X DAILY
Dissolve in 4 ounces of water
NOTE: For patients less than 25 kg
Post-Op/Phase II
polyethylene glycol (MIRALAX) oral powder -
NOTE: For patients 25 kg or greater [61829]
17 g, Oral, 1 X DAILY
Dissolve in 8 ounces of water
NOTE: For patients 25 kg or greater
Post-Op/Phase II
Anti-emetics [88788]
ondansetron (ZOFRAN) injection - NOTE:
Suggested dose 0.1 mg/kg (Maximum 4
mg/dose) [800202]
0.1 mg/kg, Intravenous, EVERY 24 HOURS PRN,
nausea/vomiting
NOTE: Suggested dose 0.1 mg/kg (Maximum 4
mg/dose)
Post-Op/Phase II
Non-categorized Medications [202767]
nalbuphine (NUBAIN) injection - Maximum Dose
= 2.5 mg [39994]
0.05 mg/kg, Intravenous, EVERY 6 HOURS PRN,
pain, 1st Line Pruiritis, for 3 Minutes
Laboratory
Labs [187524]
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?
CBC WITH DIFFERENTIAL [CBC] NEXT DRAW 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 4 of 5
Printed by O'BRIEN, RYLEY P [RPO249] at 1/9/2017 4:35:01 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

C REACTIVE PROTEIN [CRPN] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ESR [ESR] NEXT DRAW 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 [187525]
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult: Mobility
Training
for durable medical equipment needs
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Occupational Therapy Consult:
Consult Cast Room Technician - Pediatric
[CON0152]
For the pediatric cast room technician, please call
890-8151.
Consult Pediatric Pain Management (Inpatient)
[CON0165]
ONCE, Routine
Pain Problem:
Reason for Consult:
Can this consult be done via video?
Consult Pediatric Hospitalist (Inpatient)
[CON0135]
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 Inf Disease (Inpatient)
[CON0096]
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 Pulmonary (Inpatient)
[CON0098]
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 Rehab (Inpatient) [CON0138] 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:
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 5 of 5
Printed by O'BRIEN, RYLEY P [RPO249] at 1/9/2017 4:35:01 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org