/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/pulmonary/,

/clinical/cckm-tools/content/order-sets/inpatient/pulmonary/name-98029-en.cckm

201606175

page

100

UWHC,UWMF,

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

IP - Cystic Fibrosis - Distal Intestinal Obstruction Syndrome - Pediatric - Admission [1189]

IP - Cystic Fibrosis - Distal Intestinal Obstruction Syndrome - Pediatric - Admission [1189] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Pulmonary


IP - Cystic Fibrosis - Distal Intestinal Obstruction Syndrome - Pediatric - Admission [1189]
Admission Status
Admission Status [7248]
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, 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:
Admission Status [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, 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:
Patient Care Orders
Vital Signs [14977]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today with First Occurrence As
Scheduled For Until specified, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 12 hours times 2, then every 24 hours.
Activity [104957]
Ad Lib [NURACT0008] CONTINUOUS, Starting today For Until specified, Routine
Page 1 of 7
Pr i nt ed by LIND, JANNA S [JSL237] at 12/11/2014 2:31:59 PM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


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:
Nutrition [14978]
Clear Liquid 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): CLEAR LIQUID;
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:
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:
Airway Clearance Techniques [14979]
Patient May Self-Administer Airway Clearance Therapy
[NURCOM0022]
CONTINUOUS, Starting today For Until specified
Chest Physiotherapy [RT0011] 2X DAILY, Starting today For Until specified, Routine
Affected Area:
Chest Physiotherapy [RT0011] 4X DAILY, Starting today, Routine
Affected Area:
Positive Expiratory Pressure Therapy (PEP) [RT0033] 2X DAILY, Starting today For Until specified, Routine
PEP Level:
Positive Expiratory Pressure Therapy (PEP) [RT0033] 4X DAILY, Starting today, Routine
PEP Level:
Flutter Treatment [RT0018] 2X DAILY, Starting today For Until specified, Routine
Flutter Treatment [RT0018] 4X DAILY, Starting today, Routine
Acapella Treatment [RT0000] 2X DAILY, Starting today For Until specified, Routine
Self Administered (Only RT may document in this box after
patient assessment):
Page 2 of 7
Pr i nt ed by LIND, JANNA S [JSL237] at 12/11/2014 2:31:59 PM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


Acapella Treatment [RT0000] 4X DAILY, Starting today, Routine
Self Administered (Only RT may document in this box after
patient assessment):
Intrapulmonary Percussive Ventilation (IPV) [RT0023] 2X DAILY, Starting today For Until specified, Routine
Intrapulmonary Percussive Ventilation (IPV) [RT0023] 4X DAILY, Starting today, Routine
Apply Vest Treatment [RT0051] 2X DAILY, Starting today For Until specified, Routine
Vest Frequency Settings:
Vest Pressure Settings:
Apply Vest Treatment [RT0051] 4X DAILY, Starting today, Routine
Vest Frequency Settings:
Vest Pressure Settings:
Intake and Output [14980]
Measure Intake And Output [NURMON0005] EVERY 4 HOURS, Starting today For Until specified, Routine
Non-Categorized Patient Care Orders [14981]
Measure Height - On Admission [NURMON0052] ONCE For 1 Occurrences, Routine, On Admission
NG Tube Placement - Pediatric [121658]
Insert and Maintain Nasogastric Tube [NURTAD0014] CONTINUOUS, Routine
Options:
Flush with:
Flush Frequency:
Clamp NG Tube:
Check Residual:
Does this need to be inserted/placed?
Device Status:
Insert on admission
Recommendations for flush quantity:
For patients < 30 kg, use 1mL of fluid per 1 kg.
For patients >30 kg, 30 mLs of fluid should be sufficient.
In general, consider the amount of fluid needed to clear the
tube and patient’s fluid status before determining flush
quantity.
lidocaine-oxymetazoline 3%-0.01% (PEDS) nasal spray
[785104]
Nasal, ONCE For 1 Doses
For numbing prior to feeding tube insertion. Slowly spray
the chosen nostril once, if required may repeat x1 in
opposite nostril. Angle toward back of throat spraying the
anterior nostril and wait 30-60 seconds before introducing
more local anesthetic into the nostril. Caution: Entire bottle
should not be used for insertion of tube. Discard excess
solution when procedure completed.
X-RAY ABDOMEN AP VIEW (KUB) [R74000] 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 nasogastric tube 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
If Conditional, What Condition? Evaluate nasogastric tube
placement. The location of nasogastric 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
Contingency Parameters for Patients Less than 6 Months of Age [104958]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 100
If systolic blood pressure < (mmHg): 65
Page 3 of 7
Pr i nt ed by LIND, JANNA S [JSL237] at 12/11/2014 2:31:59 PM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


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):
If blood glucose < (mg/dL):
Pulse Oximetry < (%): 95
Other: When stools are clear
Contingency Parameters for Patients 7 Months to 2 Years of Age [104959]
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
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):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other: When stools are clear
Contingency Parameters for Patients 3 to 6 Years of Age [104960]
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
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: When stools are clear
Contingency Parameters for Patients 7 to 10 Years of Age [104961]
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
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 70
If respiratory rate >: 24
If respiratory rate <: 14
Page 4 of 7
Pr i nt ed by LIND, JANNA S [JSL237] at 12/11/2014 2:31:59 PM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other: When stools are clear
Contingency Parameters for Patients 11 to 17 Years of Age [104962]
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
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):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other: When stools are clear
Intravenous Therapy
Premedication for Needle Insertion [30232]
lidocaine (LMX) 4% topical dressing kit - NOTE: Order
for patients 5 Kg or less [66882]
Topical, EVERY 1 HOUR PRN, apply 20 to 30 minutes prior
to needle insertion - see Admin Instructions
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 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
lidocaine (LMX) 4% topical dressing kit - NOTE: Order
for patients 5.1-10 kg [66882]
Topical, EVERY 1 HOUR PRN, apply 20 to 30 minutes prior
to needle insertion - see Admin Instructions
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 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
lidocaine (LMX) 4% topical dressing kit - NOTE: Order
for patients greater than 10 Kg [66882]
Topical, EVERY 1 HOUR PRN, apply 20 to 30 minutes prior
to needle insertion - see Admin Instructions
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
Medications - Admission-specific
Admission-specific [17335]
metoclopramide (REGLAN) soln - NOTE: Suggested
dose 0.1 mg/kg/dose (Maximum 10 mg/dose) [800224]
1 mg/kg, Nasogastric Tube, EVERY 4 HOURS
Administer first dose 30 minutes before starting GI lavage.
Discontinue when GI lavage is discontinued.
NOTE: Suggested dose 0.1 mg/kg/dose (Maximum 10
mg/dose) Discontinue when GI lavage is discontinued.
G.I. lavage (GOLYTELY) 236 GM soln [103976] 8 L, Nasogastric Tube
NOTE: Starting dose is 4 mL/kg/hr and increase as tolerated
to 10 mL/kg/hr (Maximum 1000 mL/hr)
Note: Continuous GI Lavage Administration Instructions CONTINUOUS
Page 5 of 7
Pr i nt ed by LIND, JANNA S [JSL237] at 12/11/2014 2:31:59 PM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


[950018] Initiate at 4 mL/kg/hr and increase as tolerated to 10 mL/kg/hr
(Maximum 1000 mL/hr)
Give using a feeding pump. When stools are clear notify MD
for further assessment. Contact physician to order X-Ray
Medications - General
IV Fluids [182688]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Device:
Peripheral IV Location:
Peripheral IV Size:
Peripheral IV Status:
Does this need to be inserted/placed?
Bronchodilators [17339]
Note: Self Administered Medication Program
Documentation-RT [950019]
ONCE Starting today For 1 Doses
Patient may self-administer inhaled bronchodilators
albuterol HFA 90 mcg/act inhaler [53730] 2 puff, Inhalation, RT 4 X DAILY
Before airway clearance
Mucolytics [17343]
dornase alpha (PULMOZYME) neb soln [47475] 2.5 mg, Nebulization, 1 X DAILY
Before airway clearance
sodium chloride (HYPERSAL) 7 % neb soln [118873] 4 mL, Nebulization, RT 2 X DAILY
albuterol HFA 90 mcg/act inhaler [53730] 2 puff, Inhalation, RT 2 X DAILY
Before sodium chloride 7% nebulization
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
Laboratory [14983]
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?
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?
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?
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?
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?
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?
URINALYSIS, WITHOUT MICROSCOPY [UACHEM] ONCE, 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?
Diagnostic Tests
Page 6 of 7
Pr i nt ed by LIND, JANNA S [JSL237] at 12/11/2014 2:31:59 PM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


Imaging [14984]
X-RAY ABDOMEN >= 2 VIEWS [R74020] 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? Cystic Fibrosis-Distal Intestinal
Obstruction Syndrome
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Consults
Consults [14985]
Consult Nutrition (Inpatient) [CON0043] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Delegate to Initiate and Manage Tube Feeding:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
Consult for enzyme and fluid administration and educate on
compliance. Brief history: Cystic Fibrosis - Distal Intestinal
Obstruction Syndrome.
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 7 of 7
Pr i nt ed by LIND, JANNA S [JSL237] at 12/11/2014 2:31:59 PM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority