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IP - Cystic Fibrosis - Pulmonary Exacerbation - Pediatric - Admission [833]

IP - Cystic Fibrosis - Pulmonary Exacerbation - Pediatric - Admission [833] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Pulmonary


IP - Cystic Fibrosis - Pulmonary Exacerbation - Pediatric - Admission [833]
*Please COMPLETE the IP - Venous Access Team - PICC Placement Request - Pediatric - Supplemental [1429] and
ensure 2 lumens is ordered unless otherwise specified by Attending
Admission Status
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:
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:
Isolation Status
Isolation Status [104902]
Isolation - Contact And Droplet - Cystic Fibrosis
Pulmonary Exacerbation - Panel [116334]
Isolation - Contact and Droplet - Cystic Fibrosis
Pulmonary Exacerbation [ISO0289]
CONTINUOUS
Isolation Cart [EQP0016] CONTINUOUS, Routine
Patient Care Orders
Vital Signs [9044]
Vital Signs [NURMON0013] DAILY, Starting today with First Occurrence As Scheduled,
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


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:
Measure Weight - For Patients Greater Than 2 Years of
Age [NURMON0015]
EVERY MONDAY AND THURSDAY For Until specified,
Routine
Weigh With?
Weigh when?
Including upon admission.
Measure Weight - For Patients Less Than 2 Years of
Age [NURMON0015]
1X DAILY, Starting today For Until specified, Routine
Weigh With?
Weigh when?
Including upon admission.
Measure Height [NURMON0052] ONCE, Starting today For 1 Occurrences, Routine, Upon
admission
Measure Head Circumference - For Patients Less Than
2 Years of Age [NURMON0038]
ONCE, Starting today For 1 Occurrences, Routine, Upon
admission
Activity [18520]
Ambulate Ad Lib [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:
Sleep Hygiene - Facilitate Bed Time Routine per AFCH
Cystic Fibrosis Guidelines [NURACT0011]
CONTINUOUS, Starting today For Until specified, School
Nights: In room by 9pm and lights out by 10pm.
Weekends and Summer Nights: In room by 10pm and lights
out by 11pm.
Nutrition [9046]
For Tube Feeding Orders Refer To Tube Feeding Orderset
High Calorie and High Protein Diet [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet: PROTEIN/CALORIE, HIGH;
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:
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


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:
General Diet [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet: GENERAL;
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:
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:
Nourishments & Supplements [NUT0005] EFFECTIVE NOW, Starting today, Routine
Medical Food / Oral Supplement(s):
Nourishment / Snack Item(s):
Schedule:
Measure Caloric Intake [NURDIE0011] CONTINUOUS, Starting today For Until specified, Routine
Respiratory [9047]
Pulse Oximetry [NURMON0009] DAILY, Starting today with First Occurrence As Scheduled,
Routine
Pulse Oximetry [NURMON0009] EVERY 8 HOURS, Starting today, Routine
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


Oxygen Therapy [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%):
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 92
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Airway Clearance Technique [17944]
Patient May Self-Administer Airway Clearance Therapy
[NURCOM0022]
CONTINUOUS, Starting today
Chest Physiotherapy [RT0011] 2X DAILY, Starting today with First Occurrence As
Scheduled, Routine
Affected Area:
Chest Physiotherapy [RT0011] 4X DAILY, Starting today, Routine
Affected Area:
Positive Expiratory Pressure Therapy (PEP) [RT0033] 2X DAILY, Starting today with First Occurrence As
Scheduled, Routine
PEP Level:
Positive Expiratory Pressure Therapy (PEP) [RT0033] 4X DAILY, Starting today, Routine
PEP Level:
Flutter Treatment [RT0018] 2X DAILY, Starting today, Routine
Flutter Treatment [RT0018] 4X DAILY, Starting today, Routine
Intrapulmonary Percussive Ventilation (IPV) [RT0023] 2X DAILY, Starting today with First Occurrence As
Scheduled, Routine
Intrapulmonary Percussive Ventilation (IPV) [RT0023] 4X DAILY, Starting today, Routine
Acapella Treatment [RT0000] 2X DAILY, Starting today, Routine
Self Administered (Only RT may document in this box after
patient assessment):
Acapella Treatment [RT0000] 4X DAILY, Starting today, Routine
Self Administered (Only RT may document in this box after
patient assessment):
Apply Vest Treatment [RT0051] 2X DAILY, Starting today, Routine
Vest Frequency Settings:
Vest Pressure Settings:
Apply Vest Treatment [RT0051] 4X DAILY, Starting today, Routine
Vest Frequency Settings:
Vest Pressure Settings:
Non-Categorized Patient Care Orders [9048]
Glucose, POC [IPGLUCOSE] 1X DAILY, Starting today For 48 Hours, Routine
If Conditional, What Condition?
Once a day before breakfast for 48 hours.
Glucose, POC [IPGLUCOSE] 2X DAILY, Starting today, Routine
If Conditional, What Condition?
Two times a day (2 hours postprandial) for 48 hours.
Glucose, POC [IPGLUCOSE] SUPPLEMENTAL CHECK AT 0200, Routine
If Conditional, What Condition? If patient is on tube feeding
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Routine
If Conditional, What Condition?
Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA TREATMENT,
Routine
If Conditional, What Condition?
Contingency Parameters [104903]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 100
If systolic blood pressure < (mmHg): 65
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
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


If heart rate < (bpm): 90
If respiratory rate >: 50
If respiratory rate <: 25
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
Pulse Oximetry < (%): 95
Other: If unsuccessful after three attempts for peripheral
intravenous line
Contingency Parameters [104904]
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): 400
If blood glucose < (mg/dL): 40
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other: If unsuccessful after three attempts for peripheral
intravenous line
Contingency Parameters [104905]
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): 400
If blood glucose < (mg/dL): 40
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other: If unsuccessful after three attempts for peripheral
intravenous line
Contingency Parameters [104906]
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
If blood glucose > (mg/dL): 400
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


If blood glucose < (mg/dL): 40
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other: If unsuccessful after three attempts for peripheral
intravenous line
Contingency Parameters [104907]
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): 400
If blood glucose < (mg/dL): 40
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other: If unsuccessful after three attempts for peripheral
intravenous line
Intravenous Therapy
IV Fluids [12007]
If a PICC Needs to be Placed, Refer to Venous Access Team - PICC Placement Request Order Set
sodium chloride 0.45% infusion [42187] Intravenous, CONTINUOUS
For medications; may cap between medications
For children less than 10 kg run at 5 mL/hr;
For children 10-25 kg run at 10 mL/hr;
For children greater than 25 kg run at 20 mL/hr
Maintain PICC [NURVAD0050] CONTINUOUS, Routine
Device Status:
Site:
PICC Secured With:
Flush With(Must also enter separate medication order to
obtain drug):
Site Assessment Frequency:
Care Frequency:
Wash With:
Primary Dressing:
Secondary Dressing:
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?
Replace Intravenous Access at 0800 When Intravenous
Access Lost After 2200 [NURVAD0053]
CONTINUOUS, Starting today
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
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


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
Bronchodilators [12008]
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
Inhaled Corticosteroids [12009]
Note: Self Administered Medication Program
Documentation-RT [950019]
ONCE For 1 Doses
Inhaled corticosteroids
fluticasone HFA (FLOVENT HFA) 44 MCG/ACT inhaler
[106425]
Inhalation, RT 2 X DAILY
fluticasone HFA (FLOVENT HFA) 110 MCG/ACT inhaler
[106426]
Inhalation, RT 2 X DAILY
fluticasone-salmeterol (ADVAIR DISKUS) 100-50
MCG/DOSE inhaler [62984]
1 puff, Inhalation, RT 2 X DAILY
fluticasone-salmeterol (ADVAIR DISKUS) 250-50
MCG/DOSE inhaler [62985]
1 puff, Inhalation, RT 2 X DAILY
fluticasone-salmeterol (ADVAIR DISKUS) 500-50
MCG/DOSE inhaler [62986]
1 puff, Inhalation, RT 2 X DAILY
fluticasone-salmeterol (ADVAIR HFA) 45-21 mcg/dose
inhaler [113962]
2 puff, Inhalation, RT 2 X DAILY
fluticasone-salmeterol (ADVAIR HFA) 115-21 mcg/dose
inhaler [113963]
2 puff, Inhalation, RT 2 X DAILY
fluticasone-salmeterol (ADVAIR HFA) 230-21 mcg/dose
inhaler [113964]
2 puff, Inhalation, RT 2 X DAILY
Nebulized antibiotics [12012]
tobramycin (NEBCIN) neb soln [800220] 300 mg, Nebulization, RT 2 X DAILY
After airway clearance
colistimethate (COLISTIN) neb soln [780155] 75 mg, Nebulization, RT 2 X DAILY
After airway clearance
colistimethate (COLISTIN) neb soln [780155] 150 mg, Nebulization, RT 2 X DAILY
After airway clearance
Mucolytics [12013]
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 4 X DAILY
Anti-infectives [12014]
azithromycin (ZITHROMAX) susp [780021] 10 mg/kg, Oral, EVERY MON, WED, FRI
NOTE: Suggested dose 10 mg/kg/dose (Maximum 500
mg/dose)
cefepime (MAXIPIME) injection 50 mg/kg - Maximum
Dose is 2000 mg [800016]
50 mg/kg, Intravenous, EVERY 8 HOURS
Administer over 2 hours
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


ciprofloxacin (CIPRO) intraVENOUS - Maximum Dose is
600 mg [800031]
15 mg/kg, Intravenous, EVERY 8 HOURS
ciprofloxacin (CIPRO) 250 mg/5 mL susp - NOTE: For
MIC greater than 1 dose every 8 hours. Maximum Dose
is 750 mg [780086]
20 mg/kg, Oral, 2 X DAILY
meropenem (MERREM) intraVENOUS - Maximum Dose
is 1500 mg [800055]
30 mg/kg, Intravenous, EVERY 6 HOURS For 1000 Doses
piperacillin-tazobactam (ZOSYN) injection 100 mg/kg -
Maximum Dose is 6000 mg [800074]
100 mg/kg, Intravenous, EVERY 6 HOURS
Administer over 1-3 hours
piperacillin-tazobactam (ZOSYN) in sodium chloride
0.9% 500 mL 24hr infusion bag [700887]
400 mg/kg, Intravenous, EVERY 24 HOURS
ticarcillin-clavulanate (TIMENTIN) intraVENOUS
[800078]
100 mg/kg, Intravenous, EVERY 6 HOURS
tobramycin (NEBCIN) intraVENOUS - NOTE: Suggested
dose 10 mg/kg/dose. Contact Pediatric RPh to
determine precise dose [800081]
10 mg/kg, Intravenous, EVERY 24 HOURS
Contact Pediatric RPh to determine precise dose
sulfamethoxazole-trimethoprim (BACTRIM)
intraVENOUS [800114]
5 mg/kg, Intravenous, EVERY 8 HOURS
vancomycin (VANCOCIN) intraVENOUS [800084] 15 mg/kg, Intravenous, EVERY 6 HOURS
Pancreatic Enzymes [12016]
Note: Self Administered Medication Program
Documentation [950000]
ONCE For 1 Doses
Patient may self-administer pancreatic enzymes
Note: Patient may use home supply of pancreatic
enzymes if available [950018]
ONCE For 1 Doses
Patient may use home supply of pancreatic enzymes if
available
pancrelipase (CREON 6000) EC cap [136487] Oral, 3 X DAILY (AT MEALTIME)
With meals
pancrelipase (CREON 6000) EC cap [136487] Oral, PRN, snacks
pancrelipase (CREON 12000) EC cap [136488] Oral, 3 X DAILY (AT MEALTIME)
With meals
pancrelipase (CREON 12000) EC cap [136488] Oral, PRN, snacks
pancrelipase (CREON 24000) EC Cap [136489] Oral, 3 X DAILY (AT MEALTIME)
With meals
pancrelipase (CREON 24000) EC Cap [136489] Oral, PRN, snacks
pancrelipase (ZENPEP) 5000 UNITS EC cap [138296] Oral, 3 X DAILY (AT MEALTIME)
With meals
pancrelipase (ZENPEP) 5000 UNITS EC cap [138296] Oral, PRN, snacks
pancrelipase (ZENPEP) 10000 Unit EC cap [138297] Oral, 3 X DAILY (AT MEALTIME)
With meals
pancrelipase (ZENPEP) 10000 Unit EC cap [138297] Oral, PRN, snacks
pancrelipase (ZENPEP) 15000 Unit EC cap [138298] Oral, 3 X DAILY (AT MEALTIME)
With meals
pancrelipase (ZENPEP) 15000 Unit EC cap [138298] Oral, PRN, snacks
pancrelipase (ZENPEP) 20000 Unit EC cap [138299] Oral, 3 X DAILY (AT MEALTIME)
With meals
pancrelipase (ZENPEP) 20000 Unit EC cap [138299] Oral, PRN, snacks
Vitamins [12017]
Note: Self Administered Medication Program
Documentation [950000]
ONCE For 1 Doses
Patient may self-administer vitamins
Note: Patient may use home supply of vitamins, if
available [950018]
ONCE For 1 Doses
Patient may use home supply of vitamins, if available
multivitamin cystic fibrosis cap [800234] 1 cap, Oral, 1 X DAILY
multivitamin cystic fibrosis cap [800234] 2 cap, Oral, 1 X DAILY
multivitamin cystic fibrosis chew tab PEDS [800235] 1 tab, Oral, 1 X DAILY
multivitamin cystic fibrosis chew tab PEDS [800235] 2 tab, Oral, 1 X DAILY
multivitamin cystic fibrosis soln PEDS [800236] Oral, 1 X DAILY
cholecalciferol (VITAMIN D-3) tab [720036] Oral, 1 X DAILY
Gastric [12018]
ranitidine (ZANTAC) syrup - NOTE: Suggested dose 2 2 mg/kg, Oral, 2 X DAILY
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


mg/kg/dose (Maximum 300 mg/day) [41612] NOTE: Suggested dose 2 mg/kg/dose (Maximum 300
mg/day)
pantoprazole (PROTONIX) susp - NOTE: Suggested
dose 1 mg/kg/dose (Maximum 40 mg/day) [780113]
1 mg/kg, Oral, 1 X DAILY
NOTE: Suggested dose 1 mg/kg/dose (Maximum 40 mg/day)
Bowel Management (Single Response) [19964]
polyethylene glycol (MIRALAX) oral powder [61353] 17 g, Oral, 1 X DAILY
Mixed in beverage
polyethylene glycol (MIRALAX) oral powder [61353] 8.5 g, Oral, 1 X DAILY
Mixed in beverage
Medications - General
Antipyretics (Single Response) [12019]
acetaMINOPHEN (TYLENOL) susp - NOTE: Order for
age greater than 28 days, Suggested dose 15
mg/kg/dose (Maximum 650 mg/dose) [800005]
Oral, EVERY 4 HOURS PRN, fever, maximum 5 dose/24
hours
NOTE: Order for age greater than 28 days, Suggested dose
15 mg/kg/dose (Maximum 650 mg/dose)
acetaMINOPHEN (TYLENOL) tab - NOTE: Order for
patients 45 kg or greater [34149]
650 mg, Oral, EVERY 4 HOURS PRN, fever
NOTE: Order for patients 45 kg or greater
Sucrose for Oral Analgesia [110384]
sucrose (SWEET-EASE) 24% buccal soln [794009] Oral, PRN, pain, mild pain or potentially painful procedures.
See Admin Instructions
Non-categorized [12021]
sodium chloride 0.9% flush 10 mL injection [785055] Flush, PRN, flush/line care
heparin lock flush 10 units/mL 5 mL injection [74548] 50 units, Flush, PRN, flush/line care
Laboratory
Laboratory [9050]
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?
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?
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?
If Conditional, What Condition?
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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?
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?
GGT [GGT] 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?
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL - RN COLLECT, STAT
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? Draw if blood glucose is less
than 40 or greater than 400 mg/dL
Order if Not Done in the Last 90 Days [182582]
HEMOGLOBIN A1C [HA1C] 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?
Order if Not Done in the Last Year [182590]
IMMUNOGLOBULIN E [IGE] 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?
VITAMIN D, 25-HYDROXY BY HPLC [HCLCD25] NEXT DRAW For 1 Occurrences, Routine, Screening for
Vitamin D deficiency is not covered by Medicare. If this is the
reason for the test, please advise the patient of non-coverage
via the ABN process. Coverage is allowed in some other
circumstances. If one of these diagnoses is appropriate for
your patient, please associate the corresponding code with
this order.
252.00 Hyperparathyroidism, unspecified
252.01 Primary Hyperparathyroidism
252.02 Secondary Hyperparathyroidism, Non-Renal
252.08 Other Hyperparathyroidism
252.1 Hypoparathyroidism
268.0 Rickets Active
268.2 Osteomalacia Unspecified
268.9 Established Vitamin D Deficiency (monitoring efficacy
of replacement therapy)
275.3 Disorders of Phosphorus Metabolism
275.41 Hypocalcemia
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


275.42 Hypercalcemia
585.3 Chronic Kidney Disease, Stage III (Moderate)
585.4 Chronic Kidney Disease, Stage IV (Severe)
585.5 Chronic Kidney Disease, Stage V
585.6 End Stage Renal Disease
588.81 Secondary Hyperparathyroidism (of Renal Origin)
733.00 Osteoporosis Unspecified
733.01 Senile Osteoporosis
733.02 Idiopathic Osteoporosis
733.03 Disuse Osteoporosis
733.09 Other Osteoporosis
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
VITAMIN E [HCVITE] NEXT DRAW For 1 Occurrences, Routine, Please advise
patient to fast overnight for 12 hours, avoid alcohol for 12
hours, and refrain from taking daily vitamins prior to blood
draw.
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
FATTY ACID PROFILE, ESSENTIAL [HCESSFA] 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?
Therapeutic Drug Levels/Toxicology - Unit pharmacist will schedule [9051]
Note: Tobramycin Level Per Pharmacy [950025] ONCE For 1 Doses
Tobramycin level, peak 1 to 2 hours after completion of the
infusion of the second dose.
Note: Tobramycin Level Per Pharmacy [950025] ONCE For 1 Doses
Tobramycin midpoint 12-18 hours after second dose
Microbiology [9052]
CULTURE, SPUTUM, CF PATIENT, WITH GRAM
STAIN [HCCFCS]
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?
CULTURE, FUNGAL, WITH SMEAR [HCFCULTS] ONCE, Starting today For 1 Occurrences, Routine, Smears
not routinely performed on CSF. If CSF, order Culture,
Fungal.
Indicate source if other:
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
AFB SMEAR AND CULTURE [HCAFB] 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?
For Patients on Aminoglycosides [104965]
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


URINALYSIS WITH MICROSCOPY [UA] CONDITIONAL - RN COLLECT, 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? Every Monday and Thursday
for patients on Aminoglycosides
Order if Patient is Admitted with Hemoptysis [182591]
DES Gamma Carboxy Prothrombin [RMISC] NEXT AM For 1 Occurrences, Routine
What lab test would you like to have performed? DES
Gamma Carboxy Prothrombin
For questions I can be reached at:
Indicate specimen source if other:
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [9053]
Pulmonary Lab Testing - Spirometry [999992] EVERY MONDAY AND THURSDAY, Starting today with First
Occurrence As Scheduled For 60 Days, Routine
Reason for Exam: Follow-up cystic fibrosis
Specify Test: Spirometry
In Pulmonary Function Lab.
X-RAY CHEST PA & LAT VIEWS [R71020] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered by this
exam? Cystic Fibrosis
Relevant recent/past history? Cystic Fibrosis
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
CT CHEST W/ O IV CONTRAST [R71250] 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? Cystic Fibrosis
Relevant recent/past history? Cystic Fibrosis
Is patient pregnant?
Allergies to IV contrast or iodine?
Last creatinine value? (will auto pull in date and value in
comment):
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.
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Consults
Consults [9054]
Consult Child Life Specialist (Inpatient) [CON0014] ONCE, Starting today For 1 Occurrences, Routine
Activity Level:
Reason for Consult: OTHER
Indication: Cystic Fibrosis, pulmonary exacerbation.
Consult Nutrition (Inpatient) [CON0043] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Delegate to Initiate and Manage Tube Feeding:
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
Indication: Cystic Fibrosis, pulmonary exacerbation.
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:
Consult Occupational Therapy (Inpatient) Eval and Treat
[CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Consult Physical Therapy (Inpatient) Eval and Treat
[CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Consult Pediatric Psychology (Inpatient) [CON0099] ONCE
Purpose of Consult: EVALUATE AND TREAT PATIENT
Reason for Consult:
Consulting Provider:
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Consult Speech Therapy (Inpatient) Eval and Treat
[CON0077]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Notify Hospital School of New Admission
[NURCOM0022]
ONCE, Starting today For 1 Occurrences
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.
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority