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/clinical/cckm-tools/content/order-sets/inpatient/pulmonary/name-98037-en.cckm

201709263

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

IP – Pulmonary – Pediatric – Discharge [5064]

IP – Pulmonary – Pediatric – Discharge [5064] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Pulmonary


IP - Pulmonary - Pediatric - Discharge [5064]
Patient Care Orders
Confirmed Discharge Date/Time [151653]
Confirmed Discharge Date/Time [ADT0013] Confirmed Discharge Date:
Confirmed Discharge Time:
Conditions for Discharge:
Provider to be Present at Discharge?
Why You Were Hospitalized [145901]
Why You Were Hospitalized [NURCOM0073] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, Your Child was hospitalized for ***. His
care included ***.
Activity [145899]
Activity - Up As Tolerated [NURACT0008] Routine
Discharge Activity: Up As Tolerated
Activity - Other [NURACT0008] Routine
Discharge Activity:
Nutrition [145893]
CALORIECystic Fibrosis patients, please consider HIGH PROTEIN, HIGH For
Diet - General (No Modifications) [NUT8888] Routine
General: General (No Modifications)
Diet Modifications:
Other Diet Modifications:
Diet - High Protein, High Calorie [NUT8888] Routine
General:
Diet Modifications: High Protein/High Calorie
Other Diet Modifications:
Avoid Juice [NURDIE0013] Routine
Avoid Juice [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications:
Avoid Juice
Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications:
Nutrition (Single Response) [193736]
CALORIECystic Fibrosis patients, please consider HIGH PROTEIN, HIGH For
Diet - General (No Modifications) [NUT8888] Routine
General: General (No Modifications)
Diet Modifications:
Other Diet Modifications:
Diet - High Protien, High Calorie [NUT8888] Routine
General:
Diet Modifications: High Protein/High Calorie
Other Diet Modifications:
Avoid Juice [NURDIE0013] Routine
Avoid Juice [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications:
Page 1 of 11
Printed by WILLIAMS, HEATHER R [HRS0] at 9/18/2017 11:33:52 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications:
When to Call Your Doctor [145896]
Page 2 of 11
Printed by WILLIAMS, HEATHER R [HRS0] at 9/18/2017 11:33:52 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

When to Call Your Doctor - Peds Pulmonary
[NURCOM0079]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, Contact Numbers:
- If you have questions or concerns about your child,
Monday through Friday, 8am - 4:30pm, please call the
Pediatric Pulmonary Clinic at: 608-263-6420.
- For urgent questions or concerns after hours or on
weekends, call 608-263-6400 and ask for the Pediatric
Pulmonary Doctor on call.
- If you have a serious medical concern, call 911 or
bring your child to the nearest emergency department.
Emergencies: If your child is having difficulty breathing
or struggling to get air and needs immediate
emergency care, please call 911 and arrange for an
ambulance to transport your child to the nearest
Emergency Department.
Questions? Call the American Family Children's
Hospital (AFCH) Pediatric Pulmonary nurse triage line
at 800-824-8924 or 608-263-6420 Option 2, Monday
through Friday 8:00 AM to 4:30 PM, and leave a
message with the scheduler for the Pediatric
Pulmonary Service. Your call will be returned by a
pulmonary nurse within 24 hours. If your child is
currently ill or your call is urgent because your child’s
health may be immediately at risk, please tell the
scheduler.
Test Results: Test results that do not require a
change in your child's plan of care will be mailed to
your child's primary address and will arrive 10-21 days
from the time the test is completed. If the provider
does recommend follow up, a change in medication,
or a change in your child's plan of care based on test
results, the child's primary care giver (parent or
guardian) listed in Health Link will receive a call with
this information.
Prescriptions: If your child needs a prescription
renewed, please contact your pharmacy and the
pharmacy will fax a request to us. Renewal requests
can take 3-5 days to complete and are processed
Monday through Friday during regular clinic hours.
Please plan ahead. If you are not making a follow up
appointment today, please keep in mind that we may
not renew prescriptions if you have not been seen in
the AFCH Pulmonary Clinic in over a year.
Documents and Forms: Please bring needed forms to
Page 3 of 11
Printed by WILLIAMS, HEATHER R [HRS0] at 9/18/2017 11:33:52 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

appointments or fax to Pediatric Pulmonary Office:
608-263-0510. Please allow a minimum of 5 business
days for completion.
Weekends, Nights, and Holidays: If you need to
speak to a pulmonologist urgently or if you are
currently on your way with your child to the UW
Emergency Department, please phone the AFCH
paging operator at 608-263-6420 and ask for the
pediatric pulmonologist on call.
Appointments and Cancellations: Please call 800-
824-8924 or 608-263-6420 Option 2 to reschedule or
cancel clinic appointments.
When to Call Your Doctor - PCP [NURCOM0079] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, If @FNAME@ has fever, or you
have other general pediatric questions or concerns
call your Primary Care Provider, @PCP@, at
@PCPPH@.
Nights and weekends:
For urgent general pediatric needs during evenings
and weekends, call your Primary Care Provider's
office (@PCPPH@) and ask to be connected to their
after hours line.
If you cannot reach a provider, and you have a serious
medical concern, call 911 or bring your child to the
nearest emergency department.
When to Call Your Doctor - Subspecialties
[NURCOM0079]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, Your child received care from a
pediatric subspecialist during their hospitalization. To
contact a provider from the pediatric specialty team
Monday-Friday 8:00 a.m. to 4:30 p.m., use the phone
numbers listed below: {subspecialty phone
numbers:3022232} For urgent subspecialist medical
needs during evenings and weekends, call 608-263-
6400 and ask for the Pediatric *** provider on-call. If
you cannot reach a provider, and you have a serious
medical concern, call 911 or bring your child to the
nearest emergency department.
Anticipation of Clinic Appointments or Outpatient Visits [230353]
Page 4 of 11
Printed by WILLIAMS, HEATHER R [HRS0] at 9/18/2017 11:33:52 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Anticipation of Clinic Appointments or Outpatient
Visits [NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, Always bring your home respiratory
equipment and supplies when leaving home for a
clinic visit or outpatient visit. Be sure to bring your "To
Go Bag" and supplies like your vent, vest, IPV, cough
assist, etc.
Discharge Instructions - Cystic Fibrosis
Airway Clearance [193744]
Airway Clearance [NURCOM0071] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, • Please resume airway clearance
twice per day when well and increase to 3 times per
day when sick.
• INHALED MEDICATIONS PRIOR TO AIRWAY
CLEARANCE
{UWIP INHALED MEDICATIONS PRIOR TO AIRWAY
CLEARANCE:23870}
• AIRWAY CLEARANCE
{UWIP AIRWAY CLEARANCE:23871}
• INHALED MEDICATIONS AFTER AIRWAY
CLEARANCE
- Inhaled Corticosteroids
{UWIP INHALED MEDICATIONS AFTER AIRWAY
CLEARANCE INHALED CORTICOSTEROIDS:23872}
- Aerosolized Antibiotic
{UWIP INHALED MEDICATIONS AFTER AIRWAY
CLEARANCE AEROSOLIZED ANTIBIOTIC:23874}
• Medication changes include: ***
• Home antibiotic therapy: ***
Pulmonary Function Test [193747]
Pulmonary Lab Testing [999992] Routine
Reason for Exam: Hospital Follow Up
Specify Test: Spirometry
Specify location (if desired): American Family
Childrens Hospital
Please coordinate follow up appointment
Follow Up Appointments [193846]
Schedule Appointment - Cystic Fibrosis
[NURCOM0026]
Routine
Reason for Hospital Follow Up Appointment: Cystic
Fibrosis
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty: Pediatric Pulmonary Clinic
Discharge Instructions - Sleep Study
AFCH Respiratory Therapy Sleep Study [230356]
AFCH Respiratory Therapy Sleep Study [230358]
Sleep Study Results [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Your respiratory therapy sleep
study results showed {RT Sleep Study
Results:3000051}.
The following changes were made to your device ***.
Page 5 of 11
Printed by WILLIAMS, HEATHER R [HRS0] at 9/18/2017 11:33:52 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Medications at Home [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Please continue on your current
medications.
Wisconsin Sleep Study Discharge Instructions [193748]
Sleep Study Discharge Instructions [193850]
When to Call Your Doctor [NURCOM0079] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, • If there are other health
questions like fever, cough or other general health
issues, please contact your primary care doctor.
• If there is significant redness or irritation on the skin
where the sleep study monitors were placed, lotion
or hydrocortisone cream can be applied for comfort.
If redness lasts more than 1-2 days, please contact
your primary care doctor.
• If you need to speak to a pulmonologist urgently or
if you are currently on your way with your child to the
UW Emergency Department, please phone the
AFCH paging operator at 608-263-6420 and ask for
the pediatric pulmonologist on call.
Sleep Study Results [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, • A specially trained sleep
doctor will review the results of the sleep study the
morning after the sleep study is finished. The
pulmonologist will provide the results of the sleep
study to you within the week after the sleep study. If
there are questions about the results of the sleep
study, please contact the physician who ordered the
sleep study.
• If there are ventilator changes or CPAP/BIPAP
changes that need to be done because of the sleep
study results, the pulmonologist will discuss this with
you and then an order will be sent to your durable
medical equipment provider (DME) with those
changes.
Medications at Home [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, • Please continue on your
current medications
Discharge Instructions - Tracheostomy
Trach - Equipment Care and Instructions [145927]
Page 6 of 11
Printed by WILLIAMS, HEATHER R [HRS0] at 9/18/2017 11:33:52 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Equipment and Care Instructions for NON-Cuffed
Trach Tubes - SHILEY [NURCOM0022]
Routine, - Current SHILEY Trach Tube Size: ***
- Step Down Trach Tube Size (must be a half of a size
down): ***
- MUST HAVE BOTH TUBE SIZES AVAILABLE AT
ALL TIMES.
- Change trach tube weekly and as needed.
- Each caretaker to do a trach tube change at least
every 6 months
CLEANING INSTRUCTIONS FOR NON-CUFFED
TRACH TUBES AND OBTURATOR
- Clean tube with soapy water using obturator to clear
mucus from the tube.
- Rinse with sterile water then soak in 2 parts sterile
water to 1 part vinegar solution for 20-30 minutes and
re-rinse in sterile water and let air dry thoroughly
- Place in a clean container for next use.
Equipment and Care Instructions for NON-Cuffed
Trach Tubes - BIVONA [NURCOM0022]
Routine, - Current BIVONA Trach Tube Size: ***
- Step Down Trach Tube Size (must be a half of a size
down): ***
- MUST HAVE BOTH TUBE SIZES AVAILABLE AT
ALL TIMES.
- Change trach tube weekly and as needed.
- Each caretaker to do a trach tube change at least
every 6 months
CLEANING INSTRUCTIONS FOR NON-CUFFED
BIVONA TRACH TUBE AND OBTURATOR
-Clean trach tube of secretions in soapy water and
rinse.
-Boil distilled water then place tube in boiling water,
cover and remove from heat.
-When the water is cool to the touch, remove trach
tube and allow to air dry.
-Store in sterile or clean container for next use.
Equipment and Care Instructions for Cuffed Trach
Tubes - SHILEY [NURCOM0022]
Routine, - Current SHILEY trach tube size: ***
- Step Down Trach Tube Size (must be a half size
down): ***
- MUST HAVE BOTH TUBE SIZES AVAILABLE AT
ALL TIMES.
- *** mL of {UWIP TRACH TUBE OPTIONS:22852} in
cuff
- Inflation time ***, deflation time ***
- Change trach tube every {UWIP TRACH TUBE
CHANGE:22853} weeks and as needed.
- Each caretaker to do a trach tube change at least
every 6 months
CLEANING INSTRUCTIONS FOR CUFFED TRACH
TUBES
{UWIP TRACH TUBE CLEANING
RECOMMENDATION:22855}
Page 7 of 11
Printed by WILLIAMS, HEATHER R [HRS0] at 9/18/2017 11:33:52 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Equipment and Care Instructions for Cuffed Trach
Tubes - BIVONA [NURCOM0022]
Routine, - Current BIVONA trach tube size: ***
- Step Down Trach Tube Size (must be a half size
down): ***
- MUST HAVE BOTH TUBE SIZES AVAILABLE AT
ALL TIMES.
- *** mL of {UWIP TRACH TUBE OPTIONS:22852} in
cuff
- Inflation time ***, deflation time ***
- Change trach tube every {UWIP TRACH TUBE
CHANGE:22853} weeks and as needed.
- Each caretaker to do a trach tube change at least
every 6 months
CLEANING INSTRUCTIONS FOR CUFFED BIVONA
TRACH TUBES
-Clean trach tube of secretions in soapy water and
rinse.
-Boil distilled water then place tube in boiling water,
cover and remove from heat.
-When the water is cool to the touch, remove trach
tube and allow to air dry.
Trach Suction [NURCOM0071] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, - Suction with *** Fr. Suction catheters
only to the end of the tracheostomy tube.
- Suction as needed for secretions, can apply suction
while inserting and withdrawing the catheter.
- If unable to clear secretions or in distress, suction
just beyond end of the trach tube.
- Instill normal saline as needed for thick secretions.
- Set suction at 80-100 mmHg
- DeLee suction catheters *** Fr. available use as
needed.
Trach - Safety [NURCOM0071] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, - {UWIP TRACH SAFETY:30021753}
- Use manual resuscitation bag as needed for heart
rate less than ***, cyanotic episodes, respiratory
distress or other emergencies.
Ventilator - Equipment Instructions [146031]
Page 8 of 11
Printed by WILLIAMS, HEATHER R [HRS0] at 9/18/2017 11:33:52 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

LTV Ventilator [NURCOM0071] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, - Brand: LTV {UWIP LTV
VENTILATOR:30009965}
- {UWIP LTV PRESSURE CONTROL:22128}, {UWIP
SIMV ASSIST CPAP:3000995}
- rate
- {UWIP PRESSURE TIDAL CONTROL:3000994}
- Pressure support: ***
- PEEP ***
- Sensitivity: ***
- I time *** Seconds
- FIO2 ***
ALARMS
- High Pressure alarm: ***
- Low pressure alarm: ***
- Minute Ventilation: ***
- Apnea alarm *** seconds
- High pressure delay {UWIP ZERO-TWO:3000993}
- Low pressure delay all breaths
- High PEEP ***
- Low PEEP ***
- Patient assist ***
- Flow termination ***%
- PS time termination *** seconds
- PC flow term {On/Off:11043}
- Rise profile ***
- Leak compensation on
- Alarm volume *** dB
Page 9 of 11
Printed by WILLIAMS, HEATHER R [HRS0] at 9/18/2017 11:33:52 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Trilogy Ventilator [NURCOM0071] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, - Brand: Respironics Trilogy - {UWIP
TRILOGY BRAND SELECT:3000992}
- {UWIP TRILOGY SELECT:3000991}
- Mode: ***
- Inspiratory pressure: ***
- Pressure support: ***
- Respiratory Rate: ***
- PEEP: ***
- Inspiratory time: ***
- Trigger type: {UWIP TRILOGY AUTO TRAK FLOW
TRIGGER:3000990} ***
- Flow trigger sensitivity (lower more sensitive):{UWIP
LPM SELECT:3000899} : ***
- Flow Cycle sensitivity (high more sensitive):{UWIP
CYCLE SENSITIVITY:3000898}: ***
- Rise Time: {UWIP ZERO-SIX:3000897} (x 100
msec): ***
ALARMS
- Apnea alarm: ***
- Disconnect alarm: *** seconds
- Low Vte (passive circuit): ***
- High Vt: ***
- Low Vt: ***
- High Minute ventilation: ***
- Low respiratory rate: ***
- High respiratory rate: ***
Humidity Instructions [3000897]
Trach - Humidity for NON-Ventilated Patients
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, - Heated humidification via trach collar
at 34-37 degrees Celsius.
- It CANNOT be used during travel.
- May use Heat Moisture Exchanger (artificial nose) for
*** hours, *** times per day.
- May administer nebulized saline using a portable
nebulizer for up to 30 minutes, *** times per day.
Trach - Humidity for Ventilated Patients
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, - {UWIP TRACH HUMIDITY
VENTILATED PATIENTS:22848}
- Patient may be off ventilator *** hours per day.
- Ensure heated humidity via ventilator is used over
night and when no other form of humidity is being
used.
Home Oxygen [146036]
Trach - Continuous Home Oxygen
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, - Patient is on continuous oxygen via
{UWIP TRACH HOME OXYGEN
CONTINUOUS:30022429}
- May use Ambu bag at 5 Liters/minutes as needed for
emergencies
Page 10 of 11
Printed by WILLIAMS, HEATHER R [HRS0] at 9/18/2017 11:33:52 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Trach - As Needed Home Oxygen
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, - Patient is on oxygen as needed
- May start Oxygen at *** Liters/minute when oxygen
saturation drops below ***, or there are other signs of
respiratory distress up to a maximum *** Liters/minute.
- Oxygen may be administered via {UWIP TRACH
HOME OXYGEN AS NEEDED:30022430}
- May use Ambu bag at 5 Liters/minutes as needed for
emergencies
Wound Care [146037]
Wound Care - Trach Site Care [NURWND0015] Routine, - Clean trach site with sterile water and q-tips
twice daily and as needed.
- Use velcro trach tube holders, change daily and as
needed if soiled. You may wash and reuse the velcro
trach tube holders.
- Clean neck with soap and water, dry thoroughly.
- May use {UWIP TRACH SITE
DRESSING:30022766}
Wound Care - G-tube Site Care [NURWND0015] Routine, - Clean stoma with soap and water twice
daily and as needed.
- May use pre-split 2x2 or 4x4 as needed around
g-tube site.
- Please secure G-tube tubing in place.
Other Patient Care Instructions [146038]
Home Care Orders after Discharge
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, Home Care Orders. Monitor vital signs
and perform a COMPLETE assessment every shift
and as needed. Notify provider for
Heart Rate > ***
Heart Rate < ***
Respiratory Rate > ***
Respiratory Rate < ***
Temperature > ***
SPO2 < ***
Page 11 of 11
Printed by WILLIAMS, HEATHER R [HRS0] at 9/18/2017 11:33:52 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org