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IP - IR - Pre Percutaneous Sclerotherapy - Pediatric - Preprocedure [5354]

IP - IR - Pre Percutaneous Sclerotherapy - Pediatric - Preprocedure [5354] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Radiology


IP - IR - Pre Percutaneous Sclerotherapy - Pediatric - Preprocedure [5354]
Patient Care Orders
Vital Signs [142885]
Vital Signs [NURMON0013] ONCE For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
On arrival.
Patient Monitoring [142886]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Place in *** foot or *** hand after patient anesthetized.
Insert and Maintain Urinary Catheter [NURELM0013] CONTINUOUS, Routine, To discontinue this order, enter a
new order for "Discontinue Urinary Catheter".
To modify this order, enter a new order for "Maintain Urinary
Catheter" and make the necessary changes in the new order.
Type: Indwelling Single Lumen
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Nutrition [151214]
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

NPO Except Medications [NUT0001] EFFECTIVE NOW, Starting today For Until specified, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25): NPO
EXCEPT MEDICATIONS
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):
Room Service Class:
As per anesthesia guidelines for outpatients.
Intake and Output [142888]
Void Prior to Transport [NURELM0061] ONCE For 1 Occurrences, Void prior to transport.
Non-Categorized Patient Care Orders [151216]
Nursing Communication [NURCOM0022] ONCE, Procedure to be performed ***.
Please call patient with appointment instructions.
*** called the patient.
Measure Height [NURMON0052] ONCE For 1 Occurrences, Routine
Measure Weight [NURMON0015] ONCE For 1 Occurrences, Routine
Weigh With?
Weigh when?
For Diabetic Patients [151217]
Glucose, POC [IPGLUCOSE] CONDITIONAL - RN COLLECT For 5 Occurrences, Routine,
Glucose, POC should always be ordered in conjunction with
orders for hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult) panel.
If Conditional, What Condition? On Arrival and every 60
minutes for prior glucose less than 60 or greater than 300
mg/dL.
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL - RN COLLECT For 7 Days, STAT
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? Obtain if POC glucose less
than 40 mg/dL or greater than 400 mg/dL.
Contingency Parameters for Patients 3 to 6 Years of Age [151221]
Page 2 of 5
Printed by O'BRIEN, RYLEY P [RPO249] at 12/1/2015 9:11:19 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

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
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
IV Fluids [151223]
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS
sodium chloride 0.9% infusion [64367] Intravenous, CONTINUOUS
Medications
General [151254]
alcohol dehydrated 98% injection [760003] 5 mL, Other, ON CALL For 1 Doses
For percutaneous administration only, NOT for IV use. Send
to AFCH Diagnostic Pavilion #913
dexamethasone (DECADRON) intraVENOUS [800037] Intravenous, ON CALL For 1 Doses
Send to AFCH Diagnostic Pavilion #913
chlorhexidine (PERIDEX) 0.12 % soln MULTIDOSE
[792004]
15 mL, Swish & Spit, ON CALL For 2 Doses
Swish and spit 2x preprocedure.
To cover oral cavity
microfibrillar collagen (AVITENE) powder [45755] Topical, ONCE For 1 Doses
MD to apply to affected area post sclerotherapy treatment
Page 3 of 5
Printed by O'BRIEN, RYLEY P [RPO249] at 12/1/2015 9:11:19 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

sodium tetradecyl (SOTRADECOL) 1% vial [42234] Other, ON CALL For 1 Doses
For percutaneous administration only, NOT for IV use. Send
to AFCH Diagnostic Pavilion #913. RN to document total
dose given in treatment session
sodium tetradecyl (SOTRADECOL) 3% vial [46605] Other, ON CALL For 1 Doses
For percutaneous administration only, NOT for IV use. Send
to AFCH Diagnostic Pavilion #913. RN to document total
dose given in treatment session
doxycycline (VIBRAMYCIN) vial RADIOLOGY ONLY
[785170]
Other, ON CALL For 1 Doses
Do not reconstitute. For percutaneous administration only,
NOT for IV use. Send to AFCH Diagnostic Pavilion #913.
RN to document total dose given in treatment session
Laboratory
Laboratory [151228]
HEMATOCRIT [HCT] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
PLATELET COUNT [PLT] STAT - RN COLLECT, 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?
PROTHROMBIN TIME/INR [PT] STAT - RN COLLECT, 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 WITHOUT DIFFERENTIAL [HEMO] STAT - RN COLLECT, 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] STAT - RN COLLECT, 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] STAT - RN COLLECT, 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?
HCG, QUALITATIVE, URINE [UPREG] STAT - RN COLLECT, 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?
D-DIMER, QUANT [GM1332] STAT - RN COLLECT, 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?
WHITE CELL COUNT [WBC] STAT - RN COLLECT 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 12/1/2015 9:11:19 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

FIBRINOGEN [GM1320] STAT - RN COLLECT 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 5
Printed by O'BRIEN, RYLEY P [RPO249] at 12/1/2015 9:11:19 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org