/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/transplant/,

/clinical/cckm-tools/content/order-sets/inpatient/transplant/name-97913-en.cckm

20170376

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UWHC,UWMF,

Tools,

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

IP - Liver Transplant - Pediatric - Preoperative [2705]

IP - Liver Transplant - Pediatric - Preoperative [2705] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Transplant


IP - Liver Transplant - Pediatric - Preoperative [2705]
Admission Status
Admission Status [84058]
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:
Pre-Op Day Of Procedure
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Pre-Op Day Of Procedure
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Pre-Op Day Of Procedure
Patient Care Orders
Vital Signs [84766]
Vital Signs [NURMON0013] EVERY 8 HOURS, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Pre-Op Day Of Procedure
Activity [84767]
Ad Lib [NURACT0008] CONTINUOUS, Starting today, Routine
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:
Pre-Op Day Of Procedure
Nutrition [84768]
Page 1 of 9
Printed by STRAKA, KEVIN F [KFS1] at 3/13/2017 10:33:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: NPO
NPO Diet: Strict NPO
Bedside Meal Instructions:
Room Service Class:
Pre-Op Day Of Procedure
Intake and Output [84769]
Measure Intake And Output [NURMON0005] SEE COMMENTS, Starting today For Until specified,
Routine, Measure and record intake and output with
each occurrence., Pre-Op Day Of Procedure
Non-Categorized Patient Care Orders [84770]
Measure Height [NURMON0052] ONCE, Starting today For 1 Occurrences, Routine,
On admission., Pre-Op Day Of Procedure
Measure Weight [NURMON0015] ONCE, Starting today For 1 Occurrences, Routine
Weigh With?
Weigh when?
On admission., Pre-Op Day Of Procedure
Pre-Transplant Verfication Flowsheet
[NURCOM0022]
ONCE For 1 Occurrences, Please comment in the
Pre-Transplant Verification Flowsheet. Call B4/6 with
questions (263-8737), Pre-Op Day Of Procedure
Non-Categorized Patient Care Orders for Patients Less Than 2 Years of Age [84771]
Measure Head Circumference [NURMON0038] ONCE, Starting today For 1 Occurrences, Routine,
On admission., Pre-Op Day Of Procedure
Contingency Parameters [84772]
Notify Provider [NURCOM0001] CONTINUOUS
Provider to Notify: Provider
If systolic blood pressure > (mmHg): ***
If systolic blood pressure < (mmHg): ***
If diastolic blood pressure > (mmHg): ***
If diastolic blood pressure < (mmHg): ***
If temperature > (C): 37.5
If temperature < (C):
If heart rate > (bpm): ***
If heart rate < (bpm): ***
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL): 1 milliliter/kilogram/hour
Other:
Pre-Op Day Of Procedure
Intravenous Therapy
Premedication for Needle Insertion [84316]
Lidocaine [152737]
Page 2 of 9
Printed by STRAKA, KEVIN F [KFS1] at 3/13/2017 10:33:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

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
Pre-Op Day Of Procedure
LMX Use Instructions for Premedication Prior to
Needle Insertion [NURCOM0095]
Pre-Op Day Of Procedure
Medications - Intra-Operative
Immunosuppressants [154237]
methylprednisolone sodium succ. (SOLU-
MEDROL) intraVENOUS - NOTE: Suggested
dose 10 mg/kg/dose (Minimum 125 mg/dose;
Maximum 500 mg/dose) [800058]
10 mg/kg, Intravenous, ONCE For 1 Doses
NOTE: Suggested dose 10 mg/kg/dose (Minimum
125 mg/dose; Maximum 500 mg/dose)
IntraOp
Gastric [154240]
ranitidine (ZANTAC) injection [800075] 1 mg/kg, Intravenous, ONCE For 1 Doses
Send ON CALL to OR
IntraOp
Non-Categorized [154241]
bacitracin 50,000 units in sodium chloride 0.9%
200 mL POUR bottle [700309]
Irrigation, ONCE For 1 Doses
Send ON CALL to OR
IntraOp
Laboratory
Laboratory [84782]
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?
Pre-Op Day Of Procedure
PROTHROMBIN TIME/INR [PT] 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?
Pre-Op Day Of Procedure
PTT [PTT] 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?
Pre-Op Day Of Procedure
Page 3 of 9
Printed by STRAKA, KEVIN F [KFS1] at 3/13/2017 10:33:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
Page 4 of 9
Printed by STRAKA, KEVIN F [KFS1] at 3/13/2017 10:33:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

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?
Pre-Op Day Of Procedure
MAGNESIUM [MAG] 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?
Pre-Op Day Of Procedure
PHOSPHATE [PHOS] 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?
Pre-Op Day Of Procedure
AMYLASE [AMYL] 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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
LD, TOTAL [LDH] 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?
Pre-Op Day Of Procedure
AMMONIA [GM2200] 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?
Pre-Op Day Of Procedure
CMV IGG AB [XCMVG] 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?
Pre-Op Day Of Procedure
EBV AB TO VIRAL CAPSID AG, IGG
[HCEBVIGG]
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?
Pre-Op Day Of Procedure
Page 5 of 9
Printed by STRAKA, KEVIN F [KFS1] at 3/13/2017 10:33:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

HEPATITIS A AB, IGG [HAVIGG] 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?
Pre-Op Day Of Procedure
HEPATITIS B SURFACE AG [HBSAG] 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?
Pre-Op Day Of Procedure
HEPATITIS B SURFACE AB (IMMUNE
STATUS) [HBSABI]
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?
Pre-Op Day Of Procedure
HEPATITIS B CORE AB, TOTAL [HBCAB] 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?
Pre-Op Day Of Procedure
HEPATITIS C AB [HCV] 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?
Pre-Op Day Of Procedure
URINALYSIS WITH MICROSCOPY [UA] 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?
Pre-Op Day Of Procedure
CREATININE, URINE [UCRR] 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?
Pre-Op Day Of Procedure
PROTEIN, URINE [UTPR] 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?
Pre-Op Day Of Procedure
CULTURE, URINE [URC] ONCE, Starting today For 1 Occurrences, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
Page 6 of 9
Printed by STRAKA, KEVIN F [KFS1] at 3/13/2017 10:33:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

C REACTIVE PROTEIN [CRPN] 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?
Pre-Op Day Of Procedure
Laboratory - For Patients Receiving CDC High Risk Donor [94389]
HIV-1 RNA, QUANTITATIVE [XHIV1] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, This test is not used for the
diagnosis of HIV-1 infection. This test is used to
determine viral burden in known HIV-1 positive
patients.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? For patients receiving
CDC high risk donor
Pre-Op Day Of Procedure
HEPATITIS C RNA, QUANT, PCR [XHCVRQ] 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? For patients receiving
CDC high risk donor
Pre-Op Day Of Procedure
HEPATITIS B DNA, ULTRA QUANT, PCR
[XHBVD]
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? For patients receiving
CDC high risk donor
Pre-Op Day Of Procedure
EBV AB to Viral Capsid AG, IGG (Single Response) [135575]
Draw only if the patient has had a POSITIVE EBV in the past, they DO NOT need a repeat. If
was negative.patient has never had an EBV drawn or the one they had drawn
EBV AB TO VIRAL CAPSID AG, IGG
[HCEBVIGG]
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?
NOTE: Order if never drawn or if previously negative.,
Pre-Op Day Of Procedure
Not ordered [NURCOM0022] ONCE, Not ordered. Previous result positive., Pre-
Op Day Of Procedure
Varicella AB, IGG/IGM (Single Response) [135593]
If the patient has had a POSITIVE Varicella in the past, they DO NOT need a repeat. Draw only
if patient has never had a Varicella drawn or the one they had drawn was negative.
VARICELLA ZOSTER AB, IGG/IGM [HCVZVGM] 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?
NOTE: Order if never drawn or if previously negative.,
Pre-Op Day Of Procedure
Not ordered [NURCOM0022] ONCE, Not ordered. Previous result positive., Pre-
Op Day Of Procedure
CMV AB, IGG (Single Response) [135595]
Page 7 of 9
Printed by STRAKA, KEVIN F [KFS1] at 3/13/2017 10:33:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

Draw only if the patient has had a POSITIVE CMV in the past, they DO NOT need a repeat. If
was negative.patient has never had a CMV drawn or the one they had drawn
CMV AB, IGG (IMMUNE STATUS) [XCMVG] 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?
NOTE: Order if never drawn or if previously negative.,
Pre-Op Day Of Procedure
Not ordered [NURCOM0022] ONCE, Not ordered. Previous result positive., Pre-
Op Day Of Procedure
Diagnostic Tests and Imaging
Studies [84790]
ECG - 12 Lead Without Rhythm [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: OTHER (COMMENT)
Pre-Op Day Of Procedure
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? Assess for infiltrate
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Pre-Op Day Of Procedure
US ABDOMEN COMPLETE [R76700] ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Radiology Specialty Area: ULTRASOUND
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
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.
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Pre-Op Day Of Procedure
BestPractice
No Hospital Problems have yet been identified. [107349]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing., Pre-Op Day Of Procedure
Blood Bank
ordering.Supplemental [996] Order Set for blood -Adult -Blood Transfusion -to IP Refer
Tests [83980]
Page 8 of 9
Printed by STRAKA, KEVIN F [KFS1] at 3/13/2017 10:33:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

TYPE AND SCREEN [HCTS] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, As good clinical practice and
for patient safety, the Transfusion Service will
automatically crossmatch 2 packed RBCs on all
patients with antibodies to ensure blood would be
available in the event it is needed. If you would like to
opt out of this automatic order for this patient please
contact the UWHC Blood Bank at (608) 263-8367 or
The American Center Lab at (608) 234-6600 as
appropriate., Pre-Op Day Of Procedure
Analgesics (Single Response) [83981]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, ONCE For 1 Doses
Premedication for blood product
Pre-Op Day Of Procedure
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 15 mg/kg
(Maximum 650 mg/dose) [800005]
15 mg/kg, Oral, ONCE For 1 Doses
Premedication for blood product
NOTE: Suggested dose 15 mg/kg (Maximum 650
mg/dose)
Pre-Op Day Of Procedure
Laboratory [83982]
CMV AB, IGG (IMMUNE STATUS) [XCMVG] 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?
Pre-Op Day Of Procedure
HEMATOCRIT [HCT] CONDITIONAL - RN COLLECT For 1 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Release 1 hour post-
infusion of red blood cells
Pre-Op Day Of Procedure
PLATELET COUNT [PLT] CONDITIONAL - RN COLLECT For 1 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Release 1 hour post-
infusion of platelets
Pre-Op Day Of Procedure
PROTHROMBIN TIME/INR [PT] CONDITIONAL - RN COLLECT For 1 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Release 1 hour post-
infusion of plasma
Pre-Op Day Of Procedure
Page 9 of 9
Printed by STRAKA, KEVIN F [KFS1] at 3/13/2017 10:33:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org