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GI - Endoscopy - Adult - Preprocedure

GI - Endoscopy - Adult - Preprocedure - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols, Related


OP - GI - Endoscopy - Adult - Preprocedure [3427]
Intended for Adult Patients Only
Pre-Op Day of Procedure
Premedications for Needle Insertion [106313]
Use lidocaine topical dressing kit for stable patient, no lidocaine allergies, have at least 30 minutes time prior to needing
to use IV
Sodium chloride (bacteriostatic) 0.9% intradermal: Useful for patients requiring urgent IV access; onset is within 1 minute.
Choice of medication should be based on patient’s previous experience/preference, history of lidocaine allergy and ease
of access.
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, peripheral line 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). Do NOT leave on longer than 2 hours. Use for stable
patient, no allergies to lidocaine, with at least 30 minutes time
prior to IV use
Pre-Op Day Of Procedure
lidocaine (XYLOCAINE) 1% injection [39034] 0.1-0.4 mL, Intradermal, PRN, peripheral line insertion - see
Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge needle to
inject solution and create a wheal. Wait 30 seconds to 1
minute then insert IV catheter into center of wheal. Use if IV
is needed within 30 minutes. Choice of medication should be
based on patient’s previous experience/preference, history of
lidocaine allergy and ease of access
Pre-Op Day Of Procedure
sodium chloride (bacteriostatic) 0.9 % injection [50585] 0.05-0.1 mL, Intradermal, PRN, peripheral line insertion - see
Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge needle to
inject solution and create a wheal. Wait 30 seconds to 1
minute then insert IV catheter into center of wheal. Use if IV
is needed within 30 minutes. Choice of medication should be
based on patient’s previous experience/preference, history of
lidocaine allergy and ease of access
Pre-Op Day Of Procedure
IV Fluids [102119]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today For Until specified, Routine
Peripheral IV Device:
Peripheral IV Location:
Peripheral IV Size:
Peripheral IV Status:
Does this need to be inserted/placed?
Pre-Op Day Of Procedure
sodium chloride 0.9% IV BOLUS [730003] 500 mL, Intravenous, ONCE For 1 Doses
Run at 125 mL/hr
Pre-Op Day Of Procedure
Non-Categorized Patient Care Orders [102043]
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting today, Routine
If Conditional, What Condition?
Pre-Op Day Of Procedure
Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA TREATMENT,
Starting today For Until specified, Routine
If Conditional, What Condition?
Pre-Op Day Of Procedure
Contingency Parameters [146958]
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Pr i nted by OL ENSK I , A L L I SON [AXO158] at 5/14/2014 8:23:48 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


Notify [NURCOM0001] 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):
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other:
Conditional Lab Orders [146959]
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL - RN COLLECT, Starting today, 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 < 40
mg/dL or > 400 mg/dL
Page 2 of 2
Pr i nted by OL ENSK I , A L L I SON [AXO158] at 5/14/2014 8:23:48 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority