/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/delegationpractice-protocols/,/clinical/cckm-tools/content/delegationpractice-protocols/inpatient-delegation-protocols/,/clinical/cckm-tools/content/delegationpractice-protocols/inpatient-delegation-protocols/related/,

/clinical/cckm-tools/content/delegationpractice-protocols/inpatient-delegation-protocols/related/name-97322-en.cckm

201605126

page

100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Delegation/Practice Protocols,Inpatient Delegation Protocols,Related

Cardiac Surgery - Adult - Postoperative

Cardiac Surgery - Adult - Postoperative - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols, Related


IP - Cardiac Surgery - Adult - Postoperative [2821]
Intended for Adult Patients Only
Admission Status
Admission Status [95802]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: CARDIAC SURGERY
Rationale for LOS greater than 2 midnights:
Post-Op/Phase II
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [144143]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/servlet/Satellite?
cid=1126666624583&pagename=B_EXTRANET_UWH_HOME%
2FFlexMemberFile%2FLoad_File&c=FlexMemberFile
High VTE Risk with Low Bleed Risk [130117]
enoxaparin (LOVENOX) injection [800040] 40 mg, Subcutaneous, EVERY 24 HOURS
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 HOURS Starting
tomorrow at 6:00 AM
Begin Postoperative Day 1
Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
High VTE Risk with High Bleed Risk (Single Response)
[129757]
Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Post-Op/Phase II
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
Post-Op/Phase II
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered [COR0008] ONCE, Routine
Reason Not Ordered:
Procedure
For TA-TAVI Patients Only [135476]
TA - TAVI [135439]
TROPONIN [GM2447] EVERY 2 HOURS, Starting today For 3 Occurrences,
Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Draw for three occurrences or until peak, Post-Op/Phase II
clopidogrel (PLAVIX) tab [720168] 75 mg, Oral, 1 X DAILY, Post-Op/Phase II
aspirin chew tab [720164] 81 mg, Oral, 1 X DAILY Starting today with First Dose
Include Now
Administer first dose STAT
Post-Op/Phase II
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg):
Page 1 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


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):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other:
Notify provider: chest pain, rhythm change, failure to
sense, hematoma or bleeding at puncture site, change in
neurovascular exam or affected extremity including pain,
cool/cold to touch, numbness or tingling, Post-Op/Phase II
Wound Care [NURWND0015] CONTINUOUS, Routine
Wound Type: Closed - Incision
Wound Site: Chest
Wound Location:
Assess Frequency:
Care Frequency: 1X DAILY
Wash With: Soap and Water
Irrigate/Rinse With: Other (Comment)
Apply (Must also enter separate medication order to obtain
drug):
Primary Dressing: Gauze
Secondary Dressing:
Assess frequency every 15 minutes x 4, then every 30
minutes x 4, then every 1 hour x 4, then every 4 hours,
Post-Op/Phase II
Transthoracic Resting Echocardiogram [ECH0003] ONCE, Starting 11/26/14 For 1 Occurrences, Routine
Reason for exam: TAVI
Do you want Agitated Bubble Study?
Is patient mechanically ventilated?
Is patient ICU status?
Does patient need continuous monitoring?
Patient Care Orders
Vital Signs [87678]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 15 minutes times 4, then every 30 minutes times 4,
then every hour., Post-Op/Phase II
Patient Monitoring [87681]
Measure Arterial Line [NURMON0060] CONTINUOUS, Starting today For Until specified, Post-
Op/Phase II
Measure Hemodynamic Parameters [NURMON0023] CONTINUOUS, Starting today, Routine
Pulmonary Artery Systolic Pressure (mmHg): Other
(Comment)
Pulmonary Artery Diastolic Pressure (mmHg): Other
(Comment)
Pulmonary Artery Mean Pressure (mmHg): Other (Comment)
Page 2 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


Pulmonary Artery Wedge Pressure (mmHg):
Central Venous Pressure (mmHg): Other (Comment)
Central Venous Pressure (mmH2O):
Cardiac Output: Q4 Hours
Cardiac Output Method: Thermodilution
Cardiac Index: Q4 Hours
Systemic Vascular Resistance: Q4 Hours
Pulmonary Vascular Resistance: Q4 Hours
Pulmonary Vascular Resistance Index:
Stroke Volume (mL/beat):
Stroke Volume Index:
Systemic Vascular Resistance Index:
Left Cardiac Work Index:
Right Cardiac Work Index:
Left Ventricular Stroke Work Index:
Right Ventricular Stroke Work Index:
Pulmonary Capillary Wedge Pressure (mmHg):
Measure with FloTrac? No
Every 15 minutes times 4, then every 30 minutes times 4,
then every hour. If no Drip every 2 hours., Post-Op/Phase II
Cardiac Rhythm Monitoring - Adult [NURMON0010] CONTINUOUS, Routine
Notify Provider:
Functional Cardiac Defibrillator Present:
Measure Pulmonary Artery Pressure- Continuous
[NURMON0023]
CONTINUOUS, Routine
Pulmonary Artery Systolic Pressure (mmHg): Other
(Comment)
Pulmonary Artery Diastolic Pressure (mmHg): Other
(Comment)
Pulmonary Artery Mean Pressure (mmHg): Other (Comment)
Measure with FloTrac? No
Continuous, Post-Op/Phase II
Activity [125668]
Activity Bedrest While Intubated [NURACT0008] SEE COMMENTS, Starting today For 1 Weeks, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: strict bedrest
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Increase activity to dangle once patient is extubated., Post-
Op/Phase II
Elevate Head Of Bed Unless Chest Is Open
[NURACT0002]
Equal to (degrees): 30
Greater than (degrees):
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting today, Post-Op/Phase II
High Fowler's Position During Weaning [NURACT0011] CONTINUOUS, Starting today, Post-Op/Phase II
Dangle With Leg Extension Exercises After Extubation
[NURACT0008]
CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE: 3x daily
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
Page 3 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Once extubated, increase activity to dangle., Post-Op/Phase
II
Activity Chair [NURACT0008] CONTINUOUS, Routine
AD LIB:
AMBULATE:
CHAIR: 3x daily
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
To chair if tolerate dangling, Post-Op/Phase II
Activity Ambulate [NURACT0008] CONTINUOUS, Routine
AD LIB:
AMBULATE: 4x daily
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Once pulmonary catheter is removed, Post-Op/Phase II
Reposition Patient [NURACT0005] Type:
Routine, SEE COMMENTS, Starting today, Every 2 hours.,
Post-Op/Phase II
Sternal Precautions [PRECAU0010] CONTINUOUS, Starting today, Routine, Sternal Precautions:
No lifting greater than 8 pounds.
No pushing/pulling with arms during transfers.
No shoulder elevation past 90 degrees., Post-Op/Phase II
Nutrition [87684]
NPO Except Medications [NUT0001] EFFECTIVE NOW, Starting today, 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:
Page 4 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


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:
Post-Op/Phase II
Respiratory [87685]
Respiratory Therapy per Protocol [RT0035] CONTINUOUS, Starting today, Routine
Protocol Type:
FiO2 100%, Post-Op/Phase II
Mechanical Ventilation - Adult [117146]
Provide Manual Resuscitator at Bedside [RT0039] CONTINUOUS, Routine
Mechanical Ventilation [RT0028] CONTINUOUS, Routine, For ADULT patients order
chlorihexidene gluconate (PERIDEX) 0.12% soln 15 mL to
swab oral cavity 2x daily while on ventilation.
Ventilator Management:
Mode:
Set Rate/Min:
Tidal Volume (Multiplier x Ideal Body Weight): 6
PEEP (cmH2O):
FiO2 (%):
Pressure Support:
Pressure Control:
Wean: Per Cardiothoracic Surgery Protocol
P High (cmH20):
P Low (cmH20):
T High (sec):
T Low (sec):
Ventilator Management:
Refer to Cardiac Surgery, Transplant, and VAD Early
Extubation Algorithm
chlorhexidine (PERIDEX) 0.12 % soln MULTIDOSE
[792004]
15 mL, Mouth/Throat, 2 X DAILY Starting today
Use to swab oral cavity. Discontinue when patient no
longer on ventilation.
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today, Routine, Post-Op/Phase II
Oxygen Therapy [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%):
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 90
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Post-Extubation, Post-Op/Phase II
Wound/Chest Tube Care [87688]
Wound Care [NURWND0015] CONTINUOUS, Starting today, Routine
Wound Type: Closed - Incision
Wound Site: Other (Comment)
Wound Location: Other (Comment)
Assess Frequency: EVERY 8 HOURS
Care Frequency: SEE COMMENTS
Wash With:
Irrigate/Rinse With:
Apply (Must also enter separate medication order to obtain
drug):
Page 5 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


Primary Dressing: Other (Comment)
Secondary Dressing:
Dressing change 24 hours postoperatively and then daily.
Remove Ace wrap on leg incision site on Postoperative Day
1.
Sterile technique while chest tubes are in. Clean technique
when chest tubes are out., Post-Op/Phase II
Wound Care [NURWND0015] CONTINUOUS, Starting today, Routine
Wound Type: Open
Wound Site: Chest
Wound Location:
Assess Frequency: EVERY 8 HOURS
Care Frequency:
Wash With:
Irrigate/Rinse With:
Apply (Must also enter separate medication order to obtain
drug):
Primary Dressing: Other (Comment)
Secondary Dressing:
Provider to perform dressing change if patient's chest is still
open., Post-Op/Phase II
Maintain Chest Tube [NURTAD0001] CONTINUOUS, Starting today For Until specified, Routine
Location: Other (Comment Required)
Position: Anterior
Drainage Options: -20 cm wall suction
Site Assessment Frequency: EVERY 8 HOURS
Care Frequency: 1 X DAILY
Wash With: Chlorhexidine Sponge
Primary Dressing: Gauze
Secondary Dressing:
Location applies to all chest tubes., Post-Op/Phase II
Measure Chest Tube Output [NURTAD0013] SEE COMMENTS, Starting today For Until specified, Routine,
Every 15 minutes times 4, then every 30 minutes times 4,
then every hour., Post-Op/Phase II
Intake and Output [87689]
Measure Intake And Output [NURMON0005] SEE COMMENTS, Starting today, Routine, Every 15 minutes
times 4, then every 30 minutes times 4, then every hour.,
Post-Op/Phase II
Non-Categorized Patient Care Orders [87690]
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With?
Weigh when?
Post-Op/Phase II
OG Tube Placement - Adult [120995]
Insert and Maintain Orogastric Tube [NURTAD0015] CONTINUOUS, Routine
Options: Low, Continuous Suction
Flush with:
Flush Frequency:
Check Residual:
Does this need to be inserted/placed?
Device Status: Ready For Use
No anti-reflux valve. Confirm placement prior to use.
Discontinue when extubated.
Refer to Policy 2.20 Enteral Tubes Used for Instillation of
Fluids, Medications, or Feeding., Post-Op/Phase II
X-RAY ABDOMEN AP VIEW (KUB) [R74000] CONDITIONAL For 3 Days, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? Orogastric tube placement
What specific question(s) would you like answered by this
Page 6 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


exam? Evaluate orogastric tube placement
Relevant recent/past history? Cardiac Surgery
Is patient pregnant?
If being performed remotely, where?
Last patient weight?
Transport Method: Floor Determined/Entered
If Conditional, What Condition? Evaluate orogastric tube
placement. The location of orogastric tube should be
confirmed prior to the instillation of fluids, medications, or
feedings. Refer to Policy 2.20 Enteral Tubes Used for
Instillation of Fluids, Medications, or Feeding
Post-Op/Phase II
Insert and Maintain Urinary Catheter [NURELM0013] CONTINUOUS, Starting today, 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: Monitoring of Urine Output
Initiate Urinary Catheter Removal Protocol? (NP/PA Must
Select "No"): No: Urology or Gyn/Onc Patient/Other
Details: To Dependent Drainage
Irrigate With:
Irrigation Frequency:
Does this need to be inserted/placed?
Post-Op/Phase II
Use Warm Air Blanket as Needed for Temperature Less
Than 36.0 Degrees Celsius [NURTRT0027]
PRN, Starting today, Routine, Use Warm Air Blanket as
Needed for Temperature Less Than 36.0 Degrees Celsius,
Post-Op/Phase II
Notify Primary Service to Place Diabetes Management
Service Consult Order if Patient Has A Single Blood
Glucose Result Greater Than 180 milligrams per
deciliter within 24 hours of anesthesia end time.
[NURCOM0022]
CONTINUOUS, Starting today, Post-Op/Phase II
Initiate B4/5 Insulin Infusion Protocol [NURMON0062] CONTINUOUS, Routine
Temporary Pacemaker Epicardial Settings (Single Response) [88596]
Epicardial Pacemaker Settings (ADULT) [NURTRT0077] ON, Starting today, Routine, Use .epicardialpacemaker in the
comments field to create the list of pacemaker setting fields.,
Post-Op/Phase II
Contingency Parameters [87692]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 150
If systolic blood pressure < (mmHg): 80
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <: 400
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 90
If urine output < (mL): 30 mL/hour for 2 consecutive hours
Other: Mean arterial pressure less than 60 or greater than
90mmHg
Cardiac Arrest/Change In Rhythm
Page 7 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


Resuscitation Orders [142071]
Resuscitation Progression - Ventricular
Fibrillation/Pulseless Ventricular Tachycardia
(Witnessed) [NURVENT0018]
CONTINUOUS, Starting today, Routine, Post-Op/Phase II
Resuscitation Progression - Asystole/Severe
Bradycardia [NURVENT0019]
CONTINUOUS, Starting today, Routine, Post-Op/Phase II
Resuscitation Progression - Pulseless Electrical Activity
[NURVENT0020]
CONTINUOUS, Starting today, Routine, Post-Op/Phase II
Intravenous Therapy
Premedications for Needle Insertion [106327]
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
Post-Op/Phase II
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
Post-Op/Phase II
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
Post-Op/Phase II
IV Fluids [87694]
dextrose 5%-NaCl 0.2% infusion [51615] at 5 mL/hr, Intravenous, CONTINUOUS
Per CVP port
Post-Op/Phase II
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today, Routine
Peripheral IV Size:
Peripheral IV Location:
Peripheral IV Device:
Peripheral IV Status: Capped
Does this need to be inserted/placed?
Post-Op/Phase II
Medications - Anti-Infectives
First Line for Valve Patients (Single Response) [141562]
Patients who are 40-159 kg [141582]
cefuroxime (ZINACEF) intraVENOUS [800030] 1.5 g, Intravenous, EVERY 8 HOURS For 2 Doses, Post-
Op/Phase II
Page 8 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


vancomycin (VANCOCIN) intraVENOUS [800084] 15 mg/kg, Intravenous, EVERY 12 HOURS For 1 Doses,
Post-Op/Phase II
Patients who are 160 kg or greater [141583]
cefuroxime (ZINACEF) intraVENOUS [800030] 3 g, Intravenous, EVERY 8 HOURS For 2 Doses, Post-
Op/Phase II
vancomycin (VANCOCIN) intraVENOUS - NOTE:
Vancomycin should be dosed with a total body weight if
equal to or greater than 120 kg (Maximum Dose 2
grams) [800084]
15 mg/kg, Intravenous, EVERY 12 HOURS For 1 Doses,
Post-Op/Phase II
First Line for CABG patients (Single Response) [141567]
cefuroxime (ZINACEF) intraVENOUS - NOTE: Patients
who are 40-159 kg [800030]
1.5 g, Intravenous, EVERY 8 HOURS For 2 Doses, Post-
Op/Phase II
cefuroxime (ZINACEF) intraVENOUS - NOTE: Patients
who are 160 kg or greater [800030]
3 g, Intravenous, EVERY 8 HOURS For 2 Doses, Post-
Op/Phase II
Patients with Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single Response) [141563]
Patients who are 40-159 kg [141561]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, EVERY 12 HOURS For 1 Doses,
Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS [800084] 15 mg/kg, Intravenous, EVERY 12 HOURS For 1 Doses,
Post-Op/Phase II
Patients who are 160 kg or greater [141581]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, EVERY 12 HOURS For 1 Doses,
Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS [800084] 15 mg/kg, Intravenous, EVERY 12 HOURS For 1 Doses,
Post-Op/Phase II
Medications
Analgesics [87696]
meperidine (DEMEROL) injection [800195] 25 mg, Intravenous, ONCE PRN For 1 Doses, rigors, Post-
Op/Phase II
HYDROmorphone PF (DILAUDID) injection RANGE
[750050]
0.2-0.4 mg, Intravenous, EVERY 1 HOUR PRN For 24 Hours,
pain, for 3 Minutes, Post-Op/Phase II
acetaMINOPHEN (TYLENOL) tab [34150] 1,000 mg, Oral, 4 X DAILY For 5 Days, Post-Op/Phase II
oxycodone tab RANGE [750032] 5-10 mg, Oral, EVERY 3 HOURS PRN For 5 Days, pain,
Post-Op/Phase II
Anti-emetics [87697]
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 24 HOURS PRN,
nausea/vomiting, Post-Op/Phase II
Bowel Management [87698]
bisacodyl (DULCOLAX) rectal suppository - NOTE: Give
on POD#2 [35231]
10 mg, Rectal, ONCE Starting 11/26/14 For 1 Doses
NOTE: Order on postoperative day 2
Post-Op/Phase II
bisacodyl (DUCOLAX) rectal suppository - Use if no
response to first line rescue within 24 hours [35231]
10 mg, Rectal, 1 X DAILY PRN Starting tomorrow,
constipation
Hold for loose stool. Use as second line rescue therapy if no
response to first line rescue therapy within 24 hours and
notify Primary Team.
Post-Op/Phase II
magnesium hydroxide (MILK OF MAGNESIA) susp
[65443]
30 mL, Oral, ONCE Starting 11/26/14 For 1 Doses
Hold if patient NPO
Post-Op/Phase II
senna-docusate (SENOKOT-S) 8.6-50 mg per tab
[60530]
2 tab, Oral, 2 X DAILY Starting tomorrow
Hold for loose stool or suspected obstruction. Use rescue
therapy after first 48hrs if inadequate response to scheduled
bowel management.
polyethylene glycol (MIRALAX) oral powder [61353] 17 g, Oral, 1 X DAILY PRN Starting tomorrow, constipation
Hold for loose stool or suspected obstruction. Use as first line
Page 9 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


rescue therapy if inadequate response to scheduled bowel
management.
Anti-anxiety [87699]
midazolam (VERSED) injection RANGE [750056] 1-2 mg, Intravenous, EVERY 6 HOURS PRN, agitation or
anxiety while on ventilator, Post-Op/Phase II
Potassium Supplementation (Single Response) [87702]
potassium chloride 20 mEq/ 100 mL bag [46255] 20 mEq, Intravenous, PRN, potassium supplementation - See
Admin Instructions
For potassium level between 3.8 - 4.0 mmol/L give 20 mEq x1
For potassium level between 3.5 - 3.7 mmol/L give 20 mEq x2
For potassium level between 3.2 - 3.4 mmol/L give 20 mEq x3
for 60 Minutes, Post-Op/Phase II
potassium chloride 10 mEq/100 mL bag - NOTE: Renal
dosing [46253]
10 mEq, Intravenous, PRN, potassium supplementation - See
Administration Instructions
For potassium level between 3.5 - 3.7 mmol/L give 10 mEq x1
For potassium level between 3.2 - 3.4 mmol/L give 10 mEq x2
for 60 Minutes
NOTE: Renal dosing
Post-Op/Phase II
Magnesium Supplementation (Single Response) [87703]
Magnesium Supplemental Scale [950039] PRN - NOTIFY PHARMACY WHEN NEEDED, PRN
comment: magnesium supplementation - See Administration
Instructions
For serum magnesium 1.6-1.8 mg/dL give 0.05 g/kg IV x1
over 12 hours
For serum magnesium 1.0-1.5 mg/dL give 0.1 g/kg IV x1 over
24 hours
For serum magnesium less than 1 mg/dL give 0.15 g/kg IV x1
over 24 hours
Post-Op/Phase II
Magnesium Supplemental Scale - NOTE: Order for
RENAL Dosing [950039]
PRN - NOTIFY PHARMACY WHEN NEEDED, PRN
comment: magnesium supplementation - See Administration
Instructions
For serum magnesium 1.6-1.8 mg/dL give 0.025 g/kg IV x1
over 12 hours
For serum magnesium 1.0-1.5 mg/dL give 0.05 g/kg IV x1
over 24 hours
For serum magnesium less than 1 mg/dL give 0.075 g/kg IV
x1 over 24 hours
NOTE: Order for RENAL Dosing
Post-Op/Phase II
Phosphate SODIUM [112672]
phosphate-potassium & sodium (PHOS-NAK) oral
packet [112317]
1-2 packet, Oral, PRN, phosphate supplementation - See
Admin Instructions
For serum phosphate 2.4 - 3 mg/dL, give 1 packet every 4
hours while awake x 3 doses;
For serum phosphate 1.6 - 2.3 mg/dL, give 2 packets every 4
hours while awake x 3 doses;
For serum phosphate less than 1.6 mg/dL, give 1 mmol/kg IV
over 4-6 hrs.
Hold if CrCl < 30 mL/min and notify provider for phosphate
orders
phosphate-potassium & sodium (PHOS-NAK) oral
packet - NOTE: Order in patients with RENAL
impairment (CrCl < 30 mL/min) [112317]
1 packet, Oral, PRN, phosphate supplementation - See
Admin Instructions
For serum phosphate 2.4 - 3 mg/dL, give 1 packet every 4
hours while awake x 2 doses;
For serum phosphate 1.6 - 2.3 mg/dL, give 1 packet every 4
hours while awake x 3 doses;
Page 10 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


For serum phosphate less than 1.6 mg/dL, give 0.5 mmol/kg
IV over 4-6 hrs.
Anti-arrhythmics [87704]
amiodarone (CORDARONE) BOLUS [800123] 150 mg, Intravenous, ONCE For 1 Doses, Post-Op/Phase II
amiodarone (CORDARONE) non- PVC infusion
[700135]
1 mg/min, Intravenous, Post-Op/Phase II
amiodarone (CORDARONE) non- PVC infusion
[700135]
0.5 mg/min, Intravenous, Post-Op/Phase II
amiodarone (CORDARONE) tab [44131] 600 mg, Oral, 2 X DAILY Starting tomorrow For 5 Days with
First Dose As Scheduled
Hold if 100% paced or on amiodarone infusion
Post-Op/Phase II
Gastric [87707]
ranitidine (ZANTAC) tab [46455] 150 mg, Oral, 2 X DAILY For 3 Days
Discontinue when patient extubated. Should be used on
patients who are less than the age of 65.
Post-Op/Phase II
pantoprazole (PROTONIX) susp [780113] 40 mg, Oral, 1 X DAILY Starting today For 3 Days
Discontinue when patient extubated. Should be used on
patients 65 years of age or older.
Post-Op/Phase II
Hemostatic Agents [87708]
aminocaproic acid (AMICAR) 15 g/310mL infusion
[700428]
Intravenous
Continue OR bag until empty then discontinue
Post-Op/Phase II
Flushes [145104]
sodium chloride 0.9% flush 10 mL injection [785055] 10 mL, Intravenous, EVERY 8 HOURS
Flush every saline lock port with 10mL/port for each line.
Post-Op/Phase II
Vasoactive Agents [87710]
Note: Concentrate All Drips [950029] ONCE For 1 Doses, Post-Op/Phase II
DOPamine (INTROPIN) 800 mg in dextrose 5% 250 mL
infusion [50506]
2 mcg/kg/min, Intravenous
Mean Arterial pressure greater *** or Systolic Blood Pressure
***
Post-Op/Phase II
DOBUTamine (DOBUTREX) 1000mg in dextrose 5%
250 mL infusion [51747]
Intravenous, Post-Op/Phase II
milrinone (PRIMACOR) 20 mg in dextrose 5% 100 mL
infusion [158103]
Intravenous, Post-Op/Phase II
epINEPHrine infusion [700197] Intravenous
Mean Arterial pressure greater *** or Systolic Blood Pressure
***
Post-Op/Phase II
norepinephrine (LEVOPHED) infusion [700247] Intravenous, Post-Op/Phase II
vasopressin (PITRESSIN) 100 units in dextrose 5% 250
mL infusion (SEPTIC SHOCK) [700291]
0.04-0.06 Units/min, Intravenous
Mean Arterial pressure greater *** or Systolic Blood Pressure
***
Post-Op/Phase II
nicardipine (CARDENE) 50 mg in sodium chloride 0.9 %
100 mL infusion [700426]
2.5-15 mg/hr, Intravenous
MAP > *** or SBP > ***
Post-Op/Phase II
nitroprusside 50 mg/sodium thiosulfate 0.5 g infusion
[700503]
0.1-10 mcg/kg/min, Intravenous
Mean Arterial pressure less *** or Systolic Blood Pressure ***
Post-Op/Phase II
phenylEPHRINE (NEO-SYNEPHRINE) 20 mg in
dextrose 5 % 250 mL infusion [700258]
0.3-3 mcg/kg/min, Intravenous
nitroglycerin 50 mg in dextrose 5% 250 mL infusion
[51611]
0.2-3 mcg/kg/min, Intravenous
Mean Arterial pressure less *** or Systolic Blood Pressure ***
Page 11 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


Post-Op/Phase II
Non-categorized [87709]
sodium chloride 0.9% flush 10 mL injection [785055] Flush, PRN, flush/line care
Flush per VAD guidelines
Post-Op/Phase II
sodium chloride 0.9% infusion [64367] at 4 mL/hr, Intravenous, CONTINUOUS
Per intraflow for arterial line, Swan-Ganz distal port, and
Central Venous Pressure port
Post-Op/Phase II
aspirin rectal suppository - NOTE: Start 4 hours
postoperatively if bleeding less than 50 milliliter/hour
[34799]
300 mg, Rectal, 1 X DAILY Starting today
Administer only if unable to tolerate oral aspirin. Discontinue
when tolerating oral meds. Start 4 hrs postoperatively if
bleeding less than 50 mL/hr
Post-Op/Phase II
aspirin chew tab [720014] 81 mg, Oral, 1 X DAILY, Post-Op/Phase II
lidocaine (XYLOCAINE-CARDIAC) 20 mg/mL injection
[39041]
75 mg, Intravenous, PRN, symptomatic ventricular
arrhythmias, symptomatic hypotension, decreased level of
consciousness, chest pain, shortness of breath or ventricular
tachycardia lasting greater than 30 seconds , Post-Op/Phase
II
albumin human 5% infusion [44038] 12.5 g, Intravenous, PRN For 48 Hours, systolic blood
pressure less than 80 mmHg, Post-Op/Phase II
hydrALAZINE (APRESOLINE) injection RANGE
[750049]
10-20 mg, Intravenous, EVERY 2 HOURS PRN, hypertension
Administer for SBP > 140 while ICU status. If you give more
than 3 doses of hydralazine in any 8 hour period start
nicardipine infusion.
Post-Op/Phase II
propofol (DIPRIVAN) 10 mg/mL infusion [46335] 5-50 mcg/kg/min, Intravenous
Titrate in 5-10 mcg/kg/min increments to achieve RASS of 0
to -1.
Post-Op/Phase II
Diabetes Management
Diabetes Management (Single Response) [119808]
Insulin Infusion - Cardiac Surgery [153976]
Glucose, POC [IPGLUCOSE] SEE COMMENTS, Routine
If Conditional, What Condition?
Every hour until within target range of 110-150 mg/dL for 3
hours (3 readings in a row), then decrease frequency to
every
2 hours. Hourly monitoring must be resumed if blood
glucose
deviates from target range.
GLUCOSE [GLU] CONDITIONAL - RN COLLECT For 7 Days, Routine
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
After Priming IV Tubing with Insulin, Waste 20 mL
Insulin Drip to Saturate All IV Tubing Binding Sites
[NURVAD0053]
CONTINUOUS
Cardiovascular Surgery Insulin Infusion Protocol Has
Been Initiated [NURMON0063]
CONTINUOUS, Routine
Notify Provider [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):
Page 12 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


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):
Other:
Note: Discontinue all previous insulin orders and oral
hypoglycemia agents [950018]
ONCE For 1 Doses
insulin regular (human) 250 units in sodium chloride 0.9
% 250 mL infusion [700217]
0.2-54 Units/hr, Intravenous
Administer insulin drip in accordance with Insulin Infusion
Algorithm - Adult (General Care and IMC units - use
standard
algorithm columns 1-6; ICU only - use standard and HIGH
DOSE columns 1-9)
Note: Give insulin with meals. See PRN orders [950018] 3 X DAILY (AT MEALTIME)
Initiate Insulin Infusion Algorithm Hypoglycemia
Treatment Orders [NURCOM0022]
CONTINUOUS
glucose-vitamin C chew tab [50690] 16-32 g, Oral, EVERY 15 MINUTES PRN, hypoglycemia,
see Admin Instructions
Use in patients able to safely eat/swallow but unable to
tolerate volume of fruit juice or per patient preference
For blood glucose 40-69 mg/dL give 16 g (4 tablets);
For blood glucose less than 40 mg/dL give 32 g (8 tablets).
Repeat every 15 minutes until blood glucose is 70 mg/dL
or greater
dextrose injection [800233] 12.5-50 g, Intravenous, PRN, per hypoglycemia treatment
algorithm - see Admin instructions
Use for patients who are unable to eat or swallow safely or
are NPO
For blood glucose greater than 40 mg/dl and less than 70
mg/dl give 12.5 g
For blood glucose 40 mg/dl or less give 25 g
glucagon injection kit [107799] 1 mg, Subcutaneous, PRN, per hypoglycemia treatment
algorithm - see Admin Instructions
For blood glucose less than 70 mg/dl for patients who are
unable to eat or swallow safely or are NPO AND who have
NO IV Access
Consult Diabetes Management Service (Inpatient)
[CON0022]
ONCE
New diagnosis of diabetes (any type): No
Intent: Assume Care for Specific Condition
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Diabetes Management
Consult Diabetes Education - Learning Center
(Inpatient) [CON0021]
ONCE, Routine, · If patient is newly diagnosed or is new
to insulin, provide 24 hours notice to allow adequate time
for education.
· Indicate diabetes medication/treatment plan if known.
· Consults requested after 1600 on Fridays may not be
seen until following Monday. Learning Center available
Mon-Sat 0800-1630 (only 1 RN available on Saturday for
CSC and AFCH).
· Learning Center staff are not available on holidays.
Type of Education: Diabetes Self-Management Education
New diagnosis of diabetes (any type):
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
insulin lispro (human) 100 UNIT/ML injection [760321] 4 units, Subcutaneous, 3 X DAILY (AT MEALTIME)
Hold dose if patient NPO. Give half dose if patient eating
<50% of meal. Give within 15 minutes of meal.
Patients withOUT Diabetes-Subcutaneous Insulin Note:
Page 13 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


Insulin orders must be entered. [152377]
Glucose, POC [IPGLUCOSE] EVERY 6 HRS IF NPO/ CONT. TUBE FEEDING/ OR TPN,
Starting tomorrow For Until specified, Routine
If Conditional, What Condition?
Post-Op/Phase II
Glucose, POC [IPGLUCOSE] ONCE, Starting tomorrow at 4:00 AM For 1 Occurrences,
Routine
If Conditional, What Condition?
Post-Op/Phase II
Glucose, POC [IPGLUCOSE] ONCE, Starting tomorrow at 6:00 AM For 1 Occurrences,
Routine
If Conditional, What Condition?
Post-Op/Phase II
Glucose, POC [IPGLUCOSE] BEFORE MEALS AND BEDTIME, Starting tomorrow,
Routine
If Conditional, What Condition?
When patient is eating., Post-Op/Phase II
Glucose, POC [IPGLUCOSE] EVERY 2 HOURS, Starting today For 24 Hours, Routine
If Conditional, What Condition? Draw until patient begins
on clear liquids
Draw until patient begins on clear liquids, Post-Op/Phase II
Glucose, POC [IPGLUCOSE] BEFORE MEALS AND BEDTIME, Starting today For 24
Hours, Routine
If Conditional, What Condition? If patient eating or drinking
If patient eating or drinking, Post-Op/Phase II
Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA TREATMENT,
Starting today, Routine
If Conditional, What Condition?
Per hypoglycemia algorithm., Post-Op/Phase II
Glucose, POC [IPGLUCOSE] ONCE, Starting tomorrow at 2:00 AM For 1 Occurrences,
Routine
If Conditional, What Condition?
Post-Op/Phase II
GLUCOSE [GLU] CONDITIONAL - RN COLLECT For 7 Days, Routine
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
or >400 mg/dL
Draw if blood glucose <40 or >400 mg/dL, Post-Op/Phase
II
HEMOGLOBIN A1C [HA1C] 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?
Obtain if not done in last 90 days, Post-Op/Phase II
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):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other:
Post-Op/Phase II
insulin isophane NPH (human) 100 UNIT/ML vial Subcutaneous, 1 X DAILY
Page 14 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


[45417] Administer in the morning
Post-Op/Phase II
insulin isophane NPH (human) 100 UNIT/ML vial
[45417]
Subcutaneous, 1 X DAILY (NOON)
Administer at noon
Post-Op/Phase II
insulin isophane NPH (human) 100 UNIT/ML vial
[45417]
Subcutaneous, 1 X DAILY (PM)
Administer in the evening
Post-Op/Phase II
insulin isophane NPH (human) 100 UNIT/ML vial
[45417]
Subcutaneous, 1 X DAILY (HS)
Administer at bedtime
Post-Op/Phase II
insulin glargine (LANTUS) 100 UNIT/ML injection
[760291]
Subcutaneous, 1 X DAILY
Administer in the morning. Administer even if NPO. Do
NOT mix with other insulins.
Post-Op/Phase II
insulin glargine (LANTUS) 100 UNIT/ML injection
[760291]
Subcutaneous, 1 X DAILY (NOON)
Administer at noon. Administer even if NPO. Do NOT mix
with other insulins.
Post-Op/Phase II
insulin glargine (LANTUS) 100 UNIT/ML injection
[760291]
Subcutaneous, 1 X DAILY (PM)
Administer in the evening. Administer even if NPO. Do
NOT mix with other insulins.
Post-Op/Phase II
insulin glargine (LANTUS) 100 UNIT/ML injection
[760291]
Subcutaneous, 1 X DAILY (HS)
Administer at bedtime. Administer even if NPO. Do NOT
mix with other insulins.
Post-Op/Phase II
insulin lispro (human) 100 UNIT/ML injection -
CORRECTION Insulin POD#0-1 [760321]
2-10 units, Subcutaneous, EVERY 4 HOURS PRN For 1
Days, Hyperglycemia - See Administration Instructions
Daytime hyperglycemia dosing
For blood glucose 151-200 mg/dL give 2 unit;
For blood glucose 201-250 mg/dL give 4 units;
For blood glucose 251-300 mg/dL give 6 units;
For blood glucose 301-350 mg/dL give 8 units;
For blood glucose 351-400 mg/dL give 10 units;
Give even if NPO or meals skipped. Do NOT give more
often than 4 hours when NPO
Post-Op/Phase II
insulin lispro (human) 100 UNIT/ML injection -
CORRECTION Insulin POD#2 [760321]
2-10 units, Subcutaneous
Daytime hyperglycemia dosing
For blood glucose 151-200 mg/dL give 2 unit;
For blood glucose 201-250 mg/dL give 4 units;
For blood glucose 251-300 mg/dL give 6 units;
For blood glucose 301-350 mg/dL give 8 units;
For blood glucose 351-400 mg/dL give 10 units;
Give even if NPO or meals skipped. Do NOT give more
often than 4 hours when NPO.
Post-Op/Phase II
insulin lispro (human) 100 units/mL injection - BEDTIME
1-4 Units [760321]
1-4 units, Subcutaneous, 1 X DAILY (HS) PRN,
Hyperglycemia - See Administration Instructions
For blood glucose 201-250 mg/dL give 1 units;
For blood glucose 251-300 mg/dL give 2 units;
For blood glucose 301-350 mg/dL give 3 units;
For blood glucose 351-400 mg/dL give 4 units;
Give even if NPO
Post-Op/Phase II
Hypoglycemic Treatment [NURCOM0022] SEE COMMENTS, Starting today, For patient able to
eat/swallow safely:
If blood glucose less than 40 mg/dL give 30 g carbohydrate
(8 oz. fruit juice). Repeat treatment until
glucose is 70 mg/dL or greater.
If blood glucose between 40 and 69 mg/dL give 15 g
carbohydrate (4 oz. fruit juice). Repeat treatment until
glucose is 70 mg/dL or greater., Post-Op/Phase II
Page 15 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


dextrose injection [800233] Intravenous
glucose-vitamin C chew tab [50690] 16-32 g, Oral, EVERY 15 MINUTES PRN, hypoglycemia,
see Admin Instructions
Use in patients able to safely eat/swallow but unable to
tolerate volume of fruit juice or per patient preference
For blood glucose 40-69 mg/dL give 16 g (4 tablets);
For blood glucose less than 40 mg/dL give 32 g (8 tablets).
Repeat every 15 minutes until blood glucose is 70 mg/dL
or greater
glucagon injection kit [107799] 1 mg, Subcutaneous, PRN, Per hypoglycemia treatment
algorithm, Post-Op/Phase II
Consult Diabetes Management Service (Inpatient)
[CON0022]
ONCE
New diagnosis of diabetes (any type):
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Post-Op/Phase II
Consult Diabetes Education - Learning Center
(Inpatient) [CON0021]
ONCE For 1 Occurrences, Routine, · If patient is newly
diagnosed or is new to insulin, provide 24 hours notice to
allow adequate time for education.
· Indicate diabetes medication/treatment plan if known.
· Consults requested after 1600 on Fridays may not be
seen until following Monday. Learning Center available
Mon-Sat 0800-1630 (only 1 RN available on Saturday for
CSC and AFCH).
· Learning Center staff are not available on holidays.
Type of Education: Diabetes Self-Management Education
New diagnosis of diabetes (any type):
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Post-Op/Phase II
Consult Health Psychology (Inpatient) [CON0033] ONCE For 1 Occurrences, Routine, Please notify
consulting provider if patient needs to be seen same day
(Monday-Friday) or if special assessment needs.
Intent for Consult:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Post-Op/Phase II
Consult Nutrition (Inpatient) [CON0043] ONCE For 1 Occurrences, Routine
Reason for Consult:
Delegate to Initiate and Manage Tube Feeding:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
Post-Op/Phase II
Consult Podiatry (Inpatient) [CON0063] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Post-Op/Phase II
Consult Social Work (Inpatient) [CON0076] ONCE For 1 Occurrences, Routine
Reason for Consult:
Post-Op/Phase II
Laboratory
Draw Upon Arrival to ICU [87712]
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?
Page 16 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


Post-Op/Phase II
CALCIUM [CA] 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?
Post-Op/Phase II
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?
Post-Op/Phase II
PTT [PTT] 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?
Post-Op/Phase II
MAGNESIUM [MAG] 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?
Post-Op/Phase II
PHOSPHATE [PHOS] 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?
Post-Op/Phase II
BLOOD GASES AND O2 SATURATION [HCBGASOS] STAT - RN COLLECT, Starting today For 1 Occurrences,
STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
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?
Post-Op/Phase II
GLUCOSE [GLU] 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?
Post-Op/Phase II
BUN [BUN] 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?
Post-Op/Phase II
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?
Page 17 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


If Conditional, What Condition?
Creatinine, Post-Op/Phase II
Draw Postoperative Day 1 [87714]
CALCIUM [CA] SPECIFIC TIME - RN COLLECT, Starting tomorrow at 5:00
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?
Post-Op/Phase II
GLUCOSE [GLU] SPECIFIC TIME - RN COLLECT, Starting tomorrow at 5:00
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?
Post-Op/Phase II
PHOSPHATE [PHOS] SPECIFIC TIME - RN COLLECT, Starting tomorrow For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
Draw Postoperative Day 2 [97373]
GLUCOSE [GLU] NEXT AM, Starting 11/26/14 at 6:00 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?
Post-Op/Phase II
Draw Daily [154079]
BUN [BUN] NEXT AM, Starting tomorrow For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Draw daily while on ICU status
CBC WITHOUT DIFFERENTIAL [HEMO] NEXT AM, Starting tomorrow For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Draw daily while on ICU status
CREATININE [CRET] NEXT AM, Starting tomorrow For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Draw daily while on ICU status
ELECTROLYTES [LYTE] NEXT AM, Starting tomorrow For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Draw daily while on ICU status
MAGNESIUM [MAG] NEXT AM, Starting tomorrow For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Draw daily while on ICU status
BUN [BUN] NEXT AM, Starting 12/2/14 For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Draw daily while on ICU status
Page 18 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


CBC WITHOUT DIFFERENTIAL [HEMO] NEXT AM, Starting 12/2/14 For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Draw daily while on ICU status
CREATININE [CRET] NEXT AM, Starting 12/2/14 For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Draw daily while on ICU status
ELECTROLYTES [LYTE] NEXT AM, Starting 12/2/14 For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Draw daily while on ICU status
MAGNESIUM [MAG] NEXT AM, Starting 12/2/14 For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Draw daily while on ICU status
Conditional Labs [87721]
CALCIUM [CA] 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? 1 hour after IV
supplementation
MAGNESIUM [MAG] CONDITIONAL - RN COLLECT For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? 1 hour after IV
supplementation
Post-Op/Phase II
POTASSIUM [K] CONDITIONAL - RN COLLECT For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? Draw postoperative hour 6
Post-Op/Phase II
PROTHROMBIN TIME/INR [PT] CONDITIONAL - RN COLLECT For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? 1 hour after plasma infusion
Post-Op/Phase II
HEMATOCRIT [HCT] CONDITIONAL - RN COLLECT For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? Draw postoperative hour 6
Post-Op/Phase II
PTT [PTT] CONDITIONAL - RN COLLECT For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? If chest tube output is greater
than 150 mL/hour
Post-Op/Phase II
PLATELET COUNT [PLT] CONDITIONAL - RN COLLECT, Starting 11/26/14 For 7
Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? Draw every other day while
Page 19 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


patient on subcutaneous heparin or If chest tube output is
greater than 150 mL/hour
Post-Op/Phase II
PHOSPHATE [PHOS] CONDITIONAL - RN COLLECT For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? 1 hour after IV
supplementation
Post-Op/Phase II
BLOOD GASES AND O2 SATURATION [HCBGASOS] CONDITIONAL - RN COLLECT For 7 Days, STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
VENOUS BLOOD GASES AND O2 SATURATION
[HCBGASOS]
CONDITIONAL - RN COLLECT For 7 Days, STAT
If Conditional, What Condition? Cardiac index less than 2.0
Post-Op/Phase II
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [87730]
ECG - 12 Lead [EKG0008] ONCE, Starting today For 1 Occurrences, STAT
Reason for exam: OTHER (COMMENT)
Obtain unless patient is paced.
Obtain upon arrival to ICU., Post-Op/Phase II
X-RAY CHEST AP VIEW - Upon Arrival to ICU [R71010] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms? Postoperative cardiac surgery
What specific question(s) would you like answered by this
exam? Evaluate ET tube placement and line placement
Relevant recent/past history? Postoperative cardiac surgery
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Post-Op/Phase II
X-RAY CHEST AP VIEW - Postoperative Day 1
[R71010]
ONCE-ON SPECIFIC DATE, Starting tomorrow For 1
Occurrences, Routine
Current signs and symptoms? Postoperative cardiac surgery
What specific question(s) would you like answered by this
exam? Evaluate for pneumothorax and pleural effusion
Relevant recent/past history? Postoperative cardiac surgery
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Post-Op/Phase II
ECG - 12 Lead [EKG0008] ONCE, Starting 11/27/14 For 1 Occurrences, Routine
Reason for exam: OTHER (COMMENT)
Post-Op/Phase II
Consults
Consults [87732]
Consult Cardiac Rehab/Preventive Cardiology
(Inpatient) [CON0010]
ONCE, Starting today For 1 Occurrences, Routine
Reason for consult: Other (Comment)
Indication: Exercise evaluation and instruction., Post-
Op/Phase II
Page 20 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


Consult Cardiothoracic ICU (Inpatient) [CON0210] ONCE
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Postoperatve ICU
Management
Consult Nutrition (Inpatient) [CON0043] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Nutrition Assessment w/
Recommendations
Post-Op/Phase II
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Post-Op/Phase II
Consult Occupational Therapy (Inpatient) Eval and Treat
[CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Post-Op/Phase II
Consult Physical Therapy (Inpatient) Eval and Treat
[CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Post-Op/Phase II
BestPractice
No Hospital Problems have yet been identified [107363]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing., Post-Op/Phase II
Page 21 of 21
Pr i nt ed by LIND, JANNA S [JSL237] at 11/24/2014 9:23:19 AM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority