/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/ambulatory/,/clinical/cckm-tools/content/order-sets/ambulatory/cardiologyct-surgery/,

/clinical/cckm-tools/content/order-sets/ambulatory/cardiologyct-surgery/name-98595-en.cckm

201711317

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,Cardiology/CT Surgery

Cardiac Catheterization – Heart and Vascular Delegation Protocol – Adult – Preprocedure [5173]

Cardiac Catheterization – Heart and Vascular Delegation Protocol – Adult – Preprocedure [5173] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Cardiology/CT Surgery


Cardiac Catheterization - Heart And Vascular Delegation Protocol - Adult -
Preprocedure [5173]
for Adult Patients OnlyIntended
Delegation Protocol URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/delegationpractice-
protocols/ambulatory-delegation-protocols/name-
97369-en.cckm
Patient Care Orders
Vital Signs [139633]
Vital Signs [NURMON0013] ONCE, Starting today For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location: Bilateral Arms
BP Position:
BP Restrictions:
Obtain upon admission, Cardiac Cath/EP
Nutrition [139634]
NPO Except Medications [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
Cardiac Cath/EP
Patient Monitoring [139635]
Measure Weight [NURMON0015] ONCE For 1 Occurrences, Routine
Weigh With?
Weigh when?
Upon admission, Cardiac Cath/EP
Measure Height [NURMON0052] ONCE For 1 Occurrences, Routine, Upon admission,
Cardiac Cath/EP
Pulse Oximetry [NURMON0009] CONTINUOUS, Routine, Cardiac Cath/EP
Measure Ankle/Brachial Index [NURMON0017] ONCE For 1 Occurrences, Routine, Cardiac Cath/EP
For Patients With Diabetes [139609]
Glucose, POC [IPGLUCOSE] STAT, Starting today For 1 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? Patients with Diabetes
Cardiac Cath/EP
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL For 7 Days, 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
is less than 40 mg/dL or greater than 400 mg/dL.
Draw if blood glucose is less than 40 mg/dL or greater
than 400 mg/dL., Cardiac Cath/EP
Intake/Output [139608]
Void On Call [NURELM0022] CONTINUOUS, Routine, Cardiac Cath/EP
Contingency Parameters [139636]
Page 1 of 5
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:32:24 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 160
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 39
If temperature < (C):
If heart rate > (bpm): 110
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 < (%): 92
If urine output < (mL):
Other: Chest pain/rhythm change
Cardiac Cath/EP
Respiratory [139607]
Oxygen Therapy [RT0032] CONTINUOUS, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen?
For patients on home oxygen therapy, Cardiac
Cath/EP
CPAP Overnight and Nap [RT0063] OVERNIGHT AND NAP, Routine
Therapy Settings: Per RT
CPAP Level (cm H2O):
Oxygen (LPM or %):
Self Administered (Only RT may document in this box
after patient assessment): RT Approval Required
For patients on home oxygen therapy, Cardiac
Cath/EP
Intravenous Therapy
Premedications for Needle Insertion [139592]
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
Cardiac Cath/EP
Page 2 of 5
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:32:24 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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
Cardiac Cath/EP
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
Cardiac Cath/EP
IV Fluids [139593]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Cardiac Cath/EP
sodium chloride 0.9 % infusion [64367] at 20 mL/hr, Intravenous, CONTINUOUS, Cardiac
Cath/EP
Surgical Propylaxis
First Line (Single Response) [186545]
cefuroxime (ZINACEF) intraVENOUS - Patient
who is 40-160 kg [800030]
1.5 g, Intravenous, ON CALL For 1 Doses, Cardiac
Cath/EP
cefuroxime (ZINACEF) intraVENOUS - Patient
who is 160 kg and greater [800030]
3 g, Intravenous, ON CALL For 1 Doses, Cardiac
Cath/EP
MRSA/Documented History of MRSA (Single Response) [186546]
Patients who are 40-160 kg [231391]
cefuroxime (ZINACEF) intraVENOUS [800030] 1.5 g, Intravenous, ON CALL For 1 Doses, Cardiac
Cath/EP
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses,
Cardiac Cath/EP
Patients who are 160 kg and greater [231394]
cefuroxime (ZINACEF) intraVENOUS [800030] 3 g, Intravenous, ON CALL For 1 Doses, Cardiac
Cath/EP
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses,
Cardiac Cath/EP
Immediate/Severe Reactions to Pencillin or Known Cephalosporin Allergies [186553]
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses,
Cardiac Cath/EP
Medications
Aspirin [139595]
aspirin chew tab [720164] 81 mg, Oral, ONCE PRN For 1 Doses, if patient has
not taken within the past 24 hours, Cardiac Cath/EP
Anti-platelet [202528]
clopidogrel (PLAVIX) tab [720168] 300 mg, Oral, ONCE For 1 Doses
Premedications for Patients with Contrast Allergy [139597]
Page 3 of 5
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:32:24 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

prednisone (DELTASONE) tab [41277] 50 mg, Oral, ONCE PRN For 1 Doses, premedication
for contrast allergy
Give on arrival in Heart and Vascular Care Center in
patients with contrast allergy
Cardiac Cath/EP
hydrocortisone sodium succinate injection
[800189]
200 mg, Intravenous, ONCE PRN For 1 Doses,
infusion reaction
Give on arrival in Heart and Vascular Care Center for
patients with contrast allergy who are unable to take
oral medications or for emergent procedures
Cardiac Cath/EP
diphenhydramine (BENADRYL) cap [36791] 50 mg, Oral, ONCE PRN For 1 Doses, premedication
for contrast allergy
Give on arrival in Heart and Vascular Care Center for
patients with contrast allergy
Cardiac Cath/EP
diphenhydramine (BENADRYL) injection [800106] 50 mg, Intravenous, ONCE PRN For 1 Doses,
premedication for contrast allergy
Give on arrival in Heart and Vascular Care Center for
patients with contrast allergy who are unable to take
oral medications or for emergent procedures
Cardiac Cath/EP
Laboratory
On Arrival [139600]
ACTIVATED CLOTTING TIME, POC
[HCACTPOC]
STAT For 1 Occurrences, Routine
If Conditional, What Condition?
Cardiac Cath/EP
If Not Ordered in the Last 30 Days [188056]
ELECTROLYTES [LYTE] STAT, 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?
Cardiac Cath/EP
BUN [BUN] STAT, 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?
Cardiac Cath/EP
CREATININE [CRET] STAT, 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?
Cardiac Cath/EP
CBC WITHOUT DIFFERENTIAL [HEMO] STAT, 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?
Cardiac Cath/EP
If Not Ordered in the Last 6 Months [142873]
Page 4 of 5
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:32:24 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

LIPID PANEL [LIPID] STAT, Starting today For 1 Occurrences, Routine,
Test includes Cholesterol, Total; HDL Cholesterol;
Triglyceride; LDL cholesterol, calculated; and non-
HDL cholesterol.
Patient must fast for a minimum of 10 hours and be
heparin free for 48 hours prior to specimen collection.
The patient can only have water during the fasting
period.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? If Diagnosis of Atrial
Fibrillation, Arrhythmia or Palpitations and If Not
Ordered in the Last 6 Months
Patient must have completed a minimum fast of 10
hours, Cardiac Cath/EP
Taking Warfarin [139603]
PROTHROMBIN TIME/INR [PT] STAT, Starting today For 1 Occurrences, Routine
If Conditional, What Condition? For patients on
warfarin
Cardiac Cath/EP
Laboratory - Pregnancy Test [121729]
surgery is pelvic, renal, pregnancy test if female between menarche & menopause and any of: (1) Obtain
intercourse, (3) patient missed menses, (4) patient says abdominal, (2) patient had unprotected -or intra
pregnant. she "could" be
Urine, Pregnancy Test [UPREG] ONCE For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Cardiac Cath/EP
Diagnostic Test and Imaging
Diagnostic Tests and Imaging [139605]
ECG - 12 Lead [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: PRE-OPERATIVE
ECG - 12 Lead [EKG0008] PRN, Starting today For Until specified, STAT
Reason for exam: OTHER (COMMENT) (Chest
Pain/Rhythym Change)
If patient develops chest pain or rhythm change
Page 5 of 5
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:32:24 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org