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/clinical/cckm-tools/content/order-sets/ambulatory/digestive-health-center/name-98504-en.cckm

20180236

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UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,Digestive Health Center

DHC - GI - Adult - Pre/Postprocedure [4958]

DHC - GI - Adult - Pre/Postprocedure [4958] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Digestive Health Center


DHC - GI - Adult - Pre/Postprocedure [4958]
Intended for Adult Patients Only
PreOp Day of Procedure
Colonscopy/Upper Endoscopy Diagnosis Codes [195550]
Abdominal pain, unspecified abdominal location
[1248142]
Diagnosis
Barrett esophagus [246409] Barrett's esophagus
Change in bowel habits [242185] Other symptoms involving digestive system
Dysphagia [913327] Diagnosis
Family history of colon cancer [247258] Family history of malignant neoplasm of
gastrointestinal tract
Gastroesophageal reflux disease, esophagitis
presence not specified [1370712]
Diagnosis
History of colon polyps [459278] Personal history of colonic polyps
Iron deficiency anemia [167215] Iron deficiency anemia, unspecified
Personal history of colon cancer [273332] Personal history of malignant neoplasm of large
intestine
Screen for colon cancer [253296] Special screening for malignant neoplasms, colon
Glucose [132489]
Glucose, POC [IPGLUCOSE] Back Office, Routine, PRN: Perform pre and post
procedure
Diagnostic Tests and Imaging [132490]
ECG - 12 Lead Without Rhythm [EKG0008] Status: Future, Expires: 3/5/2019, Normal, Routine
Contingency Parameters [132491]
Notify Provider [NURCOM0001] Routine, If systolic blood pressure > 180 (mmHg)
If systolic blood pressure < 90 (mmHg)
If temperature > 38 (C)
If heart rate > 120 (bpm)
Pulse Oximetry < 90 (%)
International normalized ratio (INR) > 1.4
Platelet count < 50,000/microliter
If patient has taken clopidogrel (PLAVIX) within the
last 7 days, unfractionated heparin within the last 8
hours, low molecular weight heparin within the last 12
hours, or warfarin (COUMADIN) within the last 5 days
Lab [132492]
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:3/9/19 MANUAL,Count:1,
Normal, Routine
HEMATOCRIT [HCT] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
PLATELET COUNT [PLT] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
BILIRUBIN, TOTAL [TBIL] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
AMYLASE [AMYL] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
LIPASE [LIPS] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
ALBUMIN [ALB] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
Page 1 of 4
Printed by O'BRIEN, RYLEY P [RPO249] at 2/5/2018 9:32:20 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

ALKALINE PHOSPHATASE [ALKP] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
ALT/SGPT [ALT] Status: Standing, Expires:3/9/19 MANUAL,Count:1,
Normal, Routine
AST/SGOT [AST] Status: Standing, Expires:3/9/19 MANUAL,Count:1,
Normal, Routine
Laboratory - Pregnancy Test [132495]
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] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
Premedications for Needle Insertion [241915]
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 immediate.
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
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.
Pre-Op Day Of Procedure
Intravenous Fluid [135862]
Insert and Maintain Peripheral IV [NURVAD0013] Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
sodium chloride 0.9 % infusion [64367] at 125 mL/hr, Intravenous, PRN, If clinical triggers
indicate, Pre-Op Day Of Procedure
lactated ringers infusion [38890] at 125 mL/hr, Intravenous, CONTINUOUS, Pre-Op
Day Of Procedure
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS, Pre-Op Day Of
Procedure
Medications-Preprocedure Enema [136052]
phosphate (FLEET) enema - (Maximum Dose = 2
enemas) [37517]
1 enema, Rectal, PRN For 2 Doses, constipation, Pre-
Op Day Of Procedure
IntraOp
Sedation Medications [133689]
midazolam (VERSED) injection [790033] 2-10 mg, Intravenous, ONCE PRN For 1 Doses,
Sedation for endoscopy procedure
Initial dose of 2 mg (consider lower doses for patients
older than 70 years old or less than 50 kg);
subsequent doses of 0.5-2 mg every 2 minutes as
needed for moderate sedation. Max dose 10 mg.
If ordered IV: push rate 1 mg/minute.
IntraOp
Page 2 of 4
Printed by O'BRIEN, RYLEY P [RPO249] at 2/5/2018 9:32:20 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2018CCKM@uwhealth.org

FENTanyl PF injection [800187] 25-300 mcg, Intravenous, ONCE PRN For 1 Doses,
To prevent or treat procedural pain or multimodal
therapy for sedation
Initial dose of 50 mcg (consider lower doses for
patients older than 70 years old or less than 50 kg);
subsequent doses of 12.5-50 mcg every 2 minutes as
needed for moderate sedation. Max dose 300 mcg.
IntraOp
diphenhydramine (BENADRYL) injection [800106] 12.5-50 mg, Intravenous, ONCE PRN For 1 Doses,
Multimodal therapy for difficult sedation
Once prn for moderate sedation. Do not repeat
administration.
IntraOp
Miscellaneous Medications [133690]
naloxone (NARCAN) injection [800199] 0.2-0.8 mg, Intravenous, ONCE PRN For 1 Doses,
opioid overdose, Sedation Reversal
Administer 0.1 mg every 3 minutes for 4 doses as
needed for respiratory rate less than 8 breaths per
minute or sedation score of 5 or greater. Notify
provider if administered.
IntraOp
flumazenil (ROMAZICON) injection [104460] 0.1-1 mg, Intravenous, ONCE PRN For 1 Doses,
Sedation reversal
Give 0.1-0.2 mg IV over 15 seconds; repeat dose after
45 seconds (1 minute intervals) as needed for
sedation reversal up to a maximum dose of 1 mg.
If ordered IV: push over 15-30 seconds.
Give naloxone prior to flumazenil if opioids are given
at the same time.
IntraOp
atropine injection [800178] 0.5 mg, Intravenous, PRN For 2 Doses, bradycardia
Administer over 1 minute. Administer for symptomatic
bradycardia. Symptoms include decreased level of
consciousness, nausea, and decreased heart rate for
1 minutes. May repeat 0.5 mg dose if symptoms
persist.
IntraOp
ondansetron (ZOFRAN) injection [800202] 4-8 mg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting, IntraOp
GI Medications [135237]
epINEPHrine (CARDIAC 1:10,000) 0.1 MG/ML
soln prefilled syringe [177443]
0.1-0.4 mg, Subcutaneous, ONCE PRN For 1 Doses,
Gastrointestinal bleeding
Give via scope
If ordered IV: push over 15-30 seconds.
IntraOp
glucagon injection kit [107799] 0.25-1 mg, Intravenous, ONCE PRN For 1 Doses,
Gastrointestinal motility, IntraOp
methylene blue (PROVAYBLUE) injection
[172272]
0.5-2 mg, Subcutaneous, ONCE PRN For 1 Doses, GI
marking
Dilute in 5 mL normal saline. Give via scope
If ordered IV: push 1 mL over 1-2minutes.
IntraOp
sodium tetradecyl (SOTRADECOL) 3 % vial
[46605]
2-8 mL, Subcutaneous, ONCE PRN For 1 Doses,
Sclerosing agent
Give via scope
IntraOp
Page 3 of 4
Printed by O'BRIEN, RYLEY P [RPO249] at 2/5/2018 9:32:20 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2018CCKM@uwhealth.org

lidocaine (XYLOCAINE JELLY) 2 % gel [39030] Topical, ONCE PRN For 1 Doses, pain
Apply to rectum
IntraOp
Chromoendoscopy [222674]
indigotindisulfonate (INDIGO CARMINE) injection
[45397]
80-160 mg, Other, ONCE PRN For 1 Doses,
chromoendoscopy
For intracolonic administration by gastroenterologist
for chromoendoscopy. Add volume specified by
gastroenterologist to irrigation bottle.
Standard concentration: 80 mg/10 mL added to 250
mL of diluent (0.03%)
PostOp/Phase II
Contingency Parameters [132499]
Notify Provider [NURCOM0001] Routine, If systolic blood pressure > 180 (mmHg)
If systolic blood pressure < 90 (mmHg)
If temperature > 38 (C)
If heart rate > 120 (bpm)
Pulse Oximetry < 90 (%)
New abdominal pain
New chest pain
Laboratory [132500]
GLUCOSE [GLU] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:3/9/19 MANUAL,Count:1,
Normal, Routine
HEMATOCRIT [HCT] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
PLATELET COUNT [PLT] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
BUN [BUN] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
CALCIUM [CA] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
CREATININE [CRET] Status: Standing, Expires:3/9/19 MANUAL,Count:1,
Normal, Routine
ELECTROLYTES [LYTE] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
MAGNESIUM [MAG] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
PHOSPHATE [PHOS] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
Diagnostic Tests and Imaging [132501]
X-RAY CHEST AP VIEW [R71045] Status: Future, Expires: 4/5/2019, Normal, Routine
X-RAY ABDOMEN AP VIEW (KUB) [R74018] Status: Future, Expires: 4/5/2019, Normal, Routine
GI ESOPHAGRAM [R74220] Status: Future, Expires: 4/5/2019, Normal, Routine
Miscellaneous Medications (Single Response) [185259]
ondansetron (ZOFRAN ODT) 4mg disintegrating
tab [64224]
4 mg, Sublingual, ONCE PRN For 1 Doses,
nausea/vomiting, Post-Op/Phase II
Page 4 of 4
Printed by O'BRIEN, RYLEY P [RPO249] at 2/5/2018 9:32:20 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2018CCKM@uwhealth.org