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/clinical/cckm-tools/content/order-sets/ambulatory/general-surgery/name-118589-en.cckm

201710283

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UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,General Surgery

FDS - Bariatric Surgery - Adult - Preoperative [6463]

FDS - Bariatric Surgery - Adult - Preoperative [6463] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, General Surgery


FDS - Bariatric Surgery - Adult - Preoperative [6463]
for Adult Patients OnlyIntended
Pre-Day of Procedure
Labs - Blood Bank [91701]
Antibody Screen
Use to prescreen patient for alloantibodies to red blood cell components. Order if specimen collection
will be greater than 72 hours prior to surgery. Blood products cannot be issued on the basis of this
test. Antibody Screen should be ordered with the ABO and Rh Typing.
ABO and Rh Typing
Use to determine patient blood type. Order if specimen collection will be greater than 72 hours prior to
surgery. Blood products cannot be issued on the basis of this test. ABO and Rh Typing should be
ordered with the antibody screen.
Type and Screen
Order if specimen collection will be less than 72 hours prior to surgery. Patient is required to have an
ID band in place at the time of Type and Screen blood specimen collection and remain in place
throughout admission.
TYPE AND SCREEN [HCTS] Status: Standing, Expires:11/11/17
MANUAL,Count:1, Normal, Routine
Antibody Screen and ABO and Rh Typing
[192516]
ANTIBODY SCREEN [ABSCR] Status: Standing, Expires:1/27/18
MANUAL,Count:1, Normal, Routine
ABO AND RH TYPING [ABO] Status: Standing, Expires:1/27/18
MANUAL,Count:1, Normal, Routine
Diagnostic Tests and Imaging [225392]
ECG - 12 Lead [EKG0008] Status: Future, Expires: 10/27/2018, Normal,
Routine, Pre-Operative, General Anesthesia
PreOp Day of Procedure
Isolation Status [97372]
Isolation - Enhanced Contact - Clostridium
Difficile [ISO0010]
CONTINUOUS, Separate order must be placed for
isolation cart., Pre-Op Day Of Procedure
Isolation - Contact - MRSA [ISO0039] CONTINUOUS, Separate order must be placed for
isolation cart., Pre-Op Day Of Procedure
Isolation - Contact - VRE [ISO0051] CONTINUOUS, Separate order must be placed for
isolation cart., Pre-Op Day Of Procedure
Isolation - Protective Precautions - Panel
[116356]
Protective Precautions [ISO0001] CONTINUOUS
Reason for Protective Precautions:
Pre-Op Day Of Procedure
Protective - Positive Pressure Room
[NURCOM0109]
CONTINUOUS, Pre-Op Day Of Procedure
Isolation - Contact - Multidrug Resistant
Organism - Panel [116335]
Isolation - Contact - Multidrug Resistant
Organism (MDR) [ISO0006]
CONTINUOUS, Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Page 1 of 5
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Isolation - Contact - Extensively Resistant
Organism (XDR) - Panel [193206]
Isolation - Contact - Extensively Drug
Resistant Organism (XDR) [ISO0320]
CONTINUOUS, Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Non-Categorized Patient Care Orders [225282]
Mattress Air Transfer Hovermat - Order for
Bariatric Patients [NURCOM0022]
ONCE, Patient should be on Hovermat in Pre-
Procedure for transer to OR table.  Gown untied.,
Pre-Op Day Of Procedure
PATRAN - Order for Bariatric Patients
[NURCOM0022]
ONCE For 1 Occurrences, Pre-Op Day Of Procedure
Bariatric Bed-Mighty Air Sizewise (Specialty
Bed) [EQP0034]
CONTINUOUS, Routine
Trapeze Needed: No
Time Needed: Preop for OR
Last patient height? (will auto pull in value and date
in comment):
Last patient weight? (will auto pull in value and date
in comment):
Send Request to CS? Yes
Deliver Equipment To: Preop Area
Glucose, POC [IPGLUCOSE] ONCE, 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?
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.
Insert and Maintain Peripheral IV
[NURVAD0013]
CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Pre-Op Day Of Procedure
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
Page 2 of 5
Printed by O'BRIEN, RYLEY P [RPO249] at 9/27/2017 1:20:03 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@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
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
Analgesics - Acetaminophen - On Call (Single Response) [225283]
acetaMINOPHEN (TYLENOL) tab [34150] 1,000 mg, Oral, ON CALL For 1 Doses
Give with sip of water upon arival at pre-op.
Pre-Op Day Of Procedure
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
1,000 mg, Oral, ON CALL For 1 Doses, Pre-Op Day
Of Procedure
Analgesics - NSAIDS - On Call [225284]
celecoxib (CELEBREX) cap [60834] 400 mg, Oral, ON CALL For 1 Doses
Give with sip of water upon arrival at preop
Pre-Op Day Of Procedure
Analgesics - Other - On Call [225285]
gabapentin (NEURONTIN) soln [65814] 300 mg, Oral, ON CALL For 1 Doses
Give with sip of water upon arrival at preop
Pre-Op Day Of Procedure
Non-categorized Medications [226509]
scopolamine (TRANSDERM-SCOP) 1
MG/3DAYS 72hr patch [166671]
1 patch, Transdermal, ON CALL For 1 Doses
Apply to skin (with gloved hand) upon arrival at pre-
op.
Pre-Op Day Of Procedure
Laboratory [86275]
PROTHROMBIN TIME/INR [PT] 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?
Pre-Op Day Of Procedure
POTASSIUM [K] 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?
Pre-Op Day Of Procedure
Laboratory - Pregnancy Test [81397]
surgery is pelvic, pregnancy test if female between menarche & menopause and any of: (1) Obtain
intercourse, (3) patient missed menses, (4) abdominal, (2) patient had unprotected -renal, or intra
pregnant. patient says she "could" be
Page 3 of 5
Printed by O'BRIEN, RYLEY P [RPO249] at 9/27/2017 1:20:03 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Urine, Pregnancy Test [UPREG] 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?
Pre-Op Day Of Procedure
Tests [91574]
TYPE AND SCREEN [HCTS] STAT, 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
VTE Prophylaxis
VTE Prophylaxis [233829]
Sequential Compression Device (SCD) Panel
(TREATMENT AND SUPPLY) [206111]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
IntraOp
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
IntraOp
enoxaparin (LOVENOX) injection [800040] 40 mg, Subcutaneous, ON CALL For 1 Doses
Surgical Prophylaxis - Gastroduodenal
Clean procedures may not need surgical prophylaxis (Resection with or without vagotomy
for gastric or duodenal ulcers, resection for gastric carcinoma, revision required to repair
strictures of the gastric outlet, PEG insertion, perforated ulcer procedures,
pancreaticduodenectomy, and bariatric surgical prophylaxis)
First Line (Single Response) [154704]
cefazolin (ANCEF) intraVENOUS -  Patients
who are 40 - 120 kg [800000]
2 g, Intravenous, ON CALL For 1 Doses, IntraOp
cefazolin (ANCEF) intraVENOUS - Patients who
are 121 kg or greater [800000]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
MRSA / Documented MRSA History (Single Response) [226510]
Patients who are 40 - 120 kg [231759]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are 121 kg or greater [231762]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS
[800084]
2,000 mg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
MRSA Negative and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies
(Single Response) [153523]
moxifloxacin (AVELOX) 400 mg in sodium
chloride 0.8% 250 mL bag - NOTE: Patients
who are 40 - 160 kg [68662]
400 mg, Intravenous, ON CALL For 1 Doses, for 60
Minutes, Pre-Op Day Of Procedure
Page 4 of 5
Printed by O'BRIEN, RYLEY P [RPO249] at 9/27/2017 1:20:03 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

moxifloxacin (AVELOX) 400 mg in sodium
chloride 0.8% 250 mL - NOTE: Patients who are
greater than 160 kg [68662]
400 mg, Intravenous, EVERY 1 HOUR For 2 Doses,
for 60 Minutes, Pre-Op Day Of Procedure
MRSA and Immediate Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single
Response) [226531]
URL:
Patients who are 40-160 kg [233477]
moxifloxacin (AVELOX) 400 mg in sodium
chloride 0.8% 250 mL bag [68662]
400 mg, Intravenous, ON CALL For 1 Doses, for 60
Minutes, Pre-Op Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are greater than 160 kg
 [233480]
moxifloxacin (AVELOX) 400 mg in sodium
chloride 0.8% 250 mL bag [68662]
400 mg, Intravenous, EVERY 1 HOUR For 2 Doses,
for 60 Minutes, Pre-Op Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS
[800084]
2,000 mg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Page 5 of 5
Printed by O'BRIEN, RYLEY P [RPO249] at 9/27/2017 1:20:03 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org