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/clinical/cckm-tools/content/order-sets/ambulatory/gynecology/name-115017-en.cckm

20170389

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UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,Gynecology

OP - Gynecology - Benign - Hysterectomy - Adult - Pre-Postoperative [6051]

OP - Gynecology - Benign - Hysterectomy - Adult - Pre-Postoperative [6051] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Gynecology


OP - Gynecology - Benign - Hysterectomy - Adult - Pre/Postoperative [6051]
for Adult Patients OnlyIntended
Pre-Op 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
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
VTE Prophylaxis [109260]
• If low risk for development of VTE - select VTE Prophylaxis - Reason Not Ordered
• If requires VTE prophylaxis AND
◦ LOW bleed risk - select pharmacologic agent only
◦ ABSOLUTE bleed risk - select mechanical agents only
◦ HIGH bleed risk - weigh risk of bleed vs risk of VTE development and select drug OR
mechanical agent
NOTE: Mechanical and pharmacologic agents should only be used together in patients
with a very high risk of VTE development
VTE Risk Factor Assessment Tool URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
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
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
Pre-Op Day Of Procedure
Page 1 of 6
Printed by LIND, JANNA S [JSL237] at 3/27/2017 8:55:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, ON CALL For 1 Doses
If patient scheduled for block, give after block placed
IntraOp
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE For 1 Occurrences, Routine
Reason Not Ordered:
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?
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
Medications [217214]
phenazopyridine (PYRIDIUM) tab [40946] 100 mg, Oral, ONCE For 1 Doses
Administer prior to surgery
Pre-Op Day Of Procedure
Laboratory [217202]
CBC WITHOUT DIFFERENTIAL [HEMO] 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?
Pre-Op Day Of Procedure
Page 2 of 6
Printed by LIND, JANNA S [JSL237] at 3/27/2017 8:55:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

CREATININE [CRET] 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?
Pre-Op Day Of Procedure
Laboratory - Pregnancy Test [218843]
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] 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?
Pre-Op Day Of Procedure
Tests [83980]
TYPE AND SCREEN [HCTS] STAT - RN COLLECT, 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
Surgical Prophylaxis
First Line (Single Response) [134547]
cefoxitin (MEFOXIN) intraVENOUS - NOTE:
Patient who is 40-120 kg [800022]
2 g, Intravenous, ON CALL For 1 Doses, IntraOp
cefoxitin (MEFOXIN) intraVENOUS - NOTE:
Patient who is 121 kg or greater [800022]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
MRSA/Documented MRSA History (Single Response) [145991]
Patients who are 40-120 kg [198290]
cefoxitin (MEFOXIN) intraVENOUS [800022] 2 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are 121 kg or greater [198299]
cefoxitin (MEFOXIN) intraVENOUS [800022] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
MRSA and Immediate/Severe Reaction to Penicillin or Known Cephalosporin Allergies (Single
Response) [134595]
Patients who are 40-119 kg [198273]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are 120-159 kg [198277]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Page 3 of 6
Printed by LIND, JANNA S [JSL237] at 3/27/2017 8:55:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are 160 kg or greater [198278]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, 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) [154514]
Patients who are 40-119 kg [198265]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who are 120 - 159 kg [198272]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who are greater than 160 kg [198271]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
PostOp/Phase II
Analgesics - Acetaminophen - Scheduled [218699]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 6 HOURS, Post-Op/Phase II
Analgescis - NSAIDs -Scheduled (Single Response) [218700]
ketOROLAC (TORADOL) injection - 30 mg -
NOTE: Do NOT order ketorolac if patient 65
years or older, 50 kg or less, or serum creatinine
1.2 mg/dL or more [800050]
30 mg, Intravenous, EVERY 6 HOURS For 72 Hours
Give every 6 hours until patient is ready for discharge
Post-Op/Phase II
ketOROLAC (TORADOL) injection - 15 mg -
NOTE: Do NOT order ketorolac if patient 65
years or older, 50 kg or less, or serum creatinine
1.2 mg/dL or more [800050]
15 mg, Intravenous, EVERY 6 HOURS For 72 Hours
Give every 6 hours until patient is ready for discharge
Post-Op/Phase II
Analgesics - Opioid - Oral (Single Response) [218701]
oxycodone tab RANGE [750032] 5-10 mg, Oral, EVERY 4 HOURS PRN, pain, Severe
pain, Post-Op/Phase II
Prior to Discharge [217204]
Patient Must Be Seen by Resident Prior to
Discharge [NURMON0082]
ONCE For 1 Occurrences, Routine, Pager #8900,
Post-Op/Phase II
Page 4 of 6
Printed by LIND, JANNA S [JSL237] at 3/27/2017 8:55:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

Prior to Discharge [NURMON0060] ONCE For 1 Occurrences, Prior to discharge, patient
must be able to
-tolerate oral intake
-ambulate
-void with less than 150 mL post void residual as
measured by bladder scanner
-pain must be well controlled with oral pain
medications, Post-Op/Phase II
Patient Care Orders [218844]
Notify Provider [NURCOM0001] CONTINUOUS
Provider to Notify: Provider
Notify based on: Blood Pressure,Temperature,Heart
Rate
If heart rate > (bpm): 100
If heart rate < (bpm):
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg): 60
If temperature > (C): 38
If temperature < (C):
Post-Op/Phase II
Outpatient Discharge Orders
Analgesics - Acetaminophen - Prescriptions [217217]
acetaMINOPHEN (TYLENOL) 325 MG tab
[34149]
650 mg, 60 tab, 0, starting 3/27/17, Normal
Analgesics - NSAID (Oral) - Prescriptions [217216]
ibuprofen (MOTRIN) 600 MG tab [38356] 600 mg, 60 tab, 0, starting 3/27/17, Normal
Analgesics - Opioid (Oral) - Prescriptions [217215]
oxycodone 5 MG tab [45976] 5-10 mg, 20 tab, 0, starting 3/27/17, Normal
Medications - General - Prescription [217218]
senna-docusate (SENNA-DOCUSATE SODIUM)
8.6-50 MG per tab [60530]
2 tab, starting 3/27/17, Normal
Activity/Return to Work [217208]
Discharge Activity - Up As Tolerated
[NURACT0011]
Routine, No lifting greater than 10 pounds for 4
weeks.
Nothing in the vagina for 8 weeks.
No driving while taking opioid medications.
Suture Line Care [217210]
Wound Care - Dissolvable Sutures
[NURWND0015]
Routine, Dissolvable Sutures: Okay to shower. Let
the water run over the incisions. Do not scrub. Pat
dry. Bandages can be removed 48 hours after
surgery.
Wound Care - Routine [NURWND0015] Routine
When to Call Your Doctor [217211]
Page 5 of 6
Printed by LIND, JANNA S [JSL237] at 3/27/2017 8:55:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

When to Call Your Doctor [NURCOM0079] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, Call your doctor if you have any of
these symptoms: increased pain not relieved by
medication, fever over 100.4 degrees for two readings
taken 4 hours apart, increased shortness of breath,
redness/drainage at incision site, inability to tolerate
food/liquid by mouth, vaginal bleeding greater than
one pad per hour, inability to urinate or empty your
bladder.
-Call 911 for emergencies.
-Call your doctor at Gynecology clinic Monday-Friday
8:00am to 5:00pm at 608-263-6240.
-To reach a doctor after hours or on weekends, call
608-263-6240 and ask for the gynecology physician
on call.
-For clinic appointments call 608-263-6240. Toll free
phone number is 800-323-8942. Clinic fax number is
608-265-1726.
Page 6 of 6
Printed by LIND, JANNA S [JSL237] at 3/27/2017 8:55:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org