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201606170

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MSC – Anesthesiology – Adult – Recovery/PACU [4980]

MSC – Anesthesiology – Adult – Recovery/PACU [4980] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Madison Surgery Center


MSC - Anesthesiology - Adult - Recovery/Pacu [4980]
Intended for Adult Patients Only
Patient Care Orders
Underlined description
Respiratory [128925]
Initiate Adult PACU Oxygen Titration Protocol
[NURTRT0082]
CONTINUOUS, Starting today, Routine
O2 Delivery Device: Nasal Cannula
PACU
Non-Categorized Patient Care Orders [128924]
Physiological Parameters to Notify Anesthesiologist
[NURCOM0022]
CONTINUOUS, Starting today For Until specified, SBP < 85
or >175 mmHg by either arterial line or cuff for 15 minutes or
longer.
HR < 42 or >105 bpm for 15 minutes or longer.
RR < 8 or >18 breaths per minute for 10 minutes or longer.
O2 sat < 91 % for 5 minutes or longer.
ETCO2 > 60 mmHg for 10 minutes or longer. (if CO2
measured)
Any critical laboratory value, PACU
Do NOT Discharge Patient From MSC Unless
Anesthesiologist Gives a Specific, Separate Discharge
Order. [NURCOM0022]
ONCE For 1 Occurrences, PACU
Follow PACU Pain and Sedation Score Protocol
[NURMON0080]
CONTINUOUS, Routine, PACU
Accu-Check Glucose - Immediately Postoperatively
[HCMGLUC]
ONCE, Starting today For 1 Occurrences, Routine
If Conditional, What Condition?
PACU
Accu-Check Glucose - Prior to Discharge from PACU
[HCMGLUC]
ONCE, Starting today For 1 Occurrences, Routine
If Conditional, What Condition?
PACU
Please Call Anesthesia Before Giving Any IV Medications in Phase II [144364]
Please Call Anesthesia Before Giving Any IV
Medications in Phase II [NURCOM0022]
ONCE, Starting today For 1 Occurrences, Post-Op/Phase II
Medications
Parenteral Opioid Analgesic - First Line Rescue Therapy (Single Response) [124159]
MORPHine PF injection RANGE [750057] 1-4 mg, Intravenous, EVERY 6 MINUTES PRN, pain
First Line Parenteral Analgesic Agent - Give if unable to
tolerate oral opioids or rapid response required (if for rapid
response, may give parenteral and oral pain meds
concurrently). Administer up to *** mg. If insufficient pain
relief, give Second Line Parenteral Therapy or notify provider
if no second line therapy is ordered.
for 4 Minutes, PACU
HYDROmorphone PF (DILAUDID) injection RANGE
[750050]
0.2-0.5 mg, Intravenous, EVERY 6 MINUTES PRN, pain
First Line Parenteral Analgesic Agent - Give if unable to
tolerate oral opioids or rapid response required (if for rapid
response, may give parenteral and oral pain meds
concurrently). Administer up to *** mg. If insufficient pain
relief, give Second Line Parenteral Therapy or notify provider
if no second line therapy is ordered.
for 3 Minutes, PACU
FENTanyl (SUBLIMAZE) injection RANGE [750047] 25-50 mcg, Intravenous, EVERY 6 MINUTES PRN, pain
First Line Parenteral Analgesic Agent - Give if unable to
tolerate oral opioids or rapid response required (if for rapid
response, may give parenteral and oral pain meds
concurrently). Administer up to *** mcg. If insufficient pain
relief, give Second Line Parenteral Therapy or notify provider
Page 1 of 5
Printed by GUETZLAFF, SCOTT F [SFG091] at 1/14/2016 1:51:53 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

if no second line therapy is ordered.
for 1 Minutes, PACU
Parenteral Opioid Analgesic - Second Line Rescue Therapy (Single Response) [124160]
MORPHine PF injection RANGE [750057] 1-4 mg, Intravenous, EVERY 6 MINUTES PRN, pain
Second Line Parenteral Analgesic Agent - Give if
unresponsive to maximum First Line Parenteral Therapy.
Give if unable to tolerate oral opioids or rapid response
required (if for rapid response, may give parenteral and oral
pain meds concurrently). Administer up to *** mg
for 4 Minutes, PACU
HYDROmorphone PF (DILAUDID) injection RANGE
[750050]
0.2-0.5 mg, Intravenous, EVERY 6 MINUTES PRN, pain
Second Line Parenteral Analgesic Agent - Give if
unresponsive to maximum First Line Parenteral Therapy.
Give if unable to tolerate oral opioids or rapid response
required (if for rapid response, may give parenteral and oral
pain meds concurrently). Administer up to *** mg
for 3 Minutes, PACU
FENTanyl (SUBLIMAZE) injection RANGE [750047] 25-50 mcg, Intravenous, EVERY 6 MINUTES PRN, pain
Second Line Parenteral Analgesic Agent - Give if
unresponsive to maximum First Line Parenteral Therapy.
Give if unable to tolerate oral opioids or rapid response
required (if for rapid response, may give parenteral and oral
pain meds concurrently). Administer up to *** mcg
for 1 Minutes, PACU
Oral Opiod Analgesics (Single Response) [134192]
Hyperlink to Pain Fast Fact - Multimodal Analgesia URL: https://uconnect.wisc.edu/clinical/references/pain-
management/references-guidelines/resources/name-
29968-en.file
oxycodone tab RANGE [750032] 5-10 mg, Oral, EVERY 1 HOUR PRN For 2 Doses, pain
Give parenteral opioid if patient unable to tolerate oral meds
or if rapid response required, may give parenteral and oral
pain meds concurrently. If giving oral med, and patient does
not have relief in 1 hour, titrate dose up to maximum dose. If
no benefit after 2 doses, call provider.
PACU
hydrocodone-acetaMINOPHEN (NORCO) 5-325 MG per
tab RANGE [750021]
1-2 tab, Oral, ONCE PRN For 1 Doses, pain
No more than 4 grams acetaminophen per 24 hours for adults
or 15mg/kg per dose for peds <40kg.
PACU
oxycodone-acetaMINOPHEN (PERCOCET) 5-325 MG
per tab RANGE [750033]
1-2 tab, Oral, ONCE PRN For 1 Doses, pain
No more than 4 grams acetaminophen per 24 hours for adults
or 15mg/kg per dose for peds <40kg.
PACU
Parenteral Opioid Antishivering - Meperidine [137974]
meperidine (DEMEROL) injection RANGE [750055] 12.5-25 mg, Intravenous, ONCE PRN For 1 Doses, shivering,
for 4 Minutes, PACU
Sedation / Muscle Relaxation [133542]
Hyperlink to Pain Fast Fact - Multimodal Analgesia URL: https://uconnect.wisc.edu/clinical/references/pain-
management/references-guidelines/resources/name-
29968-en.file
diazepam (VALIUM) injection RANGE [750043] 1-2.5 mg, Intravenous, EVERY 10 MINUTES PRN, Muscle
Pain
For painful muscle spasms/tightness unrelieved by opioids
IV push rate 5mg/minute. MAX 5 mg
PACU
NSAID Analgesics - Note: May only select one NSAID Analgesic (Single Response) (Single Response) [129716]
URL:
ketOROLAC (TORADOL) injection [58692] 15 mg, Intravenous, ONCE For 1 Doses, PACU
Page 2 of 5
Printed by GUETZLAFF, SCOTT F [SFG091] at 1/14/2016 1:51:53 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

ketOROLAC (TORADOL) injection [58693] 30 mg, Intravenous, ONCE For 1 Doses, PACU
ibuprofen (MOTRIN) tab [38353] 600 mg, Oral, ONCE For 1 Doses, PACU
Other Analgesics - Note: Do not order if within 6 hours of parenteral acetaminophen administration [133540]
URL:
acetaMINOPHEN (TYLENOL) tab - NOTE: Do not order
if within 6 hours of parenteral acetaminophen
administration [34149]
Oral, ONCE For 1 Doses
No more than 4 grams acetaminophen per 24 hours for adults
or 15 mg/kg per dose for peds <40 kg
PACU
Caffeine (Single Response) [137892]
caffeine tab [35435] 200 mg, Oral, ONCE For 1 Doses, PACU
Fluid Bolus for Hypotension [129717]
sodium chloride 0.9% BOLUS [730003] 500 mL, Intravenous, ONCE PRN For 1 Doses, hypotension -
see Admin Instructions
Systolic blood pressure less than *** mmHg
PACU
lactated ringers BOLUS [730001] 500 mL, Intravenous, ONCE PRN For 1 Doses, hypotension -
see Admin Instructions
Systolic blood pressure less than *** mmHg
PACU
Antiemetics - First Line Rescue Therapy [129718]
If the patient received a single prophylactic antiemetic agent during the procedure, select an agent with a different
mechanism of action for rescue therapy in the anesthesia recovery period (e.g., if ondansetron was given prophylactically,
rescue with prochlorperazine). If two - three agents are ordered within a 1st, 2nd, or 3rd Line Panel, these should be
considered as concurrent administration orders.
promethazine (PHENERGAN) injection [41412] 12.5 mg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
First Line Agent. Administer dose in a free flowing IV. If two -
three first line agents are ordered, these should be
considered as concurrent administration orders.
PACU
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
First Line Agent. Administer dose in a free flowing IV. If two-
three first line agents are ordered, these should be
considered as concurrent administration orders
metoclopramide (REGLAN) injection [39626] 10 mg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
First Line Agent. If two - three first line agents are ordered,
these should be considered as concurrent administration
orders.
If ordered IV: Administer over 2 minutes
PACU
ondansetron (ZOFRAN) injection [132824] 4 mg, Intravenous, ONCE PRN For 1 Doses
First Line Agent. If two - three first line agents are ordered,
these should be considered as concurrent administration
orders.
for 3 Minutes, PACU
diphenhydramine (BENADRYL) injection [36790] 12.5 mg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
First Line Agent. If two - three first line agents are ordered,
these should be considered as concurrent administration
orders.
for 1 Minutes, PACU
haloperidol lactate (HALDOL) injection [800108] Intravenous, ONCE PRN For 1 Doses, agitation,
Nausea/Vomiting
First Line Agent. If two - three first ilne agents are ordered,
these should be considered as concurrent administration
orders.
PACU
Page 3 of 5
Printed by GUETZLAFF, SCOTT F [SFG091] at 1/14/2016 1:51:53 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

Antiemetics - Second Line Rescue Therapy [129719]
If the patient received a single prophylactic antiemetic agent during the procedure, select an agent with a different
mechanism of action for rescue therapy in the anesthesia recovery period (e.g., if ondansetron was given prophylactically,
rescue with prochlorperazine). If two - three agents are ordered within a 1st, 2nd, or 3rd Line Panel, these should be
considered as concurrent administration orders.
promethazine (PHENERGAN) injection [41412] 12.5 mg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
Second Line Agent - Give if patient fails to respond to first line
agent after 30 minutes. Administer dose in a free flowing IV.
If two - three second line agents are ordered, these should
be considered as concurrent administration orders.
PACU
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
Second Line Agent - Give if patient fails to respond to first line
agent after 30 minutes. Administer dose in a free flowing IV. If
two-three second line agents are ordered, these should be
considered as cncurrent administration orders
metoclopramide (REGLAN) injection [39626] 10 mg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
Second Line Agent - Give if patient fails to respond to first line
agent after 30 minutes. If two - three second line agents are
ordered, these should be considered as concurrent
administration orders.
If ordered IV: Administer over 2 minutes
PACU
ondansetron (ZOFRAN) injection [132824] 4 mg, Intravenous, ONCE PRN For 1 Doses
Second Line Agent - Give if patient fails to respond to first line
agent after 30 minutes. If two - three second line agents are
ordered, these should be considered as concurrent
administration orders.
for 3 Minutes, PACU
diphenhydramine (BENADRYL) injection [36790] 12.5 mg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
Second Line Agent - Give if patient fails to respond to first line
agent after 30 minutes. If two - three second line agents are
ordered, these should be considered as concurrent
administration orders.
for 1 Minutes, PACU
haloperidol lactate (HALDOL) injection [800108] Intravenous, ONCE PRN For 1 Doses, agitation,
Nausea/Vomiting
Second Line Agent. Give if patient fails to respond to first line
agent after 30 minutes. If two - three second linie agents are
ordered, these should be considered as concurrent
administration orders.
PACU
Insulin [129721]
insulin regular (human) 100 UNIT/ML Injection [760284] Subcutaneous, ONCE For 1 Doses, PACU
insulin lispro (human) (HUMALOG) 100 UNIT/ML
injection [53264]
Subcutaneous, ONCE For 1 Doses
glucagon injection kit [107799] 1 mg, Subcutaneous, ONCE PRN For 1 Doses, hypoglycemia
dextrose 50 % vial [36634] 12.5 g, Intravenous, ONCE PRN For 1 Doses, hypoglycemia
IV Fluids [137971]
lactated ringers infusion [38890] Intravenous, CONTINUOUS
Titrate rate to keep up with fluid loss
PACU
sodium chloride 0.9 % infusion [64367] at 125 mL/hr, Intravenous, CONTINUOUS
Titrate rate to keep up with fluid loss.
PACU
Page 4 of 5
Printed by GUETZLAFF, SCOTT F [SFG091] at 1/14/2016 1:51:53 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

Respiratory/Airway [129723]
albuterol 2.5 mg/3 mL neb soln [34314] 2.5 mg, Nebulization, ONCE For 1 Doses, PACU
Self-administered Medications [24893]
Note: Self Administered Medication Program
Documentation [950000]
ONCE For 1 Doses
Patient may self-administer and use own supply of the
following medications: ***
PACU
Laboratory
Labs - Immediately Post-Op [134762]
HEMOGLOBIN [HGB] ONCE, 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?
PACU
PROTHROMBIN TIME/INR [PT] ONCE, 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?
PACU
Diagnostic Tests and Imaging
Studies [135466]
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by this
exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? IP PACU
Transport Method: Floor Determined/Entered
PACU
Page 5 of 5
Printed by GUETZLAFF, SCOTT F [SFG091] at 1/14/2016 1:51:53 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org