/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/neurosciences/,

/clinical/cckm-tools/content/order-sets/ambulatory/neurosciences/name-118583-en.cckm

201710296

page

100

UWHC,UWMF,

Tools,

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

OP - Spinraza (nusinersen) Injection - Pediatric – Pre/Postprocedure [6481]

OP - Spinraza (nusinersen) Injection - Pediatric – Pre/Postprocedure [6481] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Neurosciences


OP - Spinraza (nusinersen) Injection - Pediatric - Pre/Postprocedure [6481]
Pre-Day of Procedure
Laboratory [224362]
BUN [BUN] Status: Standing, Expires:2/22/18 MANUAL,Count:1,
Normal, Routine
CBC WITHOUT DIFFERENTIAL [HEMO] Status: Standing, Expires:2/22/18 MANUAL,Count:1,
Normal, Routine
CREATININE [CRET] Status: Standing, Expires:11/24/18
MANUAL,Count:1, Normal, Routine
Page 4876 (VAT Team) for Lab Draw
[NURCOM0022]
Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:11/24/18
MANUAL,Count:1, Normal, Routine
PTT [PTT] Status: Standing, Expires:2/22/18 MANUAL,Count:1,
Normal, Routine
URINALYSIS, NO MICROSCOPY [UACHEM] Status: Standing, Expires:2/22/18 MANUAL,Count:1,
Normal, Routine
PreOp Day of Procedure
Isolation Status [127547]
Isolation - Contact - Multidrug Resistant
Organism (MDR) [235763]
Contact Isolation - MDRO (MDR) [ISO0334] CONTINUOUS
What is the Reason for Isolation? MDR
Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Isolation - Contact - Multidrug Resistant
Organism (XDR) [235764]
Contact Isolation - MDRO (XDR) [ISO0334] CONTINUOUS
What is the Reason for Isolation? XDR
Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Enhanced Contact Isolation - CDIFF [ISO0348] What is the reason for isolation? CDIFF
Separate order must be placed for isolation cart.,
Pre-Op Day Of Procedure
Contact Isolation - MDRO (MRSA) [ISO0334] CONTINUOUS
What is the Reason for Isolation? MRSA
Separate order must be placed for isolation cart.,
Pre-Op Day Of Procedure
Contact Isolation - MDRO (VRE) [ISO0334] CONTINUOUS
What is the Reason for Isolation? VRE
Separate order must be placed for isolation cart.,
Pre-Op Day Of Procedure
Isolation - Protective Precautions [235765]
Protective Precautions [ISO0349] What is the Reason for Isolation?
Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Airborne Isolation - Confirmed/Suspecgted
Pulmonary TB [ISO0325]
Separate order must be placed for isolation cart.,
Pre-Op Day Of Procedure
Vital Signs [224363]
Page 1 of 13
Printed by O'BRIEN, RYLEY P [RPO249] at 10/23/2017 9:15:42 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Vital Signs [NURMON0013] ONCE For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Pre-Op Day Of Procedure
Nutrition [224323]
NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: NPO
NPO Diet:
Bedside Meal Instructions:
Room Service Class:
Pre-Op Day Of Procedure
Respiratory [224366]
Pulse Oximetry [NURMON0009] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Notify Respiratory Therapy when patient
arrives [RT0073]
ONCE For 1 Occurrences, Routine, Pre-Op Day Of
Procedure
In-Exsufflator Treatment [RT0021] ONCE For 1 Occurrences, Routine
I Time:
E Time:
Pause Time:
Positive Pressure (cmH2O):
Negative Pressure (cmH2O):
Pre-Op Day Of Procedure
In-Exsufflator Treatment [RT0021] RT PRN, Routine
I Time:
E Time:
Pause Time:
Positive Pressure (cmH2O):
Negative Pressure (cmH2O):
Pre-Op Day Of Procedure
Maintain home airway clearance treatments
[RT0073]
RT PRN, Routine, Pre-Op Day Of Procedure
Cough Assist [RT0008] RT PRN, Routine, Pre-Op Day Of Procedure
Maintain home ventilation respiratory support
[RT0073]
CONTINUOUS, Routine, Pre-Op Day Of Procedure
Maintain home airway clearance treatments
[RT0073]
ONCE, Routine, Pre-Op Day Of Procedure
Non-Categorized Patient Care Orders [224367]
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
Measure Weight [NURMON0015] ONCE For 1 Occurrences, Routine
Weigh With?
Weigh when?
Pre-Op Day Of Procedure
Verify patient has the following labs resulted:
CBC, INR, PTT, BUN, Creatinine, UA
[NURCOM0022]
ONCE, Pre-Op Day Of Procedure
Page 2 of 13
Printed by O'BRIEN, RYLEY P [RPO249] at 10/23/2017 9:15:42 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Maintain Gastrostomy Tube [NURTAD0035] CONTINUOUS, Routine
Drainage Options:
Flush With:
Irrigant Volume (mL):
Flush Frequency:
Site Assessment Frequency:
Care Frequency:
Wash With:
Primary Dressing:
Secondary Dressing:
Pre-Op Day Of Procedure
Maintain Gastrostomy Jejunostomy Tube
[NURTAD0008]
CONTINUOUS, Routine
Gastrostomy Port Indications:
Flush G-Port With:
G-Port Flush Volume (mL):
G-Port Flush Frequency:
Jejunostomy Port Indications:
Flush J-Port With:
J-Port Flush Volume (mL):
J-Port Flush Frequency:
Site Assessment Frequency:
Care Frequency:
Wash With:
Primary Dressing:
Secondary Dressing:
Pre-Op Day Of Procedure
Contingency Parameters for Patients 3 through 6 Years Old [224370]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 118
If systolic blood pressure < (mmHg): 87
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 140
If heart rate < (bpm): 75
If respiratory rate >: 30
If respiratory rate <: 18
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other:
Pre-Op Day Of Procedure
Non-Categorized Medications [224273]
lidocaine (LMX) 4% topical dressing kit [66882] Topical, ONCE For 1 Doses
Neurology will mark the site.  RN to place lidocaine
cream (LMX) 1 hour prior to procedure.
Pre-Op Day Of Procedure
Page 3 of 13
Printed by O'BRIEN, RYLEY P [RPO249] at 10/23/2017 9:15:42 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Lidocaince Cream (LMX) Placement - 1 hour
prior to procedure [NURCOM0022]
ONCE For 1 Occurrences, Neurology will mark the
lumbar puncture site.  RN will place lidocaine Cream
(LMX) 1 hour prior to procedure.  When lidocaine
cream (LMX) is placed, contact OR pharmacy to pull
Spinraza vial from refrigerator to allow medication
to warm to room temperature.  DO NOT DRAW UP
MEDICATION., Pre-Op Day Of Procedure
IV Fluids [224271]
dextrose 10% 1000 mL with sodium chloride
77 mEq (Equivalent to 0.45% or 1/2 Normal
Saline), potassium chloride 20 mEq infusion
[710000]
Intravenous, CONTINUOUS, Pre-Op Day Of
Procedure
Continue IV fluids until tolerating feeds
[NURCOM0022]
CONTINUOUS, Pre-Op Day Of Procedure
Intraoperative Medications [224274]
nusinersen (SPINRAZA) 12 MG/5ML
intraTHECAL injection [174871]
12 mg, Intrathecal, ONCE For 1 Doses
To be administrated by MD in O.R.
Pre-Op Day Of Procedure
Consults [225268]
Page 4876 (VAT Team) [NURCOM0022] ONCE For 1 Occurrences, Page the following
information:
Spinraza patient arrived to OR and ready for PIV
and/or labs.
Patient Name
MR#
Location
Call Back #, Pre-Op Day Of Procedure
Consult Child Life Specialist (Inpatient)
[CON0014]
ONCE For 1 Occurrences, Routine
Activity Level: BEDREST
Reason for Consult: PROCEDURE PREP
Can this consult be done via video? No
Pre-Op Day Of Procedure
Laboratory [224325]
CBC WITHOUT DIFFERENTIAL [HEMO] STAT 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
PROTHROMBIN TIME/INR [PT] STAT 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
PTT [PTT] STAT 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
BUN [BUN] STAT 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 4 of 13
Printed by O'BRIEN, RYLEY P [RPO249] at 10/23/2017 9:15:42 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

CREATININE [CRET] STAT 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
URINALYSIS, NO MICROSCOPY [UACHEM] STAT 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
Glucose Management (PreOp)
Non-Categorized Patient Care Orders [225269]
Glucose, POC [IPGLUCOSE] ONCE 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
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, 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
Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA TREATMENT,
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
Patient Unable to Eat/Swallow Safely and No IV Access [225130]
glucagon 1 mg injection kit - NOTE: Maximum
Dose = 1 mg [107799]
0.03 mg/kg, Subcutaneous, PRN, for blood glucose
less than or equal to 69 mg/dL AND patient is
unable to eat/swallow safely, NPO or unconscious
AND has NO IV access.
Reconstituted concentration equals 1 mg/mL. If no
weight entered and patient 3 years or younger, give
0.5 mg. If no weight entered and patient older than
3 years, give 1 mg.
Pre-Op Day Of Procedure
Patient Unable to Eat/Swallow Safely and Has IV Access [227550]
dextrose injection - NOTE: Maximum Dose =
25 g [800233]
0.5-1 g/kg, Intravenous, PRN, For blood glucose less
than or equal to 69 mg/dL AND patient is unable to
eat/swallow safely, NPO or unconscious AND has IV
access.
Repeat every 15 minutes until blood glucose greater
than 70 mg/dL
Pre-Op Day Of Procedure
Oral Treatment (Single Response) [225132]
Hypoglycemia Treatment - Oral Route
 [225420]
Page 5 of 13
Printed by O'BRIEN, RYLEY P [RPO249] at 10/23/2017 9:15:42 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Hypoglycemia Treatment for blood glucose
less than 40 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? For blood glucose
less than 40 mg/dL and patient able to
eat/swallow safely
Give 30 grams of carbohydrate (6-8 oz. of fruit
juice). Repeat treatment every 15 minutes until
glucose is 70 mg/dL or greater.  Give 15 gram
carbohydrate and protein snack if meal or snack is
not scheduled within 1 hour of hypoglycemic
episode., Pre-Op Day Of Procedure
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today
If Conditional, What Condition? For blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely
Give 15 grams of carbohydrate (3-4 oz. of fruit
juice). Repeat treatment every 15 minutes until
glucose is 70 mg/dL or greater. Give 15 gram
carbohydrate and protein snack if meal or snack is
not scheduled within 1 hour of hypoglycemic
episode., Pre-Op Day Of Procedure
glucose-vitamin C chew tab [50690] 16 g, Oral, EVERY 15 MINUTES PRN, hypoglycemia,
For blood glucose 40-69 mg/dL
Use in patients able to safely eat/swallow but
unable to tolerate volume of fruit juice or per
patient preference. Repeat every 15 minutes until
blood glucose is 70 mg/dL or greater
Pre-Op Day Of Procedure
glucose-vitamin C chew tab [50690] 32 g, Oral, EVERY 15 MINUTES PRN, hypoglycemia,
For blood glucose less than 40 mg/dL
Use in patients able to safely eat/swallow but
unable to tolerate volume of fruit juice or per
patient preference. Repeat every 15 minutes until
blood glucose is 70 mg/dL or greater
Pre-Op Day Of Procedure
Hypoglycemia Treatment - Gastric Tube Route
[225422]
Hypoglycemia Treatment for blood glucose
less than 40 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? For blood glucose
less than 40 mg/dL and patient able to
eat/swallow safely
Give 30 grams of carbohydrate (6-8 oz. of fruit
juice). Repeat treatment every 15 minutes until
glucose is 70 mg/dL or greater.  Give 15 gram
carbohydrate and protein snack if meal or snack is
not scheduled within 1 hour of hypoglycemic
episode., Pre-Op Day Of Procedure
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today
If Conditional, What Condition? For blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely
Give 15 grams of carbohydrate (3-4 oz. of fruit
juice). Repeat treatment every 15 minutes until
glucose is 70 mg/dL or greater. Give 15 gram
carbohydrate and protein snack if meal or snack is
not scheduled within 1 hour of hypoglycemic
episode., Pre-Op Day Of Procedure
Page 6 of 13
Printed by O'BRIEN, RYLEY P [RPO249] at 10/23/2017 9:15:42 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

glucose-vitamin C chew tab [50690] 16 g, Gastric Tube (PEG), EVERY 15 MINUTES PRN,
hypoglycemia, For blood glucose 40-69 mg/dL
Use in patients able to safely eat/swallow but
unable to tolerate volume of fruit juice or per
patient preference. Repeat every 15 minutes until
blood glucose is 70 mg/dL or greater
Pre-Op Day Of Procedure
glucose-vitamin C chew tab [50690] 32 g, Gastric Tube (PEG), EVERY 15 MINUTES PRN,
hypoglycemia, For blood glucose less than 40
mg/dL
Use in patients able to safely eat/swallow but
unable to tolerate volume of fruit juice or per
patient preference. Repeat every 15 minutes until
blood glucose is 70 mg/dL or greater
Pre-Op Day Of Procedure
IntraOp
Diagnostic Test and Imaging [228868]
FLUOROSCOPY <= 1 HOUR [R76000] ONCE-RAD NEXT AVAILABLE, Routine
Which body area is to be imaged? Lumbar Spine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? Lumbar puncture with
Spinraza injection
What specific question(s) would you like answered
by this exam? Lumbar puncture with Spinraza
injection
Relevant recent/past history? Spinal Muscular
Atrophy
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date
in comment):
Transport Method: Floor Determined/Entered
IntraOp
PACU
IV Fluids [235307]
dextrose 10% 1000 mL with sodium chloride
77 mEq (Equivalent to 0.45% or 1/2 Normal
Saline), potassium chloride 20 mEq infusion
[710000]
Intravenous, CONTINUOUS, PACU
PACU Orders [224373]
Notify Respiratory Therapy when patient
arrives [RT0073]
ONCE For 1 Occurrences, Routine, PACU
In-Exsufflator Treatment [RT0021] ONCE For 1 Occurrences, Routine
I Time:
E Time:
Pause Time:
Positive Pressure (cmH2O):
Negative Pressure (cmH2O):
PACU
Page 7 of 13
Printed by O'BRIEN, RYLEY P [RPO249] at 10/23/2017 9:15:42 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

In-Exsufflator Treatment [RT0021] RT PRN, Routine
I Time:
E Time:
Pause Time:
Positive Pressure (cmH2O):
Negative Pressure (cmH2O):
PACU
Patient to resume home ventilation in PACU
until fully awake [RT0073]
CONTINUOUS, Routine, PACU
Maintain home airway clearance treatments
[RT0073]
ONCE For 1 Occurrences, Routine, PACU
Maintain home airway clearance treatment
[RT0073]
RT PRN, Routine, PACU
Continue IV fluids until tolerating feeds
[NURCOM0022]
CONTINUOUS, PACU
Patient to lie flat on back for 1 hour
postprocedure and then up as tolerated
[NURCOM0022]
CONTINUOUS, PACU
Glucose Management (PACU)
Non-Categorized Patient Care Orders [225713]
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, 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?
PACU
Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA TREATMENT,
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?
PACU
Patient Unable to Eat/Swallow Safely and No IV Access [227551]
glucagon 1 mg injection kit - NOTE: Maximum
Dose = 1 mg [107799]
0.03 mg/kg, Subcutaneous, PRN, for blood glucose
less than or equal to 69 mg/dL AND patient is
unable to eat/swallow safely, NPO or unconscious
AND has NO IV access.
Reconstituted concentration equals 1 mg/mL. If no
weight entered and patient 3 years or younger, give
0.5 mg. If no weight entered and patient older than
3 years, give 1 mg.
PACU
Patient Unable to Eat/Swallow Safely and Has IV Access [225719]
dextrose injection - NOTE: Maximum Dose =
25 g [800233]
0.5-1 g/kg, Intravenous, PRN, For blood glucose less
than or equal to 69 mg/dL AND patient is unable to
eat/swallow safely, NPO or unconscious AND has IV
access.
Repeat every 15 minutes until blood glucose greater
than 70 mg/dL
PACU
Patient Unable to Eat/Swallow Safely and Has IV Access [227552]
Page 8 of 13
Printed by O'BRIEN, RYLEY P [RPO249] at 10/23/2017 9:15:42 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

dextrose injection - NOTE: Maximum Dose =
25 g [800233]
25 g, Intravenous, PRN, For blood glucose less than
or equal to 69 mg/dL AND patient is unable to
eat/swallow safely, NPO or unconscious AND has IV
access.
Repeat every 15 minutes until blood glucose greater
than 70 mg/dL
PACU
Oral Treatment (Single Response) [225722]
Hypoglycemia Treatment - Oral Route
 [225420]
Hypoglycemia Treatment for blood glucose
less than 40 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? For blood glucose
less than 40 mg/dL and patient able to
eat/swallow safely
Give 30 grams of carbohydrate (6-8 oz. of fruit
juice). Repeat treatment every 15 minutes until
glucose is 70 mg/dL or greater.  Give 15 gram
carbohydrate and protein snack if meal or snack is
not scheduled within 1 hour of hypoglycemic
episode., PACU
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today
If Conditional, What Condition? For blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely
Give 15 grams of carbohydrate (3-4 oz. of fruit
juice). Repeat treatment every 15 minutes until
glucose is 70 mg/dL or greater. Give 15 gram
carbohydrate and protein snack if meal or snack is
not scheduled within 1 hour of hypoglycemic
episode., PACU
glucose-vitamin C chew tab [50690] 16 g, Oral, EVERY 15 MINUTES PRN, hypoglycemia,
For blood glucose 40-69 mg/dL
Use in patients able to safely eat/swallow but
unable to tolerate volume of fruit juice or per
patient preference. Repeat every 15 minutes until
blood glucose is 70 mg/dL or greater
PACU
glucose-vitamin C chew tab [50690] 32 g, Oral, EVERY 15 MINUTES PRN, hypoglycemia,
For blood glucose less than 40 mg/dL
Use in patients able to safely eat/swallow but
unable to tolerate volume of fruit juice or per
patient preference. Repeat every 15 minutes until
blood glucose is 70 mg/dL or greater
PACU
Hypoglycemia Treatment - Gastric Tube Route
[225422]
Page 9 of 13
Printed by O'BRIEN, RYLEY P [RPO249] at 10/23/2017 9:15:42 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Hypoglycemia Treatment for blood glucose
less than 40 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? For blood glucose
less than 40 mg/dL and patient able to
eat/swallow safely
Give 30 grams of carbohydrate (6-8 oz. of fruit
juice). Repeat treatment every 15 minutes until
glucose is 70 mg/dL or greater.  Give 15 gram
carbohydrate and protein snack if meal or snack is
not scheduled within 1 hour of hypoglycemic
episode., PACU
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today
If Conditional, What Condition? For blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely
Give 15 grams of carbohydrate (3-4 oz. of fruit
juice). Repeat treatment every 15 minutes until
glucose is 70 mg/dL or greater. Give 15 gram
carbohydrate and protein snack if meal or snack is
not scheduled within 1 hour of hypoglycemic
episode., PACU
glucose-vitamin C chew tab [50690] 16 g, Gastric Tube (PEG), EVERY 15 MINUTES PRN,
hypoglycemia, For blood glucose 40-69 mg/dL
Use in patients able to safely eat/swallow but
unable to tolerate volume of fruit juice or per
patient preference. Repeat every 15 minutes until
blood glucose is 70 mg/dL or greater
PACU
glucose-vitamin C chew tab [50690] 32 g, Gastric Tube (PEG), EVERY 15 MINUTES PRN,
hypoglycemia, For blood glucose less than 40
mg/dL
Use in patients able to safely eat/swallow but
unable to tolerate volume of fruit juice or per
patient preference. Repeat every 15 minutes until
blood glucose is 70 mg/dL or greater
PACU
PostOp/Phase II
Analgesics (Single Response) [224272]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - Maximum Dose = 650 mg
[800005]
10 mg/kg, Oral, EVERY 4 HOURS PRN, pain, Post-
Op/Phase II
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - Maximum Dose = 650 mg
[800005]
15 mg/kg, Oral, EVERY 4 HOURS PRN, pain, Post-
Op/Phase II
acetaMINOPHEN (TYLENOL) tab - Maximum
Dose = 650 mg [34149]
Oral, EVERY 4 HOURS PRN, pain, Post-Op/Phase II
PostOp Phase II Orders [224341]
Pulse Oximetry [NURMON0009] CONTINUOUS, Routine, Post-Op/Phase II
In-Exsufflator Treatment [RT0021] RT PRN, Routine
I Time:
E Time:
Pause Time:
Positive Pressure (cmH2O):
Negative Pressure (cmH2O):
Post-Op/Phase II
Page 10 of 13
Printed by O'BRIEN, RYLEY P [RPO249] at 10/23/2017 9:15:42 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Patient to lie flat on back for 1 hour
postprocedure and then up as tolerated
[NURCOM0022]
CONTINUOUS, Post-Op/Phase II
Resume home medications [NURCOM0022] CONTINUOUS, Post-Op/Phase II
Maintain home ventilation respiratory support
[RT0073]
CONTINUOUS, Routine, Post-Op/Phase II
Maintain home airway clearance treatments
[RT0073]
RT PRN, Routine, Post-Op/Phase II
Continue IV fluids until tolerating feeds.
[NURCOM0022]
CONTINUOUS, Post-Op/Phase II
Resume home feeds as soon as able
[NURCOM0022]
ONCE For 1 Occurrences, Post-Op/Phase II
Glucose Management (PostOp)
Non-Categorized Patient Care Orders [225727]
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, 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?
Post-Op/Phase II
Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA TREATMENT,
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?
Post-Op/Phase II
Patient Unable to Eat/Swallow Safely and No IV Access [225728]
glucagon 1 mg injection kit - NOTE: Maximum
Dose = 1 mg [107799]
0.03 mg/kg, Subcutaneous, PRN, for blood glucose
less than or equal to 69 mg/dL AND patient is
unable to eat/swallow safely, NPO or unconscious
AND has NO IV access.
Reconstituted concentration equals 1 mg/mL. If no
weight entered and patient 3 years or younger, give
0.5 mg. If no weight entered and patient older than
3 years, give 1 mg.
Post-Op/Phase II
Patient Unable to Eat/Swallow Safely and Has IV Access [225729]
dextrose injection - NOTE: Maximum Dose =
25 g [800233]
0.5-1 g/kg, Intravenous, PRN, For blood glucose less
than or equal to 69 mg/dL AND patient is unable to
eat/swallow safely, NPO or unconscious AND has IV
access.
Repeat every 15 minutes until blood glucose greater
than 70 mg/dL
Post-Op/Phase II
Oral Treatment (Single Response) [225730]
Hypoglycemia Treatment - Oral Route
 [225420]
Page 11 of 13
Printed by O'BRIEN, RYLEY P [RPO249] at 10/23/2017 9:15:42 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Hypoglycemia Treatment for blood glucose
less than 40 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? For blood glucose
less than 40 mg/dL and patient able to
eat/swallow safely
Give 30 grams of carbohydrate (6-8 oz. of fruit
juice). Repeat treatment every 15 minutes until
glucose is 70 mg/dL or greater.  Give 15 gram
carbohydrate and protein snack if meal or snack is
not scheduled within 1 hour of hypoglycemic
episode., Post-Op/Phase II
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today
If Conditional, What Condition? For blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely
Give 15 grams of carbohydrate (3-4 oz. of fruit
juice). Repeat treatment every 15 minutes until
glucose is 70 mg/dL or greater. Give 15 gram
carbohydrate and protein snack if meal or snack is
not scheduled within 1 hour of hypoglycemic
episode., Post-Op/Phase II
glucose-vitamin C chew tab [50690] 16 g, Oral, EVERY 15 MINUTES PRN, hypoglycemia,
For blood glucose 40-69 mg/dL
Use in patients able to safely eat/swallow but
unable to tolerate volume of fruit juice or per
patient preference. Repeat every 15 minutes until
blood glucose is 70 mg/dL or greater
Post-Op/Phase II
glucose-vitamin C chew tab [50690] 32 g, Oral, EVERY 15 MINUTES PRN, hypoglycemia,
For blood glucose less than 40 mg/dL
Use in patients able to safely eat/swallow but
unable to tolerate volume of fruit juice or per
patient preference. Repeat every 15 minutes until
blood glucose is 70 mg/dL or greater
Post-Op/Phase II
Hypoglycemia Treatment - Gastric Tube Route
[225422]
Hypoglycemia Treatment for blood glucose
less than 40 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? For blood glucose
less than 40 mg/dL and patient able to
eat/swallow safely
Give 30 grams of carbohydrate (6-8 oz. of fruit
juice). Repeat treatment every 15 minutes until
glucose is 70 mg/dL or greater.  Give 15 gram
carbohydrate and protein snack if meal or snack is
not scheduled within 1 hour of hypoglycemic
episode., Post-Op/Phase II
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today
If Conditional, What Condition? For blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely
Give 15 grams of carbohydrate (3-4 oz. of fruit
juice). Repeat treatment every 15 minutes until
glucose is 70 mg/dL or greater. Give 15 gram
carbohydrate and protein snack if meal or snack is
not scheduled within 1 hour of hypoglycemic
episode., Post-Op/Phase II
Page 12 of 13
Printed by O'BRIEN, RYLEY P [RPO249] at 10/23/2017 9:15:42 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

glucose-vitamin C chew tab [50690] 16 g, Gastric Tube (PEG), EVERY 15 MINUTES PRN,
hypoglycemia, For blood glucose 40-69 mg/dL
Use in patients able to safely eat/swallow but
unable to tolerate volume of fruit juice or per
patient preference. Repeat every 15 minutes until
blood glucose is 70 mg/dL or greater
Post-Op/Phase II
glucose-vitamin C chew tab [50690] 32 g, Gastric Tube (PEG), EVERY 15 MINUTES PRN,
hypoglycemia, For blood glucose less than 40
mg/dL
Use in patients able to safely eat/swallow but
unable to tolerate volume of fruit juice or per
patient preference. Repeat every 15 minutes until
blood glucose is 70 mg/dL or greater
Post-Op/Phase II
Page 13 of 13
Printed by O'BRIEN, RYLEY P [RPO249] at 10/23/2017 9:15:42 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org