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/clinical/cckm-tools/content/order-sets/ambulatory/transformations-surgery-center/name-98456-en.cckm

201610302

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100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,Transformations Surgery Center

TSC - Anesthiology - Adult - Preoperative [4778]

TSC - Anesthiology - Adult - Preoperative [4778] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Transformations Surgery Center


TSC - Anesthiology - Adult - Preoperative [4778]
Patient Care Orders
Respiratory [128919]
Oxygen Therapy [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen?
Pre-Op Day Of Procedure
Non-Categorized Patient Care Orders [136002]
GLUCOSE, POC [HCMGLUC] ONCE, Starting today For 1 Occurrences, Routine
If Conditional, What Condition?
Pre-Op Day Of Procedure
Medications
Analgesics (Scheduled) [129163]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, ONCE For 1 Doses, Pre-Op Day Of
Procedure
HYDROmorphone HCl PF (DILAUDID) injection
[154010]
Intravenous, ONCE For 1 Doses, for 3 Minutes, Pre-
Op Day Of Procedure
MORPHine PF injection [156564] Intravenous, ONCE For 1 Doses, for 4 Minutes, Pre-
Op Day Of Procedure
Analgesics (PRN) [195286]
oxycodone-acetaMINOPHEN (PERCOCET)
5-325 mg per tab RANGE [750033]
1-2 tab, Oral, ONCE PRN For 1 Doses, pain, Pre-Op
Day Of Procedure
oxycodone tab RANGE [750032] 5-10 mg, Oral, ONCE PRN For 1 Doses, pain,
Moderate/Severe Pain, Pre-Op Day Of Procedure
Anti-emetics [129451]
diphenhydramine (BENADRYL) cap [36791] 25 mg, Oral, ONCE For 1 Doses, Pre-Op Day Of
Procedure
diphenhydramine (BENADRYL) injection [36790] 25 mg, Intravenous, ONCE For 1 Doses, for 1
Minutes, Pre-Op Day Of Procedure
meclizine (ANTIVERT) tab [47269] 25 mg, Oral, ONCE For 1 Doses, Pre-Op Day Of
Procedure
metoclopramide (REGLAN) tab [39629] 10 mg, Oral, ONCE For 1 Doses, Pre-Op Day Of
Procedure
metoclopramide (REGLAN) injection [39626] 10 mg, Intravenous, ONCE For 1 Doses, Pre-Op Day
Of Procedure
ondansetron (ZOFRAN) injection [132824] 4 mg, Intravenous, ONCE For 1 Doses, for 3 Minutes,
Pre-Op Day Of Procedure
scopolamine (TRANSDERM-SCOP) 1
MG/3DAYS 72hr patch [166671]
1 patch, Transdermal, ONCE For 1 Doses
Apply patch to dry, hairless area of skin behind the
ear
Pre-Op Day Of Procedure
olanzapine (ZYPREXA) tab [57140] Oral, ONCE For 1 Doses, Pre-Op Day Of Procedure
haloperidol lactate (HALDOL) injection [38067] 0.5 mg, Intravenous, ONCE For 1 Doses, Pre-Op Day
Of Procedure
Acid Suppressants (Single Response) [202933]
ranitidine (ZANTAC) tab [46455] 150 mg, Oral, ONCE For 1 Doses, Pre-Op Day Of
Procedure
ranitidine (ZANTAC) injection [800075] 50 mg, Intravenous, ONCE For 1 Doses, Pre-Op Day
Of Procedure
Page 1 of 3
Printed by O'BRIEN, RYLEY P [RPO249] at 10/28/2016 12:20:54 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2016CCKM@uwhealth.org

Antacids [214397]
citric acid-sodium citrate (BICITRA) soln [51447] 30 mEq, Oral, ONCE For 1 Doses
Leave dose at patient's bedside for administration by
anesthesia provider immediately prior to procedure
Pre-Op Day Of Procedure
Caffeine [129455]
caffeine tab [35435] 200 mg, Oral, ONCE For 1 Doses, Pre-Op Day Of
Procedure
Premedications for Needle Insertion [129449]
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.
lidocaine 1 % vial [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
Insulin [129452]
insulin regular (human) 100 UNIT/ML Injection
[760284]
Subcutaneous, ONCE For 1 Doses, Pre-Op Day Of
Procedure
insulin isophane NPH (human) 100 units/mL vial
[45417]
Subcutaneous, ONCE For 1 Doses, Pre-Op Day Of
Procedure
Respiratory/Airway [129453]
albuterol HFA 108 (90 BASE) MCG/ACT
(VENTOLIN HFA) inhaler [53730]
Inhalation, ONCE For 1 Doses, Pre-Op Day Of
Procedure
albuterol 2.5 mg/3 mL neb soln [34314] 2.5 mg, Nebulization, ONCE For 1 Doses, Pre-Op
Day Of Procedure
oxymetazoline (AFRIN) 0.05% nasal spray
[40671]
1 spray, Nostril (Each), EVERY 10 MINUTES For 3
Doses, Pre-Op Day Of Procedure
Sedatives [129454]
diazepam (VALIUM) tab [36679] 5 mg, Oral, ONCE For 1 Doses, Pre-Op Day Of
Procedure
midazolam (VERSED) injection [131420] 1 mg, Intravenous, ONCE For 1 Doses, Pre-Op Day
Of Procedure
Self-administer Medications [84428]
Page 2 of 3
Printed by O'BRIEN, RYLEY P [RPO249] at 10/28/2016 12:20:54 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2016CCKM@uwhealth.org

Note: Self Administered Medication Program
Documentation [950000]
ONCE For 1 Doses
Patient may self-administer and use own supply of
the following medications: ***
Pre-Op Day Of Procedure
Laboratory
Labs [136001]
HEMOGLOBIN, POC [HCHGBPOC] ONCE, Starting today For 1 Occurrences, Routine
If Conditional, What Condition?
Pre-Op Day Of Procedure
PROTHROMBIN TIME/INR, POC [HCINRPOC] ONCE, Starting today For 1 Occurrences, Routine
If Conditional, What Condition?
Pre-Op Day Of Procedure
Pregnancy Test [136000]
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
she "could" be pregnant.
HCG, QUAL, URINE, POC [HCPREGPOC] ONCE, Starting today For Until specified, Routine
If Conditional, What Condition?
Pre-Op Day Of Procedure
Page 3 of 3
Printed by O'BRIEN, RYLEY P [RPO249] at 10/28/2016 12:20:54 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2016CCKM@uwhealth.org