/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/hod/,/clinical/cckm-tools/content/order-sets/hod/diagnosticssedation/,

/clinical/cckm-tools/content/order-sets/hod/diagnosticssedation/name-122307-en.cckm

201711307

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,HOD,Diagnostics/Sedation

OP/IP - Ketamine Infusion - Adult - Pre/Postprocedure [6487]

OP/IP - Ketamine Infusion - Adult - Pre/Postprocedure [6487] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, HOD, Diagnostics/Sedation


OP/IP - Ketamine Infusion - Adult - Pre/Postprocedure [6487]
Patient Care Orders - Preprocedure
Vital Signs [225312]
Vital Signs [NURMON0013] ONCE For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Preprocedure
Nutrition [225313]
NPO for Procedure - Hold Diet [DIE0007] EFFECTIVE MIDNIGHT, Starting tomorrow at 12:01
AM For 12 Hours, Routine
NPO For Which Procedure? Ketamine Infusion
Modifiers: NPO EXCEPT MEDICATIONS
NPO except for blood pressure medications.
Respiratory [25174]
Pulse Oximetry - Preprocedure [NURMON0009] ONCE, Starting today For 1 Occurrences, Routine,
Preprocedure
Non-Categorized Patient Care Orders (Single Response) [225314]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Maintain Peripheral IV [NURCOM0052] ONCE, Routine
Order Name (Only necessary if something other than
"Nursing Communcation" is preferred.):
Contingency Parameters [25170]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 175
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm): 110
If heart rate < (bpm): 50
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 90
If urine output < (mL):
Other: Pain not controlled with ordered analgesics or
ordered interventions,Agitation
Intravenous Therapy
Premedications for Needle Insertion [228227]
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.
Page 1 of 3
Printed by O'BRIEN, RYLEY P [RPO249] at 10/31/2017 1:25:31 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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
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
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
IV Fluids [225734]
sodium chloride 0.9 % infusion [64367] at 10 mL/hr, Intravenous, CONTINUOUS
Medications
Ketamine [225735]
ketAMINE (KETALAR) in sodium chloride 0.9 %
100 mL bag [701031]
0.5 mg/kg, Intravenous, ONCE For 1 Doses
Anti-emetic [225764]
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 24 HOURS PRN,
nausea/vomiting
Patient Care Orders - Intraprocedure
Vital Signs [233633]
Vital Signs [NURMON0013] SEE COMMENTS, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 10 minutes intraop.
Assess Neurologic Status [NURMON0006] SEE COMMENTS, Routine, Every 10 minutes intraop.
Patient Care Orders - Postprocedure
Vital Signs [225353]
Page 2 of 3
Printed by O'BRIEN, RYLEY P [RPO249] at 10/31/2017 1:25:31 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Vital Signs - Postprocedure [NURMON0013] EVERY 15 MINUTES For 2 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Postprocedure
Respiratory [25169]
Pulse Oximetry - Postprocedure [NURMON0009] EVERY 15 MINUTES, Starting today For 2
Occurrences, Routine, Postprocedure
Contingency Parameters [25170]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 175
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm): 110
If heart rate < (bpm): 50
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 90
If urine output < (mL):
Other: Pain not controlled with ordered analgesics or
ordered interventions,Agitation
Page 3 of 3
Printed by O'BRIEN, RYLEY P [RPO249] at 10/31/2017 1:25:31 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org