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/clinical/cckm-tools/content/order-sets/hod/radiation-oncology/name-97778-en.cckm

201609270

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RAD ONC - Breast Brachytherapy - Pre/Postoperative [4563]

RAD ONC - Breast Brachytherapy - Pre/Postoperative [4563] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, HOD, Radiation Oncology


SmartSet: RAD ONC - BREAST BRACHYTHERAPY - PRE/POSTOPERATIVE
(ID:4563)
General Information
Display name: RAD ONC - Breast Brachytherapy - Pre/Postoperative
Type: General
Merge priority:
Version comment:
Content source:
Synonyms: 1. .RADONC
SmartSet notes:
Description: Intended for Adult Patients Only
Web information: Title URL
1.
Questionnaire:
Configuration
Pre-Day of Procedure
Medications - Prescriptions - Analgesics
hydrocodone-acetaMINOPHEN (NORCO) 5-325
mg per tab - q4hp #20
20 tab, 0, starting t, Normal, Pre-Day of Procedure
hydrocodone-acetaMINOPHEN (NORCO) 10-
325 mg per tab - q4hp #20
20 tab, 0, starting t, Normal, Pre-Day of Procedure
oxycodone-acetaminophen (PERCOCET) 5-325
mg per tab - q4hp #20
20 tab, 0, starting t, Normal, Pre-Day of Procedure
oxycodone-acetaminophen (PERCOCET)
7.5-325 mg per tab - q4hp #20
20 tab, 0, starting t, Normal
oxycodone 5 mg tab - 1-2t q4h prn #20 20 tab, 0, starting t, Normal, Pre-Day of Procedure
Medications - Prescriptions - Non-Categorized
lidocaine-prilocaine (EMLA) 2.5-2.5 % cream 1 Tube, 0, starting t, Normal, Pre-Day of Procedure
diazepam (VALIUM) 5 MG tab 10 tab, 0, starting t, Normal, Pre-Day of Procedure
Page 1 of 7
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:14:04 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

PreOp Day of Procedure
Isolation Status
Isolation - Enhanced Contact - Clostridium
Difficile
CONTINUOUS, Separate order must be placed for
isolation cart., Pre-Op Day Of Procedure
Isolation - Contact - MRSA CONTINUOUS, Separate order must be placed for
isolation cart., Pre-Op Day Of Procedure
Isolation - Contact - VRE CONTINUOUS, Separate order must be placed for
isolation cart., Pre-Op Day Of Procedure
Isolation - Protective Precautions - Panel
Protective Precautions CONTINUOUS
Reason for Protective Precautions:
Pre-Op Day Of Procedure
Protective - Positive Pressure Room CONTINUOUS, Pre-Op Day Of Procedure
Isolation - Contact - Multidrug Resistant
Organism - Panel
Isolation - Contact - Multidrug Resistant
Organism (MDR)
CONTINUOUS, Pre-Op Day Of Procedure
Isolation Cart CONTINUOUS, Routine, Pre-Op Day Of
Procedure
Isolation - Contact - Extensively Resistant
Organism (XDR) - Panel
Isolation - Contact - Extensively Drug Resistant
Organism (XDR)
CONTINUOUS, Pre-Op Day Of Procedure
Isolation Cart CONTINUOUS, Routine, Pre-Op Day Of
Procedure
Premedications for Needle Insertion
lidocaine (LMX) 4% topical dressing kit 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 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 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
Page 2 of 7
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:14:04 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

IV Fluids
Insert and Maintain Peripheral IV CONTINUOUS For Until specified, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Radiation Oncology
sodium chloride 0.9% BOLUS 1,000 mL, Intravenous, ONCE For 1 Doses
Give at 125 mL/hr
Radiation Oncology
lactated ringers BOLUS 1,000 mL, Intravenous, ONCE For 1 Doses
Give at 125 mL/hr
Radiation Oncology
Ultrasound-Guided Catheter Placement in Radiation Oncology
BREAST BRACHYTHERAPY CATHETER
PLACEMENT, ULTRASOUND GUIDED LEFT
Status: Future, Expires: M+14, Normal, Routine
BREAST BRACHYTHERAPY CATHETER
PLACEMENT, ULTRASOUND GUIDED RIGHT
Status: Future, Expires: M+14, Normal, Routine
Mammography-Guided Catheter Placement in Breast Center
BREAST ULTRASOUND PREBRACHY
ASPIRATION/ INJECTION LEFT
Status: Future, Expires: M+14, Normal, Routine
BREAST ULTRASOUND PREBRACHY
ASPIRATION/ INJECTION RIGHT
Status: Future, Expires: M+14, Normal, Routine
MAMMOGRAM DIAGNOSTIC DIGITAL
UNILATERAL LEFT
Status: Future, Expires: M+14, Normal, Routine
MAMMOGRAM DIAGNOSTIC DIGITAL
UNILATERAL RIGHT
Status: Future, Expires: M+14, Normal, Routine
BREAST STEREOTACTIC BRACHYTHERAPY
LEFT
Status: Future, Expires: M+14, Normal, Routine
BREAST STEREOTACTIC BRACHYTHERAPY
RIGHT
Status: Future, Expires: M+14, Normal, Routine
CT-Guided Insertion of Multi-Catheters
Radiation Oncology Treatment CT/ Sim without
Contrast - Panel - Right
Radiation Oncology Treatment CT/Sim without
Contrast - Right
ONCE, Starting S For 1 Occurrences, Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
Last patient height? (will auto pull in value and
date in comment):
Last patient weight? (will auto pull in value and
date in comment):
Diagnosis:
Parameters to Include:
Treatment Same Day as CT/Sim:
Page MD for Setup:
Physics Present at CT/SIM:
Patient Position - Body:
Patient Position - Other:
CT Slice Thickness:
Target Site:
Contrast:
Other Directions to CT Therapists:
Instructions for Patient:
Radiation Oncology
Radiation Oncology Treatment CT/ Sim without
Contrast - Panel - Left
Page 3 of 7
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:14:04 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

Radiation Oncology Treatment CT/Sim without
Contrast - Left
ONCE, Starting S For 1 Occurrences, Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
Last patient height? (will auto pull in value and
date in comment):
Last patient weight? (will auto pull in value and
date in comment):
Diagnosis:
Parameters to Include:
Treatment Same Day as CT/Sim:
Page MD for Setup:
Physics Present at CT/SIM:
Patient Position - Body:
Patient Position - Other:
CT Slice Thickness:
Target Site:
Contrast:
Other Directions to CT Therapists:
Instructions for Patient:
Radiation Oncology
Radiation Oncology
Medications - Local Anesthetic Solution
lidocaine-epINEPHrine 2%-0.001% 20 mL,
sodium bicarbonate 2.5 mEq in sodium chloride
0.9 % 250 mL
Subcutaneous, ONCE For 1 Doses, Radiation
Oncology
lidocaine 1%-epINEPHrine 0.01 mg/mL
(1:100000) injection
Subcutaneous, ONCE PRN For 1 Doses,
brachytherapy, Radiation Oncology
bupivacaine PF (MARCAINE) 0.75% vial Other, ONCE PRN For 1 Doses, Radiation Oncology
sodium bicarbonate injection Other, ONCE PRN For 1 Doses, Radiation Oncology
lidocaine (STERILE UROJECT) 2 % gel Topical, ONCE PRN For 1 Doses, Balloon catheter
insertions, Radiation Oncology
Medications - Procedural Sedation
midazolam (VERSED) injection RANGE 0.5-1 mg, Intravenous, EVERY 5 MINUTES PRN,
procedural sedation, Radiation Oncology
FENTanyl PF injection RANGE 12.5-25 mcg, Intravenous, EVERY 5 MINUTES PRN,
for 1 Minutes, Radiation Oncology
PostOp/Phase II
Wound Care
Wound Care ONCE, Apply triple antibiotic ointment to
brachytherapy site(s), cover with guaze and supply
support bra, Post-Op/Phase II
Surgical Bra (JODEE) with Pads ONCE, Routine
Bra Size:
Post-Op/Phase II
Diagnostic Tests and Imaging
Page 4 of 7
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:14:04 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

Radiation Oncology Treatment CT/Sim without
Contrast
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
Last patient height? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date
in comment):
Diagnosis:
Parameters to Include:
Treatment Same Day as CT/Sim:
Page MD for Setup:
Physics Present at CT/SIM:
Patient Position - Body:
Patient Position - Other:
CT Slice Thickness:
Target Site:
Contrast:
Other Directions to CT Therapists:
Instructions for Patient:
Radiation Oncology Acuity Simulation Routine
Diagnosis:
Target Site:
Patient Position:
Is There a Possibility of Pregnancy:
Treatment Same Day as Acuity Simulation:
Claustrophobia:
Treatment Fields:
Physics Present at CT/SIM:
Contingency Parameters
Notify Radiation Oncologist Provider to Notify: Provider
If systolic blood pressure > (mmHg): 160
If systolic blood pressure < (mmHg): 80
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 35.5
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 60
If respiratory rate >: 30
If respiratory rate <: 8
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
If pain score >:
Pulse Oximetry < (%): 90
If urine output < (mL): 30 mL/hour for 2 hours
Other: If pain not controlled with ordered analgesics
or interventions,If patient is nauseous,If patient has
excessive bleeding,If patient not able to urinate
Post-Op/Phase II
Prior to Discharge
Patient Must Be Seen by Attending Prior to
Discharge
ONCE, Starting S For 1 Occurrences, Routine, Post-
Op/Phase II
Patient Must Be Seen by Resident Prior to
Discharge
ONCE, Starting S For 1 Occurrences, Routine, Post-
Op/Phase II
Page 5 of 7
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:14:04 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

Outpatient Discharge Orders
Activity
Activity Routine
Discharge Activity: Other (Comment)
May resume normal activity. No lifting greater than
10 pounds during treatment regimen. May return to
work as tolerated., Phase II Discharge
Nutrition
Resume Normal Diet as Tolerated Routine
General:
Diet Modifications:
Other Diet Modifications:
Resume normal diet as tolerated
Wound Care
Wound Care Routine, Nurse to perform catheter site care when
patient is in clinic. Patient should not remove bra until
instructed.
Follow-Up Appointments
Schedule Appointment with Radiation Oncology
Nurse for Skin/Healing Check
Routine
Reason for Appointment: Skin/Healing Check
When do you want appointment: One Week Post
Procedure
Which Clinic or Specialty: Radiation Oncology Nurse
Which Provider (Optional):
Schedule Appointment with Radiation
Oncologist for Skin/Healing Check
Routine
Reason for Appointment: Skin/Healing Check
When do you want appointment: 4 Weeks Post
Procedure
Which Clinic or Specialty: Radiation Oncologist
Which Provider (Optional):
Contingency Parameters
Contact Radiation Oncology Routine, Call Radiation Oncologist on call at (608)
263-8500 for any problems after discharge
Criteria
Suggestions: UWHOD ORDERSET SUGGESTION RAD ONC[4500004]
Filter: UWIP ORDER SET RESTRICTOR - NOT TSC/MSC[3000407]
Restrict SmartSet:
Settings
Discontinue action:
Deselect sections for
Pended/Held orders:
Page 6 of 7
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:14:04 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

Pended/Held orders
display:
Release date: Use System Definitions Setting
Disallow user override:
Page 7 of 7
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:14:04 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org