/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/radiation-oncology/,

/clinical/cckm-tools/content/order-sets/hod/radiation-oncology/name-97786-en.cckm

201706156

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,HOD,Radiation Oncology

RAD ONC - Stereotactic Radiosurgery - Adult - Pre/Postprocedure [4562]

RAD ONC - Stereotactic Radiosurgery - Adult - Pre/Postprocedure [4562] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, HOD, Radiation Oncology


RAD ONC - Stereotactic Radiosurgery - Adult - Pre/Postprocedure [4562]
for Adult Patients OnlyIntended
Prior to Day of Procedure
Diagnostic Test and Imaging [123053]
CT/Sim with IV Contrast [RADONC0004] 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: Stereo Protocol
Scheduling Request: URGENT - 3DCRT Within 48
Hours
Page MD for Setup: No
Physics Present at CT/SIM: Yes
Patient Position - Body: HFS - Head First Supine
Patient Position - Other: Stereo Protocol
Approximate Number of Fractions: 1
Target Site: Brain
Brain:
Contrast: IV Contrast
Last creatinine value? (will auto pull in date and value
in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Known Allergies:
Diabetes:
Previous Scan with Contrast:
Other Directions to CT Therapists:
Instructions for Patient: NPO 4 Hours
Please link to reserved CT on ***
Page 1 of 9
Printed by STRAKA, KEVIN F [KFS1] at 5/30/2017 1:57:49 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2017CCKM@uwhealth.org

CT/Sim without Contrast [RADONC0006] 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: Stereo Protocol
Scheduling Request: URGENT - 3DCRT Within 48
Hours
Page MD for Setup: No
Physics Present at CT/SIM: Yes
Patient Position - Body: HFS - Head First Supine
Patient Position - Other: Stereo Protocol
Approximate Number of Fractions: 1
Target Site: Brain
Brain:
Contrast: No
Other Directions to CT Therapists:
Instructions for Patient: NPO 4 Hours
Please link to reserved CT on ***
Follow-Up Appointments [122734]
Schedule Appointment with RXRN
[NURCOM0026]
Routine
Reason for Hospital Follow Up Appointment: Frame
placement
Which Provider: Other Provider or Specialist
When do you want appointment: Other (Enter
comments)
Which Clinic or Specialty: Radiation Oncology
Please create above appointment for 60 minutes on
stereotactic date at *** a.m.
Schedule Appointment with Radiation Oncology
[NURCOM0026]
Routine
Reason for Hospital Follow Up Appointment: One
month post procedure therapy
Which Provider: Other Provider or Specialist
When do you want appointment: Other (Enter
comments)
Which Clinic or Specialty: Radiation Oncology
Schedule Appointment [NURCOM0026] Routine
Reason for Hospital Follow Up Appointment:
Which Provider: Other Provider or Specialist
When do you want appointment: Other (Enter
comments)
Which Clinic or Specialty:
Pre-Procedure
Level of Care (Single Response) [187484]
*An admit patient order has already been written, but the level of care at which the patient
should be placed still needs to be identified.
Place Patient on General Care [ADT0018] General Care, has already been signed. This order
will ensure that the patient is placed at the
appropriate level of care.
Place Patient on Intermediate Care [ADT0018] Intermediate Care, has already been signed. This
order will ensure that the patient is placed at the
appropriate level of care.
Page 2 of 9
Printed by STRAKA, KEVIN F [KFS1] at 5/30/2017 1:57:49 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Place Patient on Intensive Care (ICU) [ADT0018] has already been signed. This order will ensure that
the patient is placed at the appropriate level of care.
Admit to Inpatient (Single Response) [188296]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically
necessary because of either an anticipated LOS >2
midnights, complexity and/or severity of illness, an
inpatient-only surgery, or a previously-authorized
inpatient stay. Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Pre-Op Day Of Procedure
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Pre-Op Day Of Procedure
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Pre-Op Day Of Procedure
Admission Status [124019]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-only
surgery, or a previously-authorized inpatient stay.
Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Pre-Op Day Of Procedure
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Pre-Op Day Of Procedure
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor: Care Initiation Unit
Service: NEUROSURGERY
Pre-Op Day Of Procedure
Page 3 of 9
Printed by STRAKA, KEVIN F [KFS1] at 5/30/2017 1:57:49 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Isolation Status [97372]
Isolation - Enhanced Contact - Clostridium
Difficile [ISO0010]
CONTINUOUS, Separate order must be placed for
isolation cart., Pre-Op Day Of Procedure
Isolation - Contact - MRSA [ISO0039] CONTINUOUS, Separate order must be placed for
isolation cart., Pre-Op Day Of Procedure
Isolation - Contact - VRE [ISO0051] CONTINUOUS, Separate order must be placed for
isolation cart., Pre-Op Day Of Procedure
Isolation - Protective Precautions - Panel
[116356]
Protective Precautions [ISO0001] CONTINUOUS
Reason for Protective Precautions:
Pre-Op Day Of Procedure
Protective - Positive Pressure Room
[NURCOM0109]
CONTINUOUS, Pre-Op Day Of Procedure
Isolation - Contact - Multidrug Resistant
Organism - Panel [116335]
Isolation - Contact - Multidrug Resistant
Organism (MDR) [ISO0006]
CONTINUOUS, Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Isolation - Contact - Extensively Resistant
Organism (XDR) - Panel [193206]
Isolation - Contact - Extensively Drug Resistant
Organism (XDR) [ISO0320]
CONTINUOUS, Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Vital Signs [109412]
Vital Signs [NURMON0013] ONCE For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Obtain on admission, Pre-Op Day Of Procedure
Non-Categorized Patient Care Orders [122733]
Diet - NPO Except Medications [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
Pre-Op Day Of Procedure
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
May use port for venous access if available, Pre-Op
Day Of Procedure
Contingency Parameters [123052]
Page 4 of 9
Printed by STRAKA, KEVIN F [KFS1] at 5/30/2017 1:57:49 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Notify Radiation Oncology Team
[NURCOM0001]
CONTINUOUS
Provider to Notify: Other (Comment)
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: If pain not controlled with ordered analgesics
or interventions
Page Radiation Oncology team *** with questions,
Pre-Op Day Of Procedure
Premedications for Needle Insertion [106313]
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.
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
Pre-Op Day Of Procedure
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
Pre-Op Day Of Procedure
Page 5 of 9
Printed by STRAKA, KEVIN F [KFS1] at 5/30/2017 1:57:49 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

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
IV Fluids [122794]
dextrose 5%-NaCl 0.45% infusion [51613] at 50 mL/hr, Intravenous, CONTINUOUS, Pre-Op
Day Of Procedure
Medications [122795]
diazepam (VALIUM) tab [36678] 5 mg, Oral, ONCE For 1 Doses
Give immediately upon arrival
Pre-Op Day Of Procedure
Radiation Oncology - Frame Placement
Medications [123055]
lidocaine 1%-epINEPHrine 0.01 mg/mL
(1:100000) injection [45570]
10-40 mL, Other, ONCE PRN For 1 Doses, for
administration by provider for procedure
Administer two injections into anterior scalp and two
injections into posterior scalp for frame pin placement
Radiation Oncology
sodium bicarbonate injection [800214] 5-20 mEq, Other, ONCE PRN For 1 Doses, for
administration by provider for procedure
Administer two injections into anterior scalp and two
injections into posterior scalp for frame pin placement
Radiation Oncology
bupivacaine PF (MARCAINE) 0.75% vial
[158102]
5-20 mL, Other, ONCE PRN For 1 Doses, for
administration by provider for procedure
Administer two injections into anterior scalp and two
injections into posterior scalp for frame pin placement
Radiation Oncology
midazolam (VERSED) injection RANGE [750056] 1-5 mg, Intravenous, ONCE PRN For 1 Doses,
procedural sedation in Radiation Oncology, Radiation
Oncology
FENTanyl PF injection RANGE [750047] 25-100 mcg, Intravenous, ONCE PRN For 1 Doses,
procedural sedation in Radiation Oncology, for 1
Minutes, Radiation Oncology
MORPHine PF injection RANGE [750057] 1-4 mg, Intravenous, ONCE PRN For 1 Doses, pain,
procedural sedation in Radiation Oncology, for 4
Minutes, Radiation Oncology
iohexol (OMNIPAQUE) 240 MG/ML injection
[156030]
150 mL, Intravenous, ONCE For 1 Doses, Radiation
Oncology
iohexol (OMNIPAQUE) 300 mg/mL injection
[156029]
100 mL, Intravenous, ONCE For 1 Doses, Radiation
Oncology
Medications - Side Effect Management [221493]
naloxone (NARCAN) injection [800199] 0.1 mg, Intravenous, PRN, opioid overdose
Administer every 3 minutes times 4 doses as needed
for respiratory rate less tha 8 breaths/minute. Notify
physician if administered.
Radiation Oncology
Page 6 of 9
Printed by STRAKA, KEVIN F [KFS1] at 5/30/2017 1:57:49 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

flumazenil (ROMAZICON) 0.1 mg/mL 5mL vial
STOCK VIAL [790017]
0.1-1 mg, Intravenous, ONCE PRN For 1 Doses,
Sedation Reversal.
Administer 0.1-0.2 mg intravenouslly over 15
seconds; repeat dose after 45 seconds (1 minute
intervals) as needed for sedation reversal up to a
maximum dose of 1 mg.
Radiation Oncology
atropine injection [800178] 0.1 mg, Intravenous, ONCE PRN For 1 Doses,
bradycardia
Administer over 1 minute
Radiation Oncology
Flushes [124280]
sodium chloride 0.9% flush 10 mL injection
[785055]
Flush, PRN, flush/line care
Flush per VAD guidelines
Radiation Oncology
heparin lock flush 10 UNIT/ML injection [75031] 1-150 units, Flush, PRN, flush/line care
Flush per VAD Guidelines
Radiation Oncology
heparin lock flush 100 units/mL 5 mL injection
[64978]
500 units, Flush, PRN, flush/line care
Implanted port use ONLY to be used when de-
accessing port. Flush per VAD guidelines
Radiation Oncology
Post Procedure on Unit
Vital Signs [122732]
Vital Signs [NURMON0013] SEE COMMENTS, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Vital signs PRN
NOTE: If patient has angiogram follow Radiology
orders, Post-Op/Phase II
Non-Categorized Patient Care Orders [122731]
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
Activity; Ad Lib [NURACT0008] CONTINUOUS, Routine
AD LIB: ad lib
AMBULATE:
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Post-Op/Phase II
Medications [122796]
Page 7 of 9
Printed by STRAKA, KEVIN F [KFS1] at 5/30/2017 1:57:49 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

diazepam (VALIUM) tab [36678] 5 mg, Oral, ONCE PRN For 1 Doses, see Admin
Instructions
Give one hour prior to returning for Radiation
Oncology treatment.
Radiology Oncology to notify when needed.
Post-Op/Phase II
diazepam (VALIUM) tab [36678] 5 mg, Oral, EVERY 6 HOURS PRN, anxiety, Post-
Op/Phase II
ondansetron (ZOFRAN) tab [45939] 4 mg, Oral, EVERY 6 HOURS PRN, nausea/vomiting,
Post-Op/Phase II
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting, Post-Op/Phase II
acetaMINOPHEN (TYLENOL) tab RANGE
[750000]
325-650 mg, Oral, EVERY 4 HOURS PRN,
pain/fever, for mild pain, Post-Op/Phase II
oxycodone-acetaMINOPHEN (PERCOCET)
5-325 MG per tab RANGE [750033]
1-2 tab, Oral, EVERY 3 HOURS PRN, pain, for
moderate to severe pain, Post-Op/Phase II
hydrocodone-acetaMINOPHEN (NORCO) 5-325
MG per tab RANGE [750021]
1-2 tab, Oral, EVERY 3 HOURS PRN, pain, for
moderate to severe pain, Post-Op/Phase II
Note: Patient May Self-Administer Own Home
Medications as Ordered [950018]
ONCE For 1 Doses
Note: Patient may self-administer own home
medications as ordered. See orders for patient
supplied medications. ***
Post-Op/Phase II
Radiation Oncology - Treatment
Radiation Oncology - Treatment [124195]
oxycodone-acetaMINOPHEN (PERCOCET)
5-325 MG per tab RANGE [750033]
1-2 tab, Oral, EVERY 3 HOURS PRN, pain, pain
while in Radiation Oncology, Post-Op/Phase II
MORPHine PF injection RANGE [750057] 1-2 mg, Intravenous, EVERY 15 MINUTES PRN,
pain, pain while in Radiation Oncology, for 4 Minutes,
Radiation Oncology
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting, Radiation Oncology
Discharge Orders
Activity [123077]
May Resume Normal Activity One Day After
Procedure [NURACT0011]
Routine, May resume normal activity one day after
procedure
Nutrition [123080]
Resume Normal Diet as Tolerated [NUT8888] Routine
General: General (No Modifications)
Diet Modifications:
Other Diet Modifications: -
Solid Consistency:
Liquid Consistency:
Liquid:
Esophagectomy:
Fat Controlled:
Fiber:
Fluid Restriction:
Heart Healthy:
Metabolic:
Renal:
Sodium Controlled:
NPO:
Resume Normal Diet as Tolerated
Medication Instructions [123081]
Page 8 of 9
Printed by STRAKA, KEVIN F [KFS1] at 5/30/2017 1:57:49 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Resume home medications as instructed
[NURCOM0022]
Routine, Resume home medications as instructed.
No aspirin, ibuprofen (ADVIL) or naproxen (ALEVE)
for 3 days after treatment.
Hold metformin and metformin-containing
products for 48 hours after treatment
[NURCOM0022]
Routine
Resume anticoagulants [NURCOM0022] Routine, Resume warfarin (COUMADIN) in *** days
after treatment
Resume clopidogrel (PLAVIX) in *** days after
treatment
Contingency Parameters [123082]
Contact Radiation Oncology [NURCOM0066] Routine, Contact Radiaton Oncology at (608) 263-
8500 for increasing or severe headaches not relieved
by acetaminophen (TYLENOL); headaches that occur
daily or several times a day,even if relieved by
acetaminophen (TYLENOL); nausea or vomitting; any
change in strength or sensation (numbness or
tingling); vision, hearing, or speech changes or
difficulties; dizziness; onset of confusion; new
seizures or worsening of seizures; signs of infection
(swelling, redness, drainage) at the pin sites; or
temperature above 100 degrees F
Page 9 of 9
Printed by STRAKA, KEVIN F [KFS1] at 5/30/2017 1:57:49 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org