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RAD ONC – Placement of Catheters in Prostate for High-Dose Rate Radiation – Adult – Procedure [5333]

RAD ONC – Placement of Catheters in Prostate for High-Dose Rate Radiation – Adult – Procedure [5333] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, HOD, Radiation Oncology


RAD ONC - Placement of Catheters in Prostate for High-Dose Rate Radiation -
Adult - Procedure [5333]
PreProcedure
Non-Categorized Patient Care Orders [149304]
Patient Escort [PES0001] ONCE For 1 Occurrences
From: F6/4 - CARE INITIATION
To: XRT OPERATING
Transport Method: Stretcher Standard
Special Conditions: Oxygen Tank-Portable
Pre-Op Day Of Procedure
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
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
Have Patient Change Into Hospital Gown (No
Underwear) [NURCOM0022]
ONCE For 1 Occurrences, Pre-Op Day Of Procedure
Instruct Patient that Radiation Oncology
Physicians Will Meet With Patient in Treatment
Area Before Procedure to Address Any Last
Minute Questions/Concerns [NURCOM0022]
ONCE For 1 Occurrences, Pre-Op Day Of Procedure
Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, Routine, To discontinue this order,
enter a new order for "Discontinue Urinary Catheter".
To modify this order, enter a new order for "Maintain
Urinary Catheter" and make the necessary changes in
the new order.
Type:
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Pre-Op Day Of Procedure
Contingency Parameters [149306]
Page 1 of 5
Printed by STRAKA, KEVIN F [KFS1] at 1/10/2018 12:16:01 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 200
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg): 100
If diastolic blood pressure < (mmHg): 40
If temperature > (C): 38
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 50
If respiratory rate >: 30
If respiratory rate <: 8
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >: 8
Pulse Oximetry < (%): 90
If urine output < (mL):
Other: Notify *** at pager *** for patient issues. If
unavailable page Radiation Oncology Triage Nurse at
pager 8795.
Pre-Op Day Of Procedure
IV Fluids [244210]
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
Diagnostic Tests and Imaging [149307]
Radiation Oncology Treatment CT/Sim without
Contrast [RADONC0006]
Routine
Consent obtained from patient? Yes
Claustrophobia: No
Is There a Possibility of Pregnancy: No
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: Prostate Cancer
Parameters to Include: Pelvis
Scheduling Request: STANDARD - Within 7 Days
Page MD for Setup: Both
Physics Present at CT/SIM: Yes
Patient Position - Body:
Patient Position - Other:
Approximate Number of Fractions: 1
Target Site:
Contrast: No
Other Directions to CT Therapists:
Instructions for Patient:
Laborartoy [186738]
For Laboratory Orders: Okay to use PICC line
[NURCOM0022]
ONCE, Pre-Op Day Of Procedure
PACU
Non-Categorized Patient Care Orders [243994]
Discontinue Urinary Catheter [NURELM0069] ONCE For 1 Occurrences, Routine, Discontinue foley
catheter prior to transfer to Phase 2 recovery, PACU
Surgical Prophylaxis
First line [149426]
Page 2 of 5
Printed by STRAKA, KEVIN F [KFS1] at 1/10/2018 12:16:01 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

cefoxitin (MEFOXIN) intraVENOUS - NOTE: for
patients 41-120 kg [800022]
2 g, Intravenous, ON CALL For 1 Doses, Radiation
Oncology
cefoxitin (MEFOXIN) intraVENOUS - NOTE: for
patients greater than 120 mg [800022]
3 g, Intravenous, ON CALL For 1 Doses, Radiation
Oncology
Immediate/Severe Reaction to Penicillin or Known Cephalosporin Allergies [149430]
levofloxacin (LEVAQUIN) intraVENOUS [800052] 750 mg, Intravenous, ON CALL For 1 Doses,
Radiation Oncology
Post-Op/Phase II Recovery
Patient Care Orders [149435]
Vital Signs [NURMON0013] SEE COMMENTS, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
As Needed, Radiation Oncology
Diet - General [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Radiation Oncology
Diet - Diabetes Meal Plan [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Diabetes
Bedside Meal Instructions:
Room Service Class:
Radiation Oncology
Diet - Custom [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type:
Radiation Oncology
Activity [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:
Radiation Oncology
Discontinue Urinary Catheter and Initiate Bladder
Management Protocol [125356]
Page 3 of 5
Printed by STRAKA, KEVIN F [KFS1] at 1/10/2018 12:16:01 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Un-check the Initiate Bladder Management Protocol order when it does not apply.
The Bladder Management Protocol (Adult Inpatient) d oes NOT apply for patients with :
· Primary surgical urological diagnosis
· Acute spinal cord injury
· Indwelling catheters placed by urology
· Bladder outlet syndrome
· Chronic urinary retention
· Gross hematuria
· Complex pelvic reconstructive surgery
· Lumbar epidural
· End of life care
· Home straight cath regimen
Discontinue Urinary Catheter [NURELM0069] ONCE For 1 Occurrences, Routine, Okay to
discontinue foley catheter once patient is sitting up
and ambulating., Radiation Oncology
Initiate Bladder Management Protocol
[NURELM0014]
CONTINUOUS, Routine, Radiation Oncology
Non-Categorized Patient Care Orders [149437]
Complete Pre-Procedure Checklist in Health Link
[NURCOM0022]
ONCE For 1 Occurrences, Radiation Oncology
Apply Ice Pack to Affected Area [NURTRT0008] PRN, Routine
Site: Affected Area (perineum)
Radiation Oncology
Discharge Patient [ADT0004] Disposition: Discharged to Home or Self Care
Discharge Date: 1/10/2018
Discontinue IV when taking adequate oral
[NURCOM0022]
ONCE For 1 Occurrences, Radiation Oncology
Anti-emetics [149427]
ondansetron (ZOFRAN) tab [45939] 8 mg, Oral, ONCE PRN For 1 Doses,
nausea/vomiting, Radiation Oncology
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
When unable to tolerate orally
Radiation Oncology
Analgesics [201084]
acetaMINOPHEN (TYLENOL) tab RANGE
[750000]
325-650 mg, Oral, EVERY 4 HOURS PRN, pain/fever,
mild/moderate pain, multi-modal analgesic therapy, or
fever, Radiation Oncology
oxycodone-acetaMINOPHEN (PERCOCET)
5-325 MG per tab RANGE [750033]
1-2 tab, Oral, EVERY 4 HOURS PRN, pain, Severe
pain, Radiation Oncology
Medications - Flushes [186679]
heparin lock flush 10 UNIT/ML injection [75031] 50 units, Flush, PRN, flush/line care, Radiation
Oncology
sodium chloride flush 0.9% 10 mL injection
[785055]
5-10 mL, Flush, PRN, flush/line care, Radiation
Oncology
Inpatient Discharge Orders
Reason for Hospitalization [149439]
Why You Were Hospitalized [NURCOM0073] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, You were hospitalized for radiation
therapy for your cancer.
Activity [149441]
May Resume Normal Activity as Tolerated
[NURACT0011]
Routine, May resume normal activity as tolerated
Page 4 of 5
Printed by STRAKA, KEVIN F [KFS1] at 1/10/2018 12:16:01 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Nutrition [149442]
Resume Normal Diet as Tolerated [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications:
Resume normal diet as tolerated
Medication Instructions [149631]
Resume Home Medications [NURCOM0071] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, Resume home medications
immediately
Contingency Parameters [149632]
Contact Radiation Oncology [NURCOM0071] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, Contact Radiation Oncologist (608)
263-8500 if problems arise after discharge.
Page 5 of 5
Printed by STRAKA, KEVIN F [KFS1] at 1/10/2018 12:16:01 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org