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IP-RAD ONC – Interstitial Brachytherapy – Adult – Procedure [4779]

IP-RAD ONC – Interstitial Brachytherapy – Adult – Procedure [4779] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, HOD, Radiation Oncology


SmartSet: IP - RAD ONC - INTERSTITIAL BRACHYTHERAPY - ADULT -
PROCEDURE (ID:4779)
General Information
Display name: RAD ONC - Interstitial Brachytherapy - Adult - Procedure
Type: General
Merge priority:
Version comment:
Content source:
Synonyms:
SmartSet notes:
Description:
Web information: Title URL
1.
Questionnaire:
Configuration
Pre-Op 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
Page 1 of 5
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:12:49 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

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
Laboratory
CBC WITHOUT DIFFERENTIAL STAT - RN COLLECT, Starting S For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
CREATININE, WHOLE BLOOD STAT - RN COLLECT, Starting S For 1 Occurrences,
STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
HEMOGLOBIN, WHOLE BLOOD STAT - RN COLLECT, Starting S For 1 Occurrences,
STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
Page 2 of 5
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:12:49 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

POTASSIUM, WHOLE BLOOD STAT - RN COLLECT, Starting S For 1 Occurrences,
STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
PROTHROMBIN TIME/INR STAT - RN COLLECT, Starting S For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
URINALYSIS WITH MICROSCOPY STAT - RN COLLECT, Starting S For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
Medications
Verify patient completed bowel preparation and
is only passing clear liquid (no stool). If passing
stool, provide enema ONCE
ONCE For 1 Occurrences, Verify patient completed
bowel preparation and is only passing clear liquid (no
stool). If passing stool, provide enema ONCE., Pre-
Op Day Of Procedure
phosphate (FLEET) enema 1 enema, Rectal, ONCE PRN For 1 Doses, other,
Bowel Prep, Pre-Op Day Of Procedure
VTE Prophylaxis
VTE Prophylaxis
Sequential Compression Device CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
IntraOp
Apply and Maintain Anti-Embolism Stocking CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
Pre-Op Day Of Procedure
heparin PF 5000 UNIT/0.5ML injection 5,000 units, Subcutaneous, ON CALL For 1 Doses
If patient scheduled for block, give after block placed
IntraOp
VTE Prophylaxis - Reason Not Ordered ONCE For 1 Occurrences, Routine
Reason Not Ordered:
Pre-Op Day Of Procedure
Surgical Prophylaxis
First Line
cefoxitin (MEFOXIN) intraVENOUS - NOTE:
Patient who is 40-120 kg
2 g, Intravenous, ON CALL For 1 Doses, IntraOp
Page 3 of 5
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:12:49 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

cefoxitin (MEFOXIN) intraVENOUS - NOTE:
Patient who is 121 kg or greater
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
MRSA/Documented MRSA History
Patients who are 40-120 kg
cefoxitin (MEFOXIN) intraVENOUS 2 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS 20 mg/kg, Intravenous, ON CALL For 1 Doses,
Pre-Op Day Of Procedure
Patients who are 121 kg or greater
cefoxitin (MEFOXIN) intraVENOUS 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS 20 mg/kg, Intravenous, ON CALL For 1 Doses,
Pre-Op Day Of Procedure
MRSA and Immediate/Severe Reaction to Penicillin or Known Cephalosporin Allergies
Patients who are 40-119 kg
ciprofloxacin (CIPRO) intraVENOUS 400 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
metRONIDazole (FLAGYL) intraVENOUS 500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS 20 mg/kg, Intravenous, ON CALL For 1 Doses,
Pre-Op Day Of Procedure
Patients who are 120-159 kg
ciprofloxacin (CIPRO) intraVENOUS 600 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
metRONIDazole (FLAGYL) intraVENOUS 750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS 20 mg/kg, Intravenous, ON CALL For 1 Doses,
Pre-Op Day Of Procedure
Patients who are 160 kg or greater
ciprofloxacin (CIPRO) intraVENOUS 800 mg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS 750 mg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS 20 mg/kg, Intravenous, ON CALL For 1 Doses,
Pre-Op Day Of Procedure
MRSA Negative and Immediate/Severe Reactions to Penicillin or Known Cephalosporin
Allergies
Patients who are 40-119 kg
ciprofloxacin (CIPRO) intraVENOUS 400 mg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS 500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who are 120 - 159 kg
ciprofloxacin (CIPRO) intraVENOUS 600 mg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS 750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who are greater than 160 kg
ciprofloxacin (CIPRO) intraVENOUS 800 mg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS 750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Criteria
Page 4 of 5
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:12:49 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

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Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:12:49 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org