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Anesthesiology - Pediatric - Recovery_PACU [2522]

Anesthesiology - Pediatric - Recovery_PACU [2522] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Anesthesiology


Anesthesiology - Pediatric - Recovery/PACU [2522]
Patient Care Orders
Patient Monitoring [148462]
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today For 1 Days, Routine,
PACU
Cardio-Respiratory Monitor - Pediatric - Without
Rhythm [139420]
Cardio-Respiratory Monitor - Pediatric - Without
Rhythm [NURMON0074]
ONCE, Routine, Please complete the Notify
Provider order below, including specification for
apnea > *** seconds. If indicated, order pulse
oximetry separately.
Device Present:
Device Mode:
Device Low Rate Limit (BPM):
Notify Provider:
PACU
Notify [NURCOM0001] Provider to Notify: Provider
Notify based on:
Notify provider for apnea > 20 seconds, PACU
Glucose, POC [IPGLUCOSE] POST-OP, Starting today with First Occurrence
Include Now, Routine, Glucose, POC should always
be ordered in conjunction with orders for
hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
Immediately Postoperatively, PACU
Glucose, POC [IPGLUCOSE] CONDITIONAL - RN COLLECT, Starting today,
Routine, Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition?
Prior to discharge from PACU, PACU
Maintain Arterial Line [NURVAD0001] CONTINUOUS, Routine
Device Status:
Flush Solution:
Site:
PACU
Respiratory [83436]
Oxygen Therapy - Blow-By [RT0032] CONTINUOUS, Starting today For Until specified,
Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device: Blow-By
Attempt to Wean Off Oxygen?
PACU
Oxygen Therapy - Nasal Cannula [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen?
PACU
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Oxygen Therapy - Venti Mask [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device: Venturi mask
Attempt to Wean Off Oxygen?
PACU
Oxygen Therapy - Trach Mask [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device: Tracheostomy collar
Attempt to Wean Off Oxygen?
PACU
Oxygen Therapy - Non-Rebreather [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device: Non-rebreather mask
Attempt to Wean Off Oxygen?
PACU
High Flow Nasal Cannula [RT0071] CONTINUOUS, Starting today, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
Attempt to Wean Off Oxygen? Yes
PACU
CPAP Continuous [RT0009] CONTINUOUS, Starting today, Routine
PEEP (cmH2O):
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Titrate oxygen to maintain O2 sat at (%):
Self Administered (Only RT may document in this box
after patient assessment): RT Approval Required
If patient brings own device, RT to evaluate., PACU
Biphasic Positive Airway Pressure (BIPAP)
[RT0004]
CONTINUOUS, Starting today, Routine
Mode:
IPAP (cm H2O):
EPAP (cm H2O):
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Set Rate/Min:
Titrate oxygen to maintain O2 sat at (%):
Self Administered (Only RT may document in this box
after patient assessment): RT Approval Required
PACU
Non-Categorized Patient Care Orders [81238]
DISCHARGE Patient to Home, Skilled Medical
Facility, or Supervised Living Facility. IF patient is
designated as Outpatient Surgery class, AND
anesthesiology faculty have filed a postop
Faculty note, AND patient has achieved minimum
or greater Phase II Discharge Score
[NURCOM0022]
ONCE For 1 Occurrences, PACU
Do NOT Discharge Patient From Hospital After
Outpatient Surgery Unless Anesthesiologist
Gives a Specific, Separate Discharge Order
[NURCOM0022]
ONCE For 1 Occurrences, PACU
Page 2 of 11
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Do NOT Discharge from Inpatient PACU Per
Discharge Scoring System [NURCOM0022]
SEE COMMENTS, Starting today For Until specified,
Do NOT discharge from Inpatient PACU per
discharge scoring system., PACU
Follow PACU Pain and Sedation Score Protocol
[NURMON0080]
CONTINUOUS, Routine, PACU
May Use Surgeon's Postoperative Patient
Controlled Analgesia (PCA) Orders
[NURCOM0022]
ONCE, PACU
Apply Brace/Splint, Lower Body [NURTRT0009] CONTINUOUS, Routine, If ordering a Bledsoe Boot
or Hip Abduction Brace, please contact the cast room
technician at 265-0746.
Type: Knee Immobilizer
Left/Right/Bilateral?
Wearing schedule:
PACU
Contingency Parameters [148466]
Cardiovascular Parameters to Notify
Anesthesiologist [NURCOM0022]
ONCE, Call Anesthesiologist if HYPOtension: systolic
BP below *** or diastolic BP below ***
Call Anesthesiologist if HYPERtension: systolic BP
above *** or diastolic BP above ***, PACU
Notify [NURCOM0001] Provider to Notify: Provider
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): 400
If blood glucose < (mg/dL): 40
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other:
Contact Anesthesiologist
Medications
Parenteral Opioid Analgesic - First Line Rescue Therapy (Single Response) [124165]
MORPHine PF injection RANGE [750057] 0.0125 mg/kg, Intravenous, EVERY 6 MINUTES
PRN, pain
Administer up to *** mg.
First Line Parenteral Analgesic Agent - Give if unable
to tolerate oral opioids or rapid response required (if
for rapid response, may give parenteral and oral pain
meds concurrently). If insufficient pain relief, give
Second Line Parenteral Therapy or notify provider if
no second line therapy is ordered.
for 4 Minutes, PACU
Page 3 of 11
Printed by O'BRIEN, RYLEY P [RPO249] at 4/3/2017 10:05:02 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

HYDROmorphone PF (DILAUDID) injection
RANGE [750050]
0.0025 mg/kg, Intravenous, EVERY 6 MINUTES
PRN, pain
Administer up to *** mg.
First Line Parenteral Analgesic Agent - Give if unable
to tolerate oral opioids or rapid response required (if
for rapid response, may give parenteral and oral pain
meds concurrently). If insufficient pain relief, give
Second Line Parenteral Therapy or notify provider if
no second line therapy is ordered.
for 3 Minutes, PACU
FENTanyl PF injection RANGE [750047] 0.5 mcg/kg, Intravenous, EVERY 6 MINUTES PRN,
pain
Administer up to *** micrograms.
First Line Parenteral Analgesic Agent - Give if unable
to tolerate oral opioids or rapid response required (if
for rapid response, may give parenteral and oral pain
meds concurrently). If insufficient pain relief, give
Second Line Parenteral Therapy or notify provider if
no second line therapy is ordered.
for 1 Minutes, PACU
Parenteral Opioid Analgesic - Second Line Rescue Therapy (Single Response) [124166]
MORPHine PF injection RANGE [750057] 0.0125 mg/kg, Intravenous, EVERY 6 MINUTES
PRN, pain
Administer up to *** mg.
Second Line Parenteral Analgesic Agent - Give if
unresponsive to maximum First Line Parenteral
Therapy. Give if unable to tolerate oral opioids or
rapid response required (if for rapid response, may
give parenteral and oral pain meds concurrently)
for 4 Minutes, PACU
HYDROmorphone PF (DILAUDID) injection
RANGE [750050]
0.0025 mg/kg, Intravenous, EVERY 6 MINUTES
PRN, pain
Administer up to *** mg.
Second Line Parenteral Analgesic Agent - Give if
unresponsive to maximum First Line Parenteral
Therapy. Give if unable to tolerate oral opioids or
rapid response required (if for rapid response, may
give parenteral and oral pain meds concurrently)
for 3 Minutes, PACU
FENTanyl PF injection RANGE [750047] 0.5 mcg/kg, Intravenous, EVERY 6 MINUTES PRN,
pain
Administer up to *** micrograms.
Second Line Parenteral Analgesic Agent - Give if
unresponsive to maximum First Line Parenteral
Therapy. Give if unable to tolerate oral opioids or
rapid response required (if for rapid response, may
give parenteral and oral pain meds concurrently)
for 1 Minutes, PACU
Parenteral Opioid Antishivering - Meperidine [124167]
meperidine (DEMEROL) injection RANGE
[750055]
0.25 mg/kg, Intravenous, ONCE PRN For 1 Doses,
shivering, for 4 Minutes, PACU
Oral Opioid Analgesic (Single Response) [124168]
Pain Fast Fact - Multimodal Analgesia URL: https://uconnect.wisc.edu/clinical/references/pain-
management/references-
guidelines/resources/name-29968-en.file
Page 4 of 11
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

oxycodone tab RANGE - (Maximum 10 mg/dose)
[750032]
5-10 mg, Oral, EVERY 1 HOUR PRN For 2 Doses,
pain
Give parenteral opioid if patient unable to tolerate oral
meds or if rapid response required, may give
parenteral and oral pain meds concurrently. If patient
cannot swallow tablets, use oral solution. If giving oral
med, and patient does not have relief in 1 hour, titrate
dose up to maximum dose. If no benefit after 2 doses,
call provider.
PACU
oxycodone soln - (Maximum 10 mg/dose)
[45975]
0.05-0.1 mg/kg, Oral, EVERY 1 HOUR PRN For 2
Doses, pain
Give solution if patient unable to swallow tablet. Give
parenteral opioid if patient unable to tolerate oral
meds or if rapid response required, may give
parenteral and oral pain meds concurrently. If giving
oral med, and patient does not have relief in 1 hour,
titrate dose up to maximum dose. If no benefit after 2
doses, call provider
PACU
NSAID Analgesics Note: May only select one NSAID Analgesic (Single Response) [124169]
URL:
ibuprofen (MOTRIN) susp - (Maximum 600
mg/dose) [45376]
5 mg/kg, Oral, ONCE For 1 Doses, PACU
ibuprofen (MOTRIN) tab - NOTE: Suggested
dose 5 mg/kg (Maximum 600 mg/dose) [38353]
Oral, ONCE For 1 Doses
NOTE: Suggested dose 5 mg/kg (Maximum 600
mg/dose)
PACU
ketOROLAC (TORADOL) injection - (Maximum
15 mg/dose) [800050]
0.5 mg/kg, Intravenous, ONCE For 1 Doses
Administer IV push over 15-30 seconds
PACU
Other Analgesics Note: Do not order if within 6 hours of parenteral acetaminophen administration
(Single Response) [124171]
URL:
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - Note: Do not order if within 6 hours
of parenteral acetaminophen administration.
(Maximum of 1000 mg/dose) [800005]
10 mg/kg, Oral, EVERY 6 HOURS PRN, pain/fever,
PACU
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - Note: Do not order if within 6 hours
of parenteral acetaminophen administration.
(Maximum of 1000 mg/dose ) [800005]
15 mg/kg, Oral, EVERY 6 HOURS PRN, pain/fever,
PACU
acetaMINOPHEN (TYLENOL) tab [34149] Oral, ONCE For 1 Doses, PACU
Antiemetics - First Line Rescue Therapy [119185]
If the patient received a single prophylactic antiemetic agent during the procedure, select an
agent with a different mechanism of action for rescue therapy in the anesthesia recovery period
(e.g., if ondansetron was given prophylactically, rescue with prochlorperazine). If two - three
agents are ordered within a 1
st
, 2
nd
, or 3
rd
Line Panel, these should be considered as concurrent
administration orders.
haloperidol lactate (HALDOL) injection [800108] 0.01 mg/kg, Intravenous, ONCE PRN For 1 Doses,
agitation, Nausea/Vomiting
If two - three first line agents are ordered, these
should be considered as concurrent administration
orders.
Page 5 of 11
Printed by O'BRIEN, RYLEY P [RPO249] at 4/3/2017 10:05:02 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

prochlorperazine (COMPAZINE) injection -
NOTE: Do NOT Order for patients less than 2
years (Maximum Dose 10 mg/dose) [41369]
0.15 mg/kg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
First Line Agent. IV push slowly, max rate 5
mg/minute. If two - three first line agents are ordered,
these should be considered as concurrent
administration orders.
NOTE: Do NOT Order for patients less than 2 years
PACU
promethazine (PHENERGAN) injection - NOTE:
Do NOT Order for patients less than 2 years
(Maximum 12.5 mg/dose) [800112]
0.25 mg/kg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
First Line Agent. Administer dose in a free flowing IV.
Suggest dilution in 10-20 mL of sodium chloride 0.9%
and administration over 10 minutes if given IV push.
Alternatively, when administered by a CENTRAL
LINE may be diluted in a 50 mL sodium chloride 0.9%
mini-bag and administered over at least 10 minutes.
Do NOT use hand or wrist veins. If two - three first
line agents are ordered, these should be considered
as concurrent administration orders.
NOTE: Do NOT Order for patients less than 2 years
PACU
metoclopramide (REGLAN) injection - (Maximum
10 mg/dose) [800059]
0.1 mg/kg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
First Line Agent. Administer over 2 minutes. If two -
three first line agents are ordered, these should be
considered as concurrent administration orders.
PACU
ondansetron (ZOFRAN) injection - (Maximum 4
mg/dose) [800202]
0.1 mg/kg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
First Line Agent. If two - three first line agents are
ordered, these should be considered as concurrent
administration orders.
PACU
diphenhydramine (BENADRYL) injection -
(Maximum 12.5 mg/dose) [800106]
0.5 mg/kg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
First Line Agent. If two - three first line agents are
ordered, these should be considered as concurrent
administration orders.
PACU
epHEDRINE injection - NOTE: Order for age
greater than 12 years AND weight greater than
40 kg [760090]
5 mg, Intravenous, ONCE PRN For 1 Doses, postural
hypotension-induced nausea/vomiting
First Line Agent. IV push slowly. If two - three first
line agents are ordered, these should be considered
as concurrent administration orders
NOTE: Order for age greater than 12 years AND
weight greater than 40 kg
PACU
epHEDRINE injection - NOTE: Order for age
greater than 12 years AND weight greater than
40 kg [760090]
10 mg, Intramuscular, ONCE PRN For 1 Doses,
postural hypotension-induced nausea/vomiting
First Line Agent. If two - three first line agents are
ordered, these should be considered as concurrent
administration orders
If ordered IV: push slowly.
NOTE: Order for age greater than 12 years AND
weight greater than 40 kg
PACU
Page 6 of 11
Printed by O'BRIEN, RYLEY P [RPO249] at 4/3/2017 10:05:02 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

Antiemetics - Second Line Rescue Therapy [119217]
If the patient received a single prophylactic antiemetic agent during the procedure, select an
agent with a different mechanism of action for rescue therapy in the anesthesia recovery period
(e.g., if ondansetron was given prophylactically, rescue with prochlorperazine). If two - three
agents are ordered within a 1
st
, 2
nd
, or 3
rd
Line Panel, these should be considered as concurrent
administration orders.
haloperidol lactate (HALDOL) injection - NOTE:
suggested dose 0.01 mg/kg (Maximum dose 0.05
mg/kg) [800108]
0.01 mg/kg, Intravenous, ONCE PRN For 1 Doses,
agitation, Nausea/Vomiting
Second Line Agent - Give if patient fails to respond to
first line agent after 30 minutes. IV push slowly, max
rate 5 mg/minute. If two - three second line agents
are ordered, these should be considered as
concurrent administration orders.
NOTE: suggested dose 0.01 mg/kg (Maximum dose
0.05 mg/kg)
prochlorperazine (COMPAZINE) injection -
NOTE: Do NOT Order for patients less than 2
years (Maximum 10 mg/dose) [41369]
0.15 mg/kg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
Second Line Agent - Give if patient fails to respond to
first line agent after 30 minutes. IV push slowly, max
rate 5 mg/minute. If two - three second line agents
are ordered, these should be considered as
concurrent administration orders.
NOTE: Do NOT Order for patients less than 2 years
PACU
promethazine (PHENERGAN) injection - NOTE:
Do NOT Order for patients less than 2 years
(Maximum 12.5 mg/dose) [800112]
0.25 mg/kg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
Second Line Agent - Give if patient fails to respond to
first line agent after 30 minutes. Administer dose in a
free flowing IV. Suggest dilution in 10-20 mL of
sodium chloride 0.9% and administration over 10
minutes if given IV push. Alternatively, when
administered by a CENTRAL LINE may be diluted in
a 50 mL sodium chloride 0.9% mini-bag and
administered over at least 10 minutes. Do NOT use
hand or wrist veins. If two - three second line agents
are ordered, these should be considered as
concurrent administration orders.
NOTE: Do NOT Order for patients less than 2 years
PACU
metoclopramide (REGLAN) injection (Maximum
10 mg/dose) [800059]
0.1 mg/kg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
Second Line Agent - Give if patient fails to respond to
first line agent after 30 minutes. Administer over 2
minutes. If two - three second line agents are
ordered, these should be considered as concurrent
administration orders.
PACU
ondansetron (ZOFRAN) injection - (Maximum 4
mg/dose) [800202]
0.1 mg/kg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
Second Line Agent - Give if patient fails to respond to
first line agent after 30 minutes. If two - three second
line agents are ordered, these should be considered
as concurrent administration orders.
PACU
Page 7 of 11
Printed by O'BRIEN, RYLEY P [RPO249] at 4/3/2017 10:05:02 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection -
(Maximum 12.5 mg/dose) [800106]
0.5 mg/kg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
Second Line Agent - Give if patient fails to respond to
first line agent after 30 minutes. If two - three second
line agents are ordered, these should be considered
as concurrent administration orders.
epHEDRINE injection - NOTE: Order for age
greater than 12 years AND weight greater than
40 kg [760090]
5 mg, Intravenous, ONCE PRN For 1 Doses, postural
hypotension-induced nausea/vomiting
Second Line Agent - Give if patient fails to respond to
first line agent after 30 minutes. IV push slowly. If
two - three second line agents are ordered, these
should be considered as concurrent administration
orders.
NOTE: Order for age greater than 12 years AND
weight greater than 40 kg
PACU
epHEDRINE injection - NOTE: Order for age
greater than 12 years AND weight greater than
40 kg [760090]
10 mg, Intramuscular, ONCE PRN For 1 Doses,
postural hypotension-induced nausea/vomiting
Second Line Agent - Give if patient fails to respond to
first line agent after 30 minutes. If two - three second
line agents are ordered, these should be considered
as concurrent administration orders
If ordered IV: push slowly.
NOTE: Order for age greater than 12 years AND
weight greater than 40 kg
PACU
Hypotensive Therapies [81242]
sodium chloride 0.9% BOLUS [730003] 10 mL/kg, Intravenous, ONCE For 1 Doses
Maximum of 500 mL
PACU
lactated ringers BOLUS [730001] 10 mL/kg, Intravenous, ONCE For 1 Doses
Maximum of 500 mL
PACU
albumin human 5% infusion [44038] 5 mL/kg, Intravenous, ONCE For 1 Doses, PACU
epHEDRINE in sodium chloride 0.9% 5MG/ML
injection - NOTE: Suggested dose 0.05-0.1
mg/kg (Maximum 10 mg/dose); order either
ephedrine OR phenylephrine [755112]
0.1 mg/kg, Intravenous, EVERY 10 MINUTES PRN
For 3 Doses, hypotension - see Admin Instructions
Administer for systolic blood pressure less than ***
mmHg
NOTE: Suggested dose 0.05-0.1 mg/kg (Maximum 10
mg/dose)
PACU
phenylEPHRINE in sodium chloride 0.9% 0.1
MG/ML injection - NOTE: Suggested dose 1
mcg/kg (Maximum 10 mcg/dose); order either
ephedrine OR phenylephrine [755110]
1 mcg/kg, Intravenous, EVERY 10 MINUTES PRN
For 3 Doses, hypotension - see Admin Instructions
Administer for systolic blood pressure less than ***
mmHg
NOTE: Do NOT order for patients less 40 kg.
Suggested dose 1 mcg/kg (Maximum 10 mcg/dose)
PACU
Anti-hypertensives [81243]
Page 8 of 11
Printed by O'BRIEN, RYLEY P [RPO249] at 4/3/2017 10:05:02 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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04/2017CCKM@uwhealth.org

hydrALAZINE (APRESOLINE) injection - NOTE:
Suggested dose 0.1 mg/kg (Maximum 10
mg/dose) [38203]
0.1 mg/kg, Intravenous, ONCE PRN For 1 Doses,
hypertension, hypertension - see Admin Instructions
Administer for systolic blood pressure greater than ***
mmHg. Administer over 1 minute
for 1 Minutes
NOTE: Suggested dose 0.1 mg/kg (Maximum 10
mg/dose)
PACU
labetalol injection CUSTOM - NOTE: Suggested
dose 0.2 mg/kg (Maximum 20 mg/dose) [800192]
0.2 mg/kg, Intravenous, ONCE PRN For 1 Doses,
hypertension - see Admin Instructions
Administer for systolic blood pressure greater than ***
mmHg or diastolic blood pressure greater than ***
mmHg. Hold for heart rate less than *** beats/minute
(Maximum 20 mg/dose). Administer over 2 minutes
NOTE: Suggested dose 0.2 mg/kg (Maximum 20
mg/dose)
PACU
Bradycardia [81244]
atropine injection - NOTE: Suggested dose 0.01
mg/kg (Minimum 0.1 mg/dose; Maximum 0.4
mg/dose) [800178]
0.01 mg/kg, Intravenous, ONCE PRN For 1 Doses,
bradycardia, see Admin Instructions
Administer for symptomatic bradycardia. Symptoms
include decreased level of consciousness, nausea,
and decreased heart rate
NOTE: Suggested dose 0.01 mg/kg (Minimum 0.1
mg/dose; Maximum 0.4 mg/dose)
PACU
IV Fluids [111214]
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS, PACU
dextrose 10%-NaCl 0.9% infusion [700590] Intravenous, CONTINUOUS, PACU
sodium chloride 0.9% infusion [64367] Intravenous, CONTINUOUS
Titrate rate to keep up with fluid loss
PACU
lactated ringers infusion [38890] Intravenous, CONTINUOUS
Titrate rate to keep up with fluid loss
PACU
dextrose 5%-lactated ringers infusion [44897] Intravenous, CONTINUOUS, PACU
heparin lock flush 10 UNIT/ML injection [75031] Flush, PACU
heparin lock flush 100 units/mL 5 mL injection
[64978]
Flush, PACU
PLASMA-LYTE A infusion [41099] Intravenous
Titrate rate to keep up with fluid loss
sodium chloride flush 0.9% 10 mL injection
[785055]
Flush, PRN, flush/line care, PACU
Respiratory/Airway [93792]
albuterol HFA 90 mcg/act inhaler [53730] 2 puff, Inhalation, ONCE For 1 Doses, PACU
albuterol neb soln (3 mL) [800248] 2.5 mg, Nebulization, ONCE For 1 Doses, PACU
racepinephrine 2.25 % neb soln [150812] 0.5 mL, Nebulization, ONCE For 1 Doses, PACU
ipratropium (ATROVENT) neb soln [47883] 500 mcg, Nebulization, ONCE For 1 Doses, PACU
ipratropium-albuterol (DUO-NEB) 0.5-2.5 mg/3
mL neb soln [67220]
3 mL, Nebulization, ONCE For 1 Doses, PACU
Self-administered Medications [81248]
Page 9 of 11
Printed by O'BRIEN, RYLEY P [RPO249] at 4/3/2017 10:05:02 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

Note: Self Administered Medication Program
Documentation [950000]
ONCE For 1 Doses
Patient may self-administer and use own supply of
the following medications: ***
PACU
Spasms [105798]
diazepam (VALIUM) injection - NOTE:
Suggested dose 0.1 mg/kg/dose (Maximum 5
mg/dose) [36675]
0.1 mg/kg, Intravenous, ONCE For 1 Doses
NOTE: Suggested dose 0.1 mg/kg/dose (Maximum 5
mg/dose)
PACU
Bladder Spasms (Single Response) [148465]
oxybutynin (DITROPAN) 5 MG/5ML syrup
[45972]
0.1 mg/kg, Oral, ONCE PRN For 1 Doses, bladder
spasms
Supplemental Orders
order setInfusion" -to "Intravenous Patient Controlled Analgesia (PCA) Pediatric Refer
order setSupplemental" -Pediatric -Regional Analgesia Therapy -to "AFCH PACU Refer
setSupplemental" order -Pediatric -Diabetes Management with Pump -to "IP Refer
order setSupplemental" -Pediatric -Diabetes Management without Pump -to "IP Refer
Laboratory
Laboratory [81253]
CALCIUM [CA] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PACU
MAGNESIUM [MAG] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PACU
POTASSIUM [K] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Draw immediately postoperatively., PACU
TROPONIN [GM2447] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Draw immediately postoperatively., PACU
HEMOGLOBIN [HGB] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PACU
Page 10 of 11
Printed by O'BRIEN, RYLEY P [RPO249] at 4/3/2017 10:05:02 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

PROTHROMBIN TIME/INR [PT] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PACU
Diagnostic Tests and Imaging
Studies [81255]
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? IP PACU
Transport Method: Floor Determined/Entered
PACU
ECG - 12 Lead Without Rhythm [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
PACU
Page 11 of 11
Printed by O'BRIEN, RYLEY P [RPO249] at 4/3/2017 10:05:02 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org