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/clinical/cckm-tools/content/order-sets/inpatient/bmtoncologyhematology/name-97833-en.cckm

20170106

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100

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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,BMT/Oncology/Hematology

IP - BMT - Non-Ablative Allogenic Stem Cell Transplant - Adult - Admission [2328]

IP - BMT - Non-Ablative Allogenic Stem Cell Transplant - Adult - Admission [2328] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, BMT/Oncology/Hematology


SmartSet: IP - BMT - NON-ABLATIVE ALLOGENEIC STEM CELL
TRANSPLANT - ADULT - ADMISSION (ID:2328)
General Information
Display name: IP - BMT - Non-Ablative Allogeneic Stem Cell Transplant - Adult - Admission
Type: General
Merge priority: 0
Version comment:
Content source:
Synonyms: 1. NON-ABLATIVE
2. ALLOGENEIC
3. STEM CELL
4. .BMT
SmartSet notes:
Description: Intended for Adult Patients Only
Web information: Title URL
1.
Questionnaire:
Configuration
Admission Status
Level of Care
Place Patient on General Care 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 (IMC) Intermediate Care, has already been signed. This
order will ensure that the patient is placed at the
appropriate level of care.
Place Patient on Intensive Care (ICU) Intensive Care, has already been signed. This order
will ensure that the patient is placed at the
appropriate level of care.
Admit to Inpatient (Single Response)
Page 1 of 11
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

Admit To Inpatient 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:
Admit to Observation (Single Response)
Admit To Observation Attending:
Admitting Resident:
Requested Floor:
Service:
Admit to Outpatient Short Stay (Single
Response)
Admit To Outpatient Short Stay Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status
Admit To Inpatient 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:
Admit To Observation Attending:
Admitting Resident:
Requested Floor:
Admit To Outpatient Short Stay Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status
Page 2 of 11
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Admit To Inpatient 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:
Admit To Observation Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay Attending:
Admitting Resident:
Requested Floor:
Service:
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis
Low VTE Risk
VTE Prophylaxis - Reason Not Ordered ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response)
enoxaparin (LOVENOX) subcutaneous injection 40 mg, Subcutaneous, EVERY 24 HOURS
heparin PF 5000 UNIT/0.5ML injection 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE Risk
Sequential Compression Device (SCD)
(TREATMENT)
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY)
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis
VTE Prophylaxis - Reason Not Ordered ONCE, Routine
Reason Not Ordered:
VTE Prophylaxis
Low VTE Risk
VTE Prophylaxis - Reason Not Ordered ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response)
enoxaparin (LOVENOX) subcutaneous injection 40 mg, Subcutaneous, EVERY 24 HOURS
Page 3 of 11
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

heparin PF 5000 UNIT/0.5ML injection 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE Risk
Sequential Compression Device (SCD)
(TREATMENT)
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY)
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis
VTE Prophylaxis - Reason Not Ordered ONCE, Routine
Reason Not Ordered:
Patient Care Orders
Vital Signs
Vital Signs EVERY 4 HOURS, Starting S, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Activity
Ad Lib CONTINUOUS, Starting S, 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:
Nutrition
Patient Approved for Additional Menu Items CONTINUOUS
Patient may order food items from UWHC café or
Mendota Market?
Patient may order regular soda or other sugar-
sweetened beverages?
General Diet EFFECTIVE NOW, Starting S, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Intake and Output
Measure Intake And Output EVERY 8 HOURS, Starting S, Routine
BMT Transfusion Protocol
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:
 
01/2017CCKM@uwhealth.org

Initiate BMT Service Transfusion Protocol CONTINUOUS, Starting S, Routine
Analgesics to be Ordered:
Antihistamines to be Ordered:
Steroids to be Ordered:
Labs to be Ordered:
Total Volume (units) RBC (Pediatric):
Total Volume (mL) RBC (Pediatric):
Total Units Platelets (Pediatric) (1 random donor unit
= 45-65 mL; Suggested dose = 1 RDU/12kg; 4
RDU=1 SDU):
Does patient require single donor platelets (If yes,
Blood Bank MD approval required): No
Platelet Threshold: 10,000/microliter
Hemoglobin Threshold: 8 grams/deciliter
Order blood products, premeds and/or post labs as
indicated using order set #4179 IP - BMT - Blood
Transfusion - Supplemental
Non-Categorized Patient Care Orders
Measure Weight 1X DAILY, Starting S, Routine
Weigh With?
Weigh when?
Contingency Parameters
Notify Provider Provider to Notify: Provider
If systolic blood pressure > (mmHg): 160
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg): 100
If diastolic blood pressure < (mmHg): 50
If temperature > (C): 38.2
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 60
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: Pain not controlled with ordered analgesics or
ordered interventions,Pain unrelieved by ordered
interventions,Patient is not engrafted by Day +28 for
alternative pneumocystis pneumonia (PCP)
prophylaxis
Intravenous Therapy
Premedications for Needle Insertion
Page 5 of 11
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

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
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
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
Flushes
Initiate Venous Access Device Flushing Protocol ONCE, Starting S For 1 Occurrences
Medications - General
Analgesics - Acetaminophen PRN
acetaMINOPHEN (TYLENOL) tab 650 mg, Oral, EVERY 4 HOURS PRN, pain/fever
Mild pain, multimodal therapy or temperature greater
than 38.2 C
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension
650 mg, Oral, EVERY 4 HOURS PRN, pain
Mild pain, multimodal therapy or temperature greater
than 38.2 C
Analgesics - Opioids - PRN
oxycodone tab RANGE 5-10 mg, Oral, EVERY 4 HOURS PRN, pain
Severe pain
Anti-emetics
ondansetron (ZOFRAN ODT) disintegrating tab 8 mg, Oral, EVERY 4 HOURS PRN, nausea/vomiting
First line therapy. Administer if patient not already on
scheduled ondansetron (ZOFRAN) as part of
chemotherapy plan. Maximum 24 mg every 24
hours.
Page 6 of 11
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2017 3:35:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) injection 8 mg, Intravenous, EVERY 8 HOURS PRN,
nausea/vomiting
Maximum 24 mg every 24 hours. For first line
therapy. Administer if patient not already on
scheduled ondanestron (ZOFRAN) as part of
chemotherapy plan. Administer if patient is unable to
tolerate orally.
prochlorperazine (COMPAZINE) tab 10 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
Second line therapy. Administer when there is no
response to first line therapy with 30 minutes.
prochlorperazine (COMPAZINE) injection 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Second line therapy. Administer if there is no
response to first line therapy within 30 minutes.
Anti-infectives
acyclovir (ZOVIRAX) cap 400 mg, Oral, 2 X DAILY
Note: Initiate acyclovir 200 mg IV every 12 hours
if patient unable to tolerate oral acyclovir
PRN - NOTIFY PHARMACY WHEN NEEDED,
unable to tolerate oral acyclovir
Note: Initiate acyclovir 200 mg every 12 hours if
patient unable to tolerate oral acyclovir
fluconazole (DIFLUCAN) tab 400 mg, Oral, 1 X DAILY
Start on Day 0
Note: On Day 0 initiate fluconazole 400 mg IV
every 24 hours if patient unable to tolerate oral
fluconazole
PRN - NOTIFY PHARMACY WHEN NEEDED,
patient unable to tolerate oral fluconazole
Note: On Day 0 initiate fluconazole 400 mg IV every
24 hours if patient unable to tolerate oral fluconazole
sulfamethoxazole-trimethoprim (BACTRIM) 400-
80 mg per tab
2 tab, Oral, EVERY MON, WED, FRI
Start on Day +28
Anti-infectives - Start on Day 0
Note: Initiation of sulfamethoxazole-trimethoprim PRN - NOTIFY PHARMACY WHEN NEEDED, See
Admin Instructions
NOTE: Start sulfamethoxazole-trimethoprim
(BACTRIM) 400-80 mg 2 tab by mouth every
Monday, Wednesday and Friday when absolute
neutrophil count is greater than 1,000/microliter
levofloxacin (LEVAQUIN) tab 500 mg, Oral, 1 X DAILY (HS) For 365 Days
Discontinue when ANC has been greater than
500/microliter for 3 consecutive days. Discontinue if
patient develops neutropenic fever and is started on
additional antibiotic therapy. Administer at least 4
hours before or 8 hours after antacids containing
magnesium or aluminum, sucralfate, iron,
multivitamin preparations with zinc, or didanosine.
Antacids
mag-al-simeth (MYLANTA ES) susp
MULTIDOSE
15 mL, Oral, EVERY 4 HOURS PRN, dyspepsia
Bowel Management
polyethylene glycol (MIRALAX) oral powder 17 g, Oral, 1 X DAILY PRN, constipation
Dissolve in 240 mL of liquid For first line therapy.
senna-docusate (SENOKOT S) 8.6-50 MG per
tab
2 tab, Oral, 2 X DAILY PRN, constipation
For second line therapy
Page 7 of 11
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

magnesium hydroxide (MILK OF MAGNESIA)
susp
30 mL, Oral, 1 X DAILY PRN, constipation
Third line therapy. Administer when there is no
response to first and second line therapies and
immediate laxation is needed.
Hypnotics
traZODONE (DESYREL) tab 25-50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions. May repeat X 1 if no response within
60 minutes. If there is no sufficient response to
second dose, contact physician for further direction.
Stress Ulcer Prophylaxis
ranitidine (ZANTAC) tab 150 mg, Oral, 1 X DAILY (HS)
Non-Categorized
labetalol injection 20 mg, Intravenous, EVERY 1 HOUR PRN, For
Systolic Blood Pressure greater than or equal to 160
mmHg or Diastolic Blood Pressure greater than or
equal to 100 mmHg. Hold for blood pressure less
than 40 mmHg.
Hold and notify physician if heart rate less than 60
mmHg.
naloxone (NARCAN) injection 0.1 mg, Intravenous, PRN, opioid overdose
Administer every 3 minutes times 4 doses for
respiratory rate less than 8 breaths/minute or
sedation score of 5 or greater. Notify MD if naloxone
administered.
sodium chloride (SALINE) 0.65 % nasal spray 2 spray, Nostril (Each), EVERY 4 HOURS PRN,
nasal dryness
May leave at bedside.
biotene calcium mouthwash RANGE 10-15 mL, Swish & Spit, EVERY 4 HOURS PRN, dry
mouth
Leave at bedside
guaifenesin (ROBITUSSIN) 100 MG/5ML soln Oral, EVERY 4 HOURS PRN, cough
Laboratory
Draw Once for First Temperature Greater than or Equal to 38.2 Degrees Celsius or Sustained
Fever of 38.0 Degrees Celsius for Greater than 1 Hour - Days 1-7
For First Fever Spike: ONCE, Starting S For 1 Occurrences, Routine, For
first fever spike, draw from all ports of line and
peripheral. To be placed with Culture, Blood,
Bacteria and Yeast order.
Page 8 of 11
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2017 3:35:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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01/2017CCKM@uwhealth.org

CULTURE, BLOOD, BACTERIA AND YEAST CONDITIONAL - RN COLLECT For 7 Days, Routine,
For optimum diagnosis of sepsis, sample 3-4 sites
only on the first day of a septic episode. Cultures on
subsequent days are of minimal diagnostic value.
Culture detects bacteria, Candida and Cryptococcus.
If filamentous fungi are suspected see Culture,
Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1
hour.
Days 1-7.
CULTURE, BLOOD, BACTERIA AND YEAST CONDITIONAL - RN COLLECT For 7 Days, Routine,
For optimum diagnosis of sepsis, sample 3-4 sites
only on the first day of a septic episode. Cultures on
subsequent days are of minimal diagnostic value.
Culture detects bacteria, Candida and Cryptococcus.
If filamentous fungi are suspected see Culture,
Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1
hour.
Days 1-7.
URINALYSIS WITH MICROSCOPY CONDITIONAL - RN COLLECT For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1
hour. Days 1 - 7
CULTURE, URINE CONDITIONAL - RN COLLECT For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1
hour.
Days 1-7.
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging
ECG - 12 Lead ONCE, Starting S For 1 Occurrences, Routine
Reason for exam: OTHER (COMMENT)
Indication: Baseline prior to chemotherapy.
Page 9 of 11
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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Consults
Consults
Consult Physical Therapy (Inpatient) Eval and
Treat
ONCE, Starting S For 1 Occurrences, Routine
Reason for Physical Therapy Consult:
Consult Social Work (Inpatient) ONCE, Starting S For 1 Occurrences, Routine
Reason for Consult: OTHER
Evaluate and follow during stem cell transplant.
Consult Interventional Radiology (Inpatient) ONCE
Reason for Consult:
Modality Type:
Call back number:
Intent:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Consult Radiation Oncology (Inpatient) ONCE
Intent:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis): Evaluate
and plan for total body radiation therapy
Consult Ophthalmology-General (Inpatient) ONCE
Intent:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis): Baseline
exam to include Slit Lamp and Schirmir's test
BestPractice
No Hospital Problems have yet been identified.
Specify Hospital Problem(s) You will be prompted to specify a hospital problem on
signing.
Criteria
Suggestions: UWIP C LOGIN DEPT IP ONCOLOGY/HEMATOLOGY/BMT[3001756]
Filter: UWIP ORDER SET RESTRICTION - HOSPITAL ENCOUNTERS EXCEPT ED -
NOT IP DC[3000400]
Restrict SmartSet:
Settings
Discontinue action:
Deselect sections for
Pended/Held orders:
Page 10 of 11
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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Pended/Held orders
display:
Release date: Use System Definitions Setting
Disallow user override:
Page 11 of 11
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2017 3:35:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org