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/clinical/cckm-tools/content/order-sets/inpatient/bmtoncologyhematology/name-97840-en.cckm

20170120

page

100

UWHC,UWMF,

Tools,

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

IP - Chemotherapy Short Stay - Adult - Admission [1101]

IP - Chemotherapy Short Stay - Adult - Admission [1101] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, BMT/Oncology/Hematology


SmartSet: IP - CHEMOTHERAPY SHORT STAY - ADULT - ADMISSION
(ID:1101)
General Information
Display name: IP - Chemotherapy Short Stay - Adult - Admission
Type: General
Merge priority: 0
Version comment:
Content source:
Synonyms: 1. CHEMOTHERAPY
2. CHEMO
3. INDUCTION CHEMOTHERAPY
4. CONSOLIDATION CHEMOTHERAPY
5. BMT
6. ONCOLOGY
7. BONE MARROW TRANSPLANT
8. .ONC
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.
Page 1 of 9
Printed by STRAKA, KEVIN F [KFS1] at 1/19/2017 4:26:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

Admit to Inpatient (Single Response)
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 Status Attending:
Admitting Resident:
Requested Floor:
Service: HEMATOLOGY
Rationale for LOS greater than 2 midnights:
Admit To Observation Status Attending:
Admitting Resident:
Requested Floor:
Service:
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:
Page 2 of 9
Printed by STRAKA, KEVIN F [KFS1] at 1/19/2017 4:26:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Admit To Observation Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay Attending:
Admitting Resident:
Requested Floor:
Service:
Isolation Status
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
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
Page 3 of 9
Printed by STRAKA, KEVIN F [KFS1] at 1/19/2017 4:26:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

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
Vitals
Vital Signs SEE COMMENTS, Starting S with First Occurrence
Include Now, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 4 hours for 24 hours, then every 8 hours
Vital Signs EVERY 8 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:
Ambulate CONTINUOUS, Starting S, Routine
AD LIB:
AMBULATE: 3x daily
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Page 4 of 9
Printed by STRAKA, KEVIN F [KFS1] at 1/19/2017 4:26:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Chair CONTINUOUS, Starting S, Routine
AD LIB:
AMBULATE:
CHAIR: 3x daily
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Nutrition
General Diet EFFECTIVE NOW, Starting S, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Patient Approved for Additional Menu Items CONTINUOUS
Patient may order food items from UWHC café or
Mendota Market? Yes
Patient may order regular soda or other sugar-
sweetened beverages? Yes
Respiratory
Pulse Oximetry EVERY 8 HOURS, Starting S, Routine
Oxygen Therapy CONTINUOUS, Starting S, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 90
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen?
Intake and Output
Measure Intake And Output EVERY 8 HOURS, Starting S, Routine
Non-Categorized Patient Care Orders
Measure Weight 1X DAILY, Starting S, Routine
Weigh With?
Weigh when?
Contingency Parameters
Page 5 of 9
Printed by STRAKA, KEVIN F [KFS1] at 1/19/2017 4:26:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Notify Provider to Notify: Provider
If systolic blood pressure > (mmHg): 160
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg): 90
If diastolic blood pressure < (mmHg):
If temperature > (C): greater than or equal to 38.2
If temperature < (C):
If heart rate > (bpm): 100
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:
Intravenous Therapy
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
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
IV Fluids
Insert and Maintain Peripheral IV CONTINUOUS, Starting S For Until specified,
Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Note: Refer to Chemotherapy Treatment Plan
for Intravenous Fluids
ONCE For 1 Doses
Refer to Chemotherapy Treatment Plan for
Intravenous Fluids
Page 6 of 9
Printed by STRAKA, KEVIN F [KFS1] at 1/19/2017 4:26:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

sodium chloride 0.9 % infusion Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.45% infusion Intravenous, CONTINUOUS
Medications
Analgesics
acetaMINOPHEN (TYLENOL) tab 650 mg, Oral, EVERY 4 HOURS PRN, pain/fever
No more than 4 grams acetaminophen per 24 hours
for adults or 15 mg/kg per dose for peds < 40 kg
Mild pain, multimodal therapy or temperature greater
than 38.2 C. Evaluate temperature before
administering
Hypnotics
traZODONE (DESYREL) tab 25 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see IPOC supplemental Sleep/Rest
Disturbance Adult)
Laboratory
Admission Labs
CBC WITH DIFFERENTIAL NEXT DRAW, 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?
ELECTROLYTES NEXT DRAW, 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?
BUN NEXT DRAW, 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?
CREATININE NEXT DRAW, 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?
GLUCOSE NEXT DRAW, 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?
CALCIUM NEXT DRAW, 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?
BILIRUBIN, TOTAL NEXT DRAW, 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?
Page 7 of 9
Printed by STRAKA, KEVIN F [KFS1] at 1/19/2017 4:26:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

PROTEIN, TOTAL NEXT DRAW, 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?
ALBUMIN NEXT DRAW, 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?
ALKALINE PHOSPHATASE NEXT DRAW, 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?
AST/SGOT NEXT DRAW, 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?
ALT/SGPT NEXT DRAW, 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?
MAGNESIUM NEXT DRAW, 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?
PHOSPHATE NEXT DRAW, 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?
URIC ACID NEXT DRAW, 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?
LD, TOTAL NEXT DRAW, 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?
PT-INR NEXT DRAW, Starting S For 1 Occurrences, Routine
Consults
Consults
Consult Social Work (Inpatient) ONCE, Starting S For 1 Occurrences, Routine
Reason for Consult: OTHER
Evaluate and follow during chemotherapy.
PICC Placement Request ONCE, Starting S For 1 Occurrences, Routine
PICC Line Placement Reason:
PICC Line Placement Duration:
Mastectomy?
Dialysis Graft/Shunt?
Thrombosis?
Existing Venous Access Device(s)?
Over 400 lbs?
Number of Lumens:
Do Not Use:
Do Not Use Reason:
Page 8 of 9
Printed by STRAKA, KEVIN F [KFS1] at 1/19/2017 4:26:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Consult Venous Access Team (Inpatient) ONCE, Starting S For 1 Occurrences, Routine
Reason for consult:
Can this consult be done via video?
Consult Occupational Therapy (Inpatient) Eval
and Treat
ONCE, Starting S For 1 Occurrences, Routine
Reason for Consult:
Consult Physical Therapy (Inpatient) Eval and
Treat
ONCE, Starting S For 1 Occurrences, Routine
Reason for Physical Therapy Consult:
Consult Nutrition (Inpatient) ONCE, Starting S For 1 Occurrences, Routine
Reason for Consult: Nutrition Assessment w/
Recommendations
Delegate to Initiate and Manage Tube Feeding:
Delegate to Initiate Feeding Tube Placement Order
Set:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
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:
Pended/Held orders
display:
Release date: Use System Definitions Setting
Disallow user override:
Page 9 of 9
Printed by STRAKA, KEVIN F [KFS1] at 1/19/2017 4:26:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org