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/clinical/cckm-tools/content/order-sets/inpatient/breast-center/name-97809-en.cckm

201709258

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100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Breast Center

IP – Breast Surgery – No Reconstruction – Adult – Discharge [5785]

IP – Breast Surgery – No Reconstruction – Adult – Discharge [5785] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Breast Center


IP - Breast Surgery - No Reconstruction - Adult - Discharge [5785]
and Intended for Total Mastectomy, Modified Radical Mastectomy (MRM), Axillary NOTE:
Lymph Node Dissection (ALND)
Skilled Nursing Facility Orders
This Patient is going to a skilled nursing facilty, directly below is a group of orders commonly
associated with this patient population. Please review the orders below and select the appropriate
ones for this patient. If this patient is not going to a SNF, contact Case Management to update the
discharge plan. Updating the discharge plan will remove this set of SNF orders from the order set.
Skilled Nursing Facility Certification Statement [114940]
Facility Certification Statement [NURCOM0069] Routine
Skilled Nursing Facility Certification Statement [118260]
Facility Certification Statement [NURCOM0069] Routine
Skilled Nursing Facility Admit Order [114941]
Admit to Skilled Nursing Facility [ADT0015] Routine
Skilled Nursing Facility Admit Order [118261]
Admit to Skilled Nursing Facility [ADT0015] Routine
Skilled Nursing Facility Patient Care Orders [111713]
For dyspnea, Oxygen at 2 L/minute per nasal
canula; If this is an acute change for the patient
call PCP with assessment ASAP after oxygen is
started. Suction PRN to clear airways.
[NURCOM0022]
Routine
DME - Home Oxygen [1009468] Patient's O2 Requirements Assessed and Meets
Criteria for Home O2:
Delivery Device:
Equipment Needed:
Continuous (liters/min):
Continuous (FiO2):
With Activity (liters/min):
With Activity (FiO2):
With Sleep (liters/min):
With Sleep (FiO2):
Length of Need:
Vendor:
DME - CPAP [1009443] Formal Sleep Study Completed:
Diagnosis:
CPAP Pressure (cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Page 1 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 9/13/2017 8:24:20 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

DME - BiPAP (S) [1009441] Patient Has Been Assessed and Meets Criteria for
Home BiPAP (S):
Diagnosis:
BiPAP Pressure - IPAP - Inspiratory Pressure
(cmH2O):
BiPAP Pressure - EPAP - Expiratory Pressure
(cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
DME - BiPAP (S/T) [1009442] Patient Has Been Assessed and Meets Criteria for
Home BiPAP (S/T):
Diagnosis:
Respiratory Rate:
BiPAP Pressure - IPAP - Inspiratory Pressure
(cmH2O):
BiPAP Pressure - EPAP - Expiratory Pressure
(cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Patient may self administer medication per RN
assessment [NURCOM0022]
Routine
Patient medications (per Skilled Nursing Facility
policy) may be left at bedside [NURCOM0022]
Routine
Facility Therapy Needs [113391]
Physical Therapy to Evaluate and Treat at Next
Facility [NURCOM0022]
Routine
Occupational Therapy to Evaluate and Treat at
Next Facility [NURCOM0022]
Routine
Speech Therapy to Evaluate and Treat at Next
Facility [NURCOM0022]
Routine
Communicable Diseases [111717]
State Law requires at least one of the following statements be checked for your patient. May check both if
applicable
DHS 132.52 URL: http://docs.legis.wisconsin.gov/code/admin_code/dhs/110/132/V/52
Patient has been screened for TB within the last
90 days prior to admission and does not have any
other clinically apparent communicable diseases.
[NURCOM0022]
Routine
Patient has been found to have a communicable
disease, procedures to treat and limit the spread
of the disease have been ordered.
[NURCOM0022]
Routine
Page 2 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 9/13/2017 8:24:20 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Communicable Diseases [118262]
State Law requires at least one of the following statements be checked for your patient. May check both if
applicable
DHS 132.52 URL: http://docs.legis.wisconsin.gov/code/admin_code/dhs/110/132/V/52
Patient has been screened for TB within the last
90 days prior to admission and does not have any
other clinically apparent communicable diseases.
[NURCOM0022]
Routine
Patient has been found to have a communicable
disease, procedures to treat and limit the spread
of the disease have been ordered.
[NURCOM0022]
Routine
Analgesics [111708]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, 1 tab, 1, starting 9/13/17, No Print
acetaMINOPHEN (TYLENOL) suppository
[34153]
650 mg, 1 suppository, 1, starting 9/13/17, No Print
Blood Glucose Management [111710]
glucagon 1 mg injection kit [107799] 1 mg, 1 each, 1, starting 9/13/17, No Print
Glucose 40 % oral gel [118089] 10 g, 1 Tube, 1, starting 9/13/17, No Print
Nursing Communication [NURCOM0022] Routine, Notify {Notify for Blood Glucose:3004146} if
blood glucose is greater than 400 mg/dL or less than
40 mg/dL
Diabetes Care Instructions [NURCOM0112] Routine, - Patient's blood glucose goal range before
meals is *** mg/dL.
- Monitor patient's blood glucose {Glucose Monitoring
Frequency:25242}.
- If your patient's blood glucoses are uncontrolled
contact provider.
- "Uncontrolled" blood glucoses mean:
* Blood glucose above 150 mg/dL more than half the
time during a week.
* Blood glucose over *** mg/dL.
* Blood glucose less than 70 mg/dL two or more times
per week (or if having signs/symptoms of low blood
glucose such as shaking, sweating, or light-
headedness).
Bowel Management [111709]
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, 1 suppository, 1, starting 9/13/17, No Print
Senna-Docusate Sodium 8.6-50 MG per tab
[70181]
1-2 tab, 1 tab, 1, starting 9/13/17, No Print
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, 1 Bottle, 1, starting 9/13/17, No Print
polyethylene glycol (MIRALAX) oral powder
[61353]
17 g, 1 Bottle, 1, starting 9/13/17, No Print
Non-categorized Medications [111711]
guaifenesin-dextroMETHORPHAN (ROBITUSSIN
DM) syrup [51568]
10 mL, 1 Bottle, 1, starting 9/13/17, No Print
carbamide peroxide (DEBROX) 6.5% otic soln
[35545]
3 drop, 1 Bottle, 1, starting 9/13/17 until 9/18/17, No
Print
alum-mag-simeth (MYLANTA ES) susp [44073] 30 mL, 1 Bottle, 1, starting 9/13/17, No Print
Patient Care Orders
Confirmed Discharge Date/Time [151653]
Page 3 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 9/13/2017 8:24:20 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Confirmed Discharge Date/Time [ADT0013] Confirmed Discharge Date:
Confirmed Discharge Time:
Conditions for Discharge:
Provider to be Present at Discharge?
Reason For Hospitalization [130535]
Why You Were Hospitalized [NURCOM0073] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
Activity [196101]
Driving Restrictions [NURACT0011] Routine, Do not drive while taking narcotic
medications.
Activity [NURACT0008] Routine
Discharge Activity:
No heavy lifting over 10 pounds until follow up.
Continue with range of motion exercises as directed
by occupational therapy.
Nutrition [130538]
Diet - General (No Modifications) [NUT8888] Routine
General: General (No Modifications)
Diet Modifications:
Other Diet Modifications:
Wound Care [192992]
Wound Care [NURWND0015] Routine, May shower, let water run over incision with
soap and water. Do not rub or scrub site. Pat dry with
a towel. Do not use lotions and/or ointments on
incision. Monitor wounds for signs and symptoms of
infection (redness, swelling, drainage, odor). Cover
with dry gauze, do not use tape. If you have a
dressing, keep it dry and intact and remove it in 48
hours. If you have steri-strips, do not pick at or
remove them, they will fall off on their own as the
incision heals.
Apply Ice as needed [NURWND0018] Routine, Apply ice to surgical site for 20 minute
intervals as needed for pain relief.
Jobst Bra / Breast Binder / Straps
[NURWND0018]
Routine, Wear Jobst bra, breast binder or straps as
instructed.
Bathing Instructions [NURWND0018] Routine, May shower, but no bath tubs for 14 days. Do
not soak incision in water (no swimming, no hot tubs,
no baths).
Drain Care [NURWND0018] Routine, Strip drain and record every 8 hours. If
greater than 100 cc per drain in 24 hours over 2
consecutive days, call your provider. If less than 30 cc
per drain in 24 hours over 2 consecutive days, call
your provider for possible removal. Follow nursing's
direction for disc care, if applicable.
Nursing to teach disc care at drain site if
applicable [NURCOM0022]
Routine, Nursing to teach disc care at drain site, if
applicable.
Bladder Care [130540]
Bladder Care [NURELM0067] Routine
Bowel Care [130541]
Page 4 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 9/13/2017 8:24:20 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Bowel Care [NURELM0068] Routine, • Please take stool softeners daily if taking
narcotics.
• If having difficulty with stools may increase to twice
daily stool softeners.
• You may also add Miralax powder once or twice daily
if needed (this is a mild laxative).
• If no bowel movement in 3 days, after trying these,
may try a bisacodyl suppository once daily.
• Please call if unable to have a bowel movement after
3 days, surgery clinic 608-263-7502.
Other Patient Care Instructions [196026]
Other Discharge Patient Care Instructions
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, Please refer to your education
materials in the breast binder for further information.
When to Call Your Doctor [197476]
When to Call Your Doctor [NURCOM0079] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, Call your provider if you have any of
the following symptoms:
-increased pain not relieved by medication
-fever over 100.5 degrees F for two readings taken
four hours apart
-signs of infection (excess swelling or bleeding from
surgical wound, increased redness and/or warmth at
the incision site, or pus-like drainage)
-nausea or vomiting lasting more than 24 hours
-problems urinating or emptying your bladder
-cramping or swelling of leg(s)
-if you have not had a bowel movement in 3 days
For severe chest pain or shortness of breath call 911.
Contact the Breast Center Clinic at 608-266-6400 with
any questions or problems Monday-Friday
8am-4:30pm. If after hours, contact the paging
operator at 608-263-6400 and ask for the general
surgery resident on call.
Medications
Analgesics - Acetaminophen [192823]
acetaMINOPHEN (TYLENOL) 500 MG tab
[34150]
500 mg, starting 9/13/17, Normal
Analgesics - NSAIDS [231219]
ibuprofen (MOTRIN) 400 MG tab [38355] 400 mg, starting 9/13/17, Normal
Analgesics - Opioids [196027]
oxycodone 5 MG tab [45976] 5 mg, 0, starting 9/13/17, Normal
oxycodone 10 MG tab [128434] 10 mg, 0, starting 9/13/17, Normal
traMADOL (ULTRAM) 50 MG tab [50258] 50 mg, 0, starting 9/13/17, Normal
Analgesics - Other [196062]
Page 5 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 9/13/2017 8:24:20 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

gabapentin (NEURONTIN) 300 MG cap [54257] 300 mg, starting 9/13/17, Normal
Bowel management - As Needed [231247]
senna-docusate (SENOKOT S) 8.6-50 MG per
tab - NOTE: Order if patients are taking
oxycodone or other opioids [60530]
2 tab, starting 9/13/17, Normal
docusate sodium (COLACE) 100 MG cap -
NOTE: Order only if patient is not receiving
opioids [36857]
100 mg, starting 9/13/17, Normal
Follow-Up Care
Follow-Up Appointments [196102]
Discharge Labs Workflow URL: https://uconnect.wisc.edu/growth/training--
education/health-link/10-minutes/inpatient-
discharge-consult/resources/name-82993-en.file
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment: follow up
When do you want appointment: 1-2weeks after
surgery
Which Clinic or Specialty: Breast Center Clinic
Which Provider (Optional):
Schedule follow-up appointment 1-2 weeks after
surgery with the Breast Center Clinic if not already
scheduled.
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Which Provider:
Recommended Discharge Labs [NURCOM0075] Details
Discharge Labs [134929]
Page 6 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 9/13/2017 8:24:20 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Please use the table below to determine what type of order to use to place discharge lab
orders.
Discharge Labs Workflow URL: https://uconnect.wisc.edu/growth/training--
education/health-link/10-minutes/inpatient-
discharge-consult/resources/name-82993-en.file
Recommended Discharge Labs [NURCOM0075] Details
Who is Responsible for the
Result?
Where Will Labs be
Completed?
What Order Should You
Use?
Current Attending Provider UW Health Lab Specific lab orders (A)
Non-UW Health Lab
Specific lab orders with order
class changed to OUTSIDE
(B)
Current Consulting Provider
UW Health Lab
Specific lab orders with
AUTHORIZING PROVIDER
CHANGED TO
CONSULTANT (A)
Non-UW Health Lab
Specific lab orders with order
class changed to OUTSIDE
and AUTHORIZING
PROVIDER CHANGED TO
CONSULTANT (B)
Another Provider
UW Health Lab
Recommended Discharge
Labs (C)
Non-UW Health Lab
Recommended Discharge
Labs (C)
(A) SPECIFIC LAB ORDERS:
These orders should be used if the CURRENT ATTENDING OR CONSULTING PROVIDER
will be responsible for the result of the lab AND the patient will have the labs completed at a
UW HEALTH LAB.
If a CONSULTING PROVIDER currently involved in the patient's care will be responsible for the
result, you must change the AUTHORIZING PROVIDER on the order to the CONSULTING
PROVIDER before signing the order. To do this, click the Providers button near the top of the
Review, Sign & Hold tab of the discharge navigator. Update the authorizing provider to the
consulting provider.
(B) SPECIFIC LAB ORDER WITH ORDER CLASS CHANGED TO OUTSIDE:
These orders should be used if the CURRENT ATTENDING OR CONSULTING PROVIDER
will be responsible for the result of the lab AND the patient will have labs completed at a NON-
UW HEALTH LAB.
If a CONSULTING PROVIDER currently involved in the patient’s care will be responsible for the
result, you must change the AUTHORIZING PROVIDER on the order to the CONSULTING
PROVIDER before signing the order. To do this, click the Providers button near the top of the
Review, Sign & Hold tab of the discharge navigator. Update the authorizing provider to the
consulting provider.
The patient will receive a paper order to take to the lab.
(C) RECOMMENDED DISCHARGE LABS:
This order should be used to recommend to another provider labs that a patient should have
completed after discharge. The provider designated in the 'Send Recommendations To' field is
responsible for PLACING the lab orders AND will be responsible for the RESULTS of any
ordered labs.
Page 7 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 9/13/2017 8:24:20 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org