/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/inpatient/,/clinical/cckm-tools/content/order-sets/inpatient/breast-center/,

/clinical/cckm-tools/content/order-sets/inpatient/breast-center/name-97810-en.cckm

201710291

page

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 – Postoperative [5775]

IP – Breast Surgery – No Reconstruction – Adult – Postoperative [5775] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Breast Center


IP - Breast Surgery - No Reconstruction - Adult - Postoperative [5775]
for Adult Patients OnlyIntended
Admission Status
Level of Care (Single Response) [187516]
*An admit patient order has already been written, but the level of care at which the patient
should be placed still needs to be identified.
Place Patient on General Care [ADT0018] 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)
[ADT0018]
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 [ADT0018] 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) [188296]
Admit To Inpatient [ADT0001] 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:
Post-Op/Phase II
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admission Status [196000]
Page 1 of 14
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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10/2017CCKM@uwhealth.org

Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: GENERAL SURGERY
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.
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Post-Op/Phase II
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service: GENERAL SURGERY
Post-Op/Phase II
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service: GENERAL SURGERY
Post-Op/Phase II
Admission Status [120289]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: GENERAL SURGERY
Rationale for LOS greater than 2 midnights:
Post-Op/Phase II
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service: GENERAL SURGERY
Post-Op/Phase II
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service: GENERAL SURGERY
Post-Op/Phase II
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [132018]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
Moderate VTE Risk with Low Bleed Risk (Single
Response) [206300]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 HOURS
Page 2 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/11/2017 8:02:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Sequential Compression Device (SCD) / Foot
Pump [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Post-Op/Phase II
High VTE Risk with Low Bleed Risk [211841]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 HOURS
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
High Bleed Risk [129757]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
Post-Op/Phase II
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
VTE Prophylaxis (Single Response) [150179]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
Moderate VTE Risk with Low Bleed Risk (Single
Response) [206308]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 HOURS
Sequential Compression Device (SCD) / Foot
Pump [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Post-Op/Phase II
High VTE Risk with Low Bleed Risk [211862]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 HOURS
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Page 3 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/11/2017 8:02:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
High Bleed Risk [129757]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
Post-Op/Phase II
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
PACU Normoglycemia Management
Normoglycemia Management (Single Response) [217140]
Patients withOUT Diabetes and NOT on Insulin
Infusion [231555]
Glucose, POC [IPGLUCOSE] ONCE For 1 Occurrences, 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?
PACU
If Glucose POC 200 mg/dL or Greater Initiate
Perioperative Normoglycemia for Surgical
Patients Adult Delegation Protocol
[NURMON0167]
CONTINUOUS For 24 Hours, Routine, Use order set
Perioperative Normoglycemia for Surgical Patients
Delegation Protocol order set [6133] to place orders,
PACU
Patients WITH Diabetes and NOT on Insulin
Infusion [231558]
Glucose, POC [IPGLUCOSE] ONCE For 1 Occurrences, 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?
PACU
If Glucose POC is 180 mg/dL or Greater Initiate
Perioperative Normoglycemia for Surgical
Patients Adult Delegation Protocol
[NURMON0167]
ONCE For 1 Occurrences, Routine, Use order set
Perioperative Normoglycemia for Surgical Patients
Delegation Protocol order set [6133] to place orders,
PACU
Patient ON Insulin Infusion [217180]
insulin infusionSupplemental order set [1345] to order -Adult -Insulin Infusion -IP Use
Confirm Time and Value of Last Glucose POC
and Insulin Infusion Column [NURCOM0022]
ONCE, PACU
Hypoglycemia Management [216855]
URL:
Hypoglycemia Management (Adult) [191576]
Page 4 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/11/2017 8:02:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting today For Until specified,
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?
PACU
Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA
TREATMENT, Starting today For Until specified,
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?
Per hypoglycemia treatment algorithm Recheck
glucose 15 minutes after providing treatment until
glucose is greater than or equal to 70 mg/dL. If
patient has been critically low (i.e., glucose less than
40 mg/dL), recheck glucose after 1 hour to ensure
glucose remains greater than or equal to 70mg/dL.
After resolution of mild hypoglycemia (i.e., glucose
40-69 mg/dL), consider rechecking after 1 hour if
patient has signs/symptoms of hypoglycemia or is at
risk for a subsequent hypoglycemic event (e.g.,
previously administered insulin still active, altered
renal status, altered mental status, NPO or
interrupted nutrition, or any other condition that
increases hypoglycemia risk), PACU
Notify Provider [NURCOM0001] Provider to Notify: Provider
Notify based on: Blood Glucose,Other
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
Other: Nutritional status changes
PACU
Hypoglycemia Treatment for blood glucose less
than 40 mg/dL and patient able to eat/swallow
safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If blood glucose less
than 40mg/dL and patient able to eat/swallow safely.
Give 30 grams of carbohydrate (8 oz. of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater., PACU
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If glucose is 40-69
mg/dL and patient able to eat/swallow safely
Give 15 grams of carbohydrate (4 oz of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater., PACU
glucose-vitamin C chew tab [50690] 16 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose 40-
69 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
PACU
Page 5 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/11/2017 8:02:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

glucose-vitamin C chew tab [50690] 32 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose
less than 40 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
PACU
glucagon injection kit [107799] 1 mg, Subcutaneous, PRN, For blood glucose less
than 69 mg/dL and patient unable to eat/swallow
safely AND has NO IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
PACU
dextrose injection [800233] 12.5 g, Intravenous, PRN, For blood glucose 40-69
mg/dL and patient unable to eat/swallow safely AND
has IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
PACU
dextrose injection [800233] 25 g, Intravenous, PRN, For blood glucose less than
40 mg/dL and patient unable to eat/swallow safely
AND has IV access.
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
PACU
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
PACU
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting 10/19/17 For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
PACU
Post-OP Normoglycemia Management
Normoglycemia Management (Single Response) [216839]
Patients withOUT Diabetes and NOT on Insulin
Infusion [231573]
Glucose, POC [IPGLUCOSE] CONDITIONAL For 8 Hours, 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?
Check once on arrival if PACU Glucose POC is >/=
180 mg/dL
Recheck in 4 hours if initial floor Glucose POC is
180-199 mg/dL, Post-Op/Phase II
Page 6 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/11/2017 8:02:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Glucose Monitoring and Response
[NURCOM0022]
ONCE For 1 Occurrences, If Glucose POC obtained
on arrival is:
< 180 mg/dL - no further action needed.
180-199 mg/dL - recheck and contact provider to
order the following: if patient is NPO, provider to
order glucose POC every 6 hours; if eating glucose
POC before meals and at bedtime. Provider should
order an A1c if not performed in the last 90 days.
200 mg/dL or greater - initiate Perioperative
Normoglycemia Delegation Protocol, Post-Op/Phase
II
If Glucose POC is 200 mg/dL or Greater Initiate
Perioperative Normoglycemia for Surgical
Patients Adult Delegation Protocol
[NURMON0167]
CONTINUOUS For 24 Hours, Routine, Use order set
Perioperative Normoglycemia for Surgical Patients
Delegation Protocol order set [6133] to place orders,
Post-Op/Phase II
Patients WITH Diabetes and NOT on Insulin
Infusion [231576]
Glucose, POC [IPGLUCOSE] ONCE For 1 Occurrences, 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?
Post-Op/Phase II
Glucose Monitoring and Response
[NURCOM0022]
ONCE For 1 Occurrences, If Glucose POC obtained
on arrival is:
<180 mg/dL - contact provider to order the following:
if patient is NPO, provider to order glucose POC
every 6 hours; if eating glucose POC before meals
and at bedtime. Provider should order an A1c if not
performed in the last 90 days.
180 mg/dL or greater - initiate Perioperative
Normoglycemia Delegation Protocol, Post-Op/Phase
II
If Glucose POC 180 mg/dL or Greater Initiate
Perioperative Normoglycemia for Surgical
Patients Adult Delegation Protocol
[NURMON0167]
CONTINUOUS, Routine, Use order set Perioperative
Normoglycemia for Surgical Patients Delegation
Protocol order set [6133] to place orders, Post-
Op/Phase II
Patient ON Insulin Infusion [217180]
insulin infusionSupplemental order set [1345] to order -Adult -Insulin Infusion -IP Use
Confirm Time and Value of Last Glucose POC
and Insulin Infusion Column [NURCOM0022]
ONCE, Post-Op/Phase II
Hypoglycemia Management [217170]
Hypoglycemia Management (Adult) [191576]
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting today For Until specified,
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?
Post-Op/Phase II
Page 7 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/11/2017 8:02:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA
TREATMENT, Starting today For Until specified,
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?
Per hypoglycemia treatment algorithm Recheck
glucose 15 minutes after providing treatment until
glucose is greater than or equal to 70 mg/dL. If
patient has been critically low (i.e., glucose less than
40 mg/dL), recheck glucose after 1 hour to ensure
glucose remains greater than or equal to 70mg/dL.
After resolution of mild hypoglycemia (i.e., glucose
40-69 mg/dL), consider rechecking after 1 hour if
patient has signs/symptoms of hypoglycemia or is at
risk for a subsequent hypoglycemic event (e.g.,
previously administered insulin still active, altered
renal status, altered mental status, NPO or
interrupted nutrition, or any other condition that
increases hypoglycemia risk), Post-Op/Phase II
Notify Provider [NURCOM0001] Provider to Notify: Provider
Notify based on: Blood Glucose,Other
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
Other: Nutritional status changes
Post-Op/Phase II
Hypoglycemia Treatment for blood glucose less
than 40 mg/dL and patient able to eat/swallow
safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If blood glucose less
than 40mg/dL and patient able to eat/swallow safely.
Give 30 grams of carbohydrate (8 oz. of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater., Post-Op/Phase II
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If glucose is 40-69
mg/dL and patient able to eat/swallow safely
Give 15 grams of carbohydrate (4 oz of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater., Post-Op/Phase II
glucose-vitamin C chew tab [50690] 16 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose 40-
69 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
Post-Op/Phase II
glucose-vitamin C chew tab [50690] 32 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose
less than 40 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
Post-Op/Phase II
Page 8 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/11/2017 8:02:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

glucagon injection kit [107799] 1 mg, Subcutaneous, PRN, For blood glucose less
than 69 mg/dL and patient unable to eat/swallow
safely AND has NO IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
Post-Op/Phase II
dextrose injection [800233] 12.5 g, Intravenous, PRN, For blood glucose 40-69
mg/dL and patient unable to eat/swallow safely AND
has IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
Post-Op/Phase II
dextrose injection [800233] 25 g, Intravenous, PRN, For blood glucose less than
40 mg/dL and patient unable to eat/swallow safely
AND has IV access.
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
Post-Op/Phase II
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
Post-Op/Phase II
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting 10/19/17 For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
Post-Op/Phase II
Patient Care Orders
Vital Signs [152569]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 1 hour times 2, then every 2 hours times 2, then
every 4 hours., Post-Op/Phase II
Orthostatic Vital Signs [NURMON0007] ONCE For 1 Occurrences, Routine, Post-Op/Phase II
Activity [196001]
Page 9 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/11/2017 8:02:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Ambulate with Assistance on Day of Surgery
[NURACT0008]
SEE COMMENTS, Starting today For Until specified,
Routine
AD LIB:
AMBULATE: with assistance,other (comment)
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
On day of surgery, Post-Op/Phase II
Ambulate 3 Times Daily [NURACT0008] CONTINUOUS, Starting tomorrow, 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:
Starting postoperative day 1., Post-Op/Phase II
Patient may shower 24 hours postoperatively
[NURCOM0022]
ONCE, Post-Op/Phase II
Nutrition [196002]
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
Respiratory [196003]
Pulse Oximetry [NURMON0009] PRN, Starting today For 24 Hours, Routine, Post-
Op/Phase II
Oxygen Therapy [RT0032] CONTINUOUS, Starting today For Until specified,
Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 92
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Post-Op/Phase II
Cough And Deep Breathe [NURTRT0019] EVERY 1 HOUR, Starting today For Until specified,
Routine, While awake., Post-Op/Phase II
Incentive Spirometry [NURTRT0018] EVERY 1 HOUR, Starting today For Until specified,
Routine, While awake., Post-Op/Phase II
Wound Care [196004]
Page 10 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/11/2017 8:02:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Wound Care [NURWND0015] CONTINUOUS, Routine
Wound Type: Closed - Incision
Wound Site: Chest
Wound Location: Anterior
Assess Frequency: EVERY 8 HOURS
Care Frequency: 2X DAILY
Wash With:
Irrigate/Rinse With: Do Not Irrigate
Apply (Must also enter separate medication order to
obtain drug):
Primary Dressing: Gauze (No Tape)
Secondary Dressing: Jobst Garments
Post-Op/Phase II
Maintain Drain [NURTAD0003] CONTINUOUS, Routine
Type: Closed Suction (Jackson-Pratt)
Site: Chest
Location:
Drainage Options: Bulb
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip: EVERY 4 HOURS
Strip For:
Dressing Change Frequency: DAILY
Dressing Type: Gauze (No Tape)
Post-Op/Phase II
Apply Ice PRN [NURCOM0022] ONCE, Apply ice to surgical site for 20 minute
intervals as needed for pain relief, Post-Op/Phase II
Intake Output [87147]
Measure Intake And Output [NURMON0005] EVERY 4 HOURS, Starting today For Until specified,
Routine, Post-Op/Phase II
Non-Categorized Patient Care Orders [196005]
Jobst Bra or Breast Binder [NURCOM0022] CONTINUOUS, Wear Jobst Bra Or Breast Binder as
instructed, Post-Op/Phase II
Contingency Parameters [196006]
Notify Provider [NURCOM0001] Provider to Notify: Other (Comment)
If systolic blood pressure > (mmHg): 180
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg): 110
If diastolic blood pressure < (mmHg): 50
If temperature > (C): 38
If temperature < (C):
If heart rate > (bpm): 110
If heart rate < (bpm): 50
If respiratory rate >: 20
If respiratory rate <: 8
If blood glucose > (mg/dL): 150
If blood glucose < (mg/dL): 60
If pain score >:
Pulse Oximetry < (%): 92
If urine output < (mL): 30 milliliters/hour for 4 hours
Other: Pain not controlled with ordered analgesics or
ordered interventions,If drain output is bloody and/or
not holding suction
On Call General Surgery Resident, Post-Op/Phase II
Intravenous Therapy
Page 11 of 14
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IV Therapy [195996]
Maintain Peripheral IV [NURVAD0013] CONTINUOUS For Until specified, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Post-Op/Phase II
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L
infusion [44910]
at 75 mL/hr, Intravenous, CONTINUOUS, Post-
Op/Phase II
lactated ringers infusion [38890] at 75 mL/hr, Intravenous, CONTINUOUS, Post-
Op/Phase II
dextrose 5%-NaCl 0.45% infusion [51613] at 75 mL/hr, Intravenous, CONTINUOUS, Post-
Op/Phase II
Discontinue IV when Tolerating Oral Intake
[NURCOM0022]
ONCE, Post-Op/Phase II
Medications - General
Analgesics - Acetaminophen - PRN [196007]
acetaMINOPHEN (TYLENOL) tab [34150] 500 mg, Oral, EVERY 4 HOURS PRN, pain, mild-
moderate pain; multi-modal therapy, Post-Op/Phase II
Analgesics - NSAIDS- PRN [196008]
ibuprofen (MOTRIN) tab [38353] 400 mg, Oral, EVERY 8 HOURS PRN, pain, mild-
moderate pain; multi-modal therapy
Do NOT administer ibuprofen if patient taking
ketorolac
Post-Op/Phase II
ketOROLAC (TORADOL) injection - NOTE: Do
NOT order ketorolac if patient 65 years or older,
50 kg or less, or serum creatinine 1.2 mg/dL or
more [800050]
15 mg, Intravenous, EVERY 6 HOURS PRN For 5
Days, pain, Mild-moderate pain or multi-modal
therapy, Post-Op/Phase II
Analgesics - Opioids - ORAL - PRN [232212]
oxycodone tab [45976] 5 mg, Oral, EVERY 4 HOURS PRN, pain, Severe
pain, Post-Op/Phase II
oxycodone tab [45976] 10 mg, Oral, EVERY 4 HOURS PRN, pain, Severe
pain, Post-Op/Phase II
traMADOL (ULTRAM) tab [720174] 50-100 mg, Oral, EVERY 6 HOURS PRN, pain,
Moderate-severe pain
Analgesics - Opioids - Intravenous - PRN (Single Response) [232214]
HYDROmorphone PF (DILAUDID) injection
[800120]
0.5 mg, Intravenous, EVERY 2 HOURS PRN, pain,
Severe pain when unable to take by mouth. Do not
administer opioids by both the IV and oral route., Post-
Op/Phase II
MORPHine PF injection RANGE [750057] 1-4 mg, Intravenous, EVERY 2 HOURS PRN, pain,
severe pain, for 4 Minutes, Post-Op/Phase II
Analgesics - Other [232805]
gabapentin (NEURONTIN) cap [54258] 300 mg, Oral, 1 X DAILY (HS) PRN, pain, Post-
Op/Phase II
Anti-emetics [195997]
ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
4 mg, Oral, EVERY 12 HOURS PRN,
nausea/vomiting, First line therapy if tolerating oral
medications, Post-Op/Phase II
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 12 HOURS PRN,
nausea/vomiting, For first line therapy use if not
tolerating oral medications, Post-Op/Phase II
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting, For second line therapy if
unresponsive to first line therapy within 30 minutes,
Post-Op/Phase II
Page 12 of 14
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10/2017CCKM@uwhealth.org

prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting, For second line therapy if
unresponsive to first line thrapy within 30 minutes and
unable to tolerate oral., Post-Op/Phase II
Bowel Management - Scheduled (Single Response) [195998]
senna-docusate (SENOKOT S) 8.6-50 MG per
tab - NOTE: Order if patients are taking
oxycodone or other opioids [60530]
2 tab, Oral, 2 X DAILY
Hold for loose stools
Post-Op/Phase II
docusate sodium (COLACE) cap - NOTE: Order
only if patient is not receiving opioids [36859]
100 mg, Oral, 2 X DAILY
Hold for loose stools
Post-Op/Phase II
Bowel Management - PRN [195999]
polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 1 X DAILY PRN, constipation, Use as first
line rescue therapy if inadequate response to
scheduled bowel management after 48 hours, Post-
Op/Phase II
Non-categorized [200917]
diphenhydramine (BENADRYL) injection RANGE
[750044]
25-50 mg, Intravenous, EVERY 6 HOURS PRN,
itching, for 1 Minutes, Post-Op/Phase II
Consults
Consults [195981]
Diabetes Consult Order Panel (Adult) [188497]
Diabetes Management Service : Will provide management or treatment recommendations for
patients with hyperglycemia and/or those who report outpatient use of insulin or other diabetes
medications. Patients should be expected to remain inpatient > 24 hrs from time of consult.
Consult is required for patients with insulin pumps or who use U-500 insulin. Consult Endocrine
for any non-diabetes-related endocrine questions.
Learning Center - Diabetes Education (Adult): Diabetes Education (Adult): Diabetes education
(meter/insulin skills/other diabetes survival skills) for patients/families with knowledge deficits
and/or need for diabetes knowledge assessment. Recommended for all new diagnoses or
patients with A1C > 9.
Diabetes Education – Nutrition: Diabetes nutrition therapy including nutrition assessment,
carbohydrate education (consistent carbohydrate meals, use of insulin-to-carbohydrate ratio),
and/or individualized, nutritious meal planning for carbohydrates, portions, or considering other
comorbidities. Recommended for all new diagnoses or patients with A1C > 9
Consult Diabetes Management Service (DMS)
(Inpatient) [CON0022]
ONCE
Can this consult be done via video?
Call back number:
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Post-Op/Phase II
Page 13 of 14
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10/2017CCKM@uwhealth.org

Consult Learning Center - Diabetes Education
(Adult) [CON0021]
ONCE, Routine, - If patient is newly diagnosed or is
new to insulin, provide 24 hours notice to allow
adequate time for education,
- Indicate diabetes medication/treatment plan if
known.
- Consults requested after 1600 on Fridays may not
be seen until following Monday. Learning Center
available Mon-Sat 0800-1630 (only 1 RN available
on Saturday for CSC and AFCH).
- Staff may be contacted by Pager 7927 on
weekdays and Pager 3276 on weekends.
- Learning Center staff are not available on holidays.
Type of Education: Diabetes Self-Management
Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Post-Op/Phase II
Consult Diabetes Education - Nutrition (Inpatient)
[CON0126]
ONCE, Routine, · If your patient is newly diagnosed
and/or is new to insulin therapy, provide 24 hours
notice to allow adequate time for nutrition education.
· Indicate diabetes medication/treatment plan if
known.
· Consults requested after 1300 on Friday may not
be completed until the following Monday.
· If you are placing a consult on a weekend day for a
patient who will be discharging that weekend, please
have the Paging Center contact the on-call dietitian
to help you facilitate the diabetes nutrition education
session prior to the patient's discharge.
Type of Education: Diabetes Self-Management
Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Post-Op/Phase II
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Routine
Reason for Occupational Therapy Consult: UE
ROM/Strengthening
Post-Op/Phase II
Respiratory Therapy per Protocol [RT0035] Routine
Protocol Type:
Post-Op/Phase II
Page 14 of 14
Printed by STRAKA, KEVIN F [KFS1] at 10/11/2017 8:02:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org