/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/burn/,

/clinical/cckm-tools/content/order-sets/inpatient/burn/name-97818-en.cckm

201712342

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Burn

IP – Small Burn and Wound – Adult – Admission [1475]

IP – Small Burn and Wound – Adult – Admission [1475] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Burn


IP - Small Burn and Wound - Adult - Admission [1475]
Admission Status
Level of Care (Single Response) [186484]
*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 (ICU) [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:
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status (Single Response) [82665]
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:
Page 1 of 15
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status [7248]
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:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Anticipated Discharge [151652]
Anticipated Discharge Date [ADT0016] Anticipated Discharge Date:
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [130119]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response) [129777]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE 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
Page 2 of 15
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
VTE Prophylaxis (Single Response) [150156]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response) [129777]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE 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
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Patient Care Orders
Vital Signs [20339]
Vital Signs [NURMON0013] EVERY 4 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Activity (Single Response) [22471]
Ambulate 4x daily, Chair 3x daily [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE: 4x daily
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:
Page 3 of 15
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:03:46 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Strict Bedrest [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: strict bedrest
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Burn Positioning [97620]
Burn and Graft Positioning and Splinting
[NURWND0030]
CONTINUOUS, Starting today, Routine
Burn Location #1:
Position:
Frequency:
Burn Location #2:
Position:
Frequency:
Burn Location #3:
Position:
Frequency:
Burn Location #4:
Position:
Frequency:
Burn Location #5:
Position:
Frequency:
Burn Positioning - Head - Neck - Ears
[NURWND0030]
CONTINUOUS, Routine
Burn Location:
Elevate:
Position:
Frequency:
Nutrition [205509]
Diet - Protein/Calorie High [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Miscellaneous
Miscellaneous: High Protein/High Calorie
Bedside Meal Instructions:
Room Service Class:
Burn patient - please send automatic breakfast tray
Diet - Other [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type:
Bedside Meal Instructions:
Room Service Class:
Burn patient - please send automatic breakfast tray
Nutrition - Other [187548]
SetSupplemental" Order -Tube Feeding Orders, Refer to "Tube Feeding For
NPO for Procedure - Hold Diet 8 hours - NOTE:
Modify start time as appropriate [DIE0007]
CONTINUOUS NPO, Starting today For 8 Hours,
Routine
NPO For Which Procedure?
Modifiers:
- NPO solids and full liquids at *** (6 hours prior to
sedation)
- Clear liquids at *** (2 hours prior to sedation)
Page 4 of 15
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:03:46 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Nourishments & Supplements [NUT0005] EFFECTIVE NOW, Starting today, Routine
Medical Food / Oral Supplement(s): OTHER
PRODUCTS (COMMENT)
Nourishment / Snack Item(s):
Schedule:
Medical Food/Oral Supplement(s) per patient
preference.
Encourage PO Intake [NURDIE0008] CONTINUOUS, Starting today, Routine
RN to Mix Protein Modular with Beverages
[DIE0011]
Instructions for Patient: RN to Mix Protein Modular
with Beverages
Routine, CONTINUOUS, Starting today
Measure Caloric Intake [NURDIE0011] 1X DAILY, Starting today For 8 Weeks, Routine
Respiratory [20303]
Oxygen Therapy [RT0032] PRN, 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? Yes
Provide Manual Resuscitator at Bedside [RT0039] CONTINUOUS, Starting today, Routine
ETCO2 Monitoring [RT0006] RT PRN, Starting today, Routine, For Sedation
Monitoring
Pulse Oximetry [NURMON0009] PRN, Starting today, Routine
Incentive Spirometry [NURTRT0018] EVERY 2 HOURS, Starting today, Routine
Cough And Deep Breathe [NURTRT0019] EVERY 2 HOURS, Starting today, Routine
Respiratory Therapy Communication [RT0073] SEE COMMENTS, Routine, Assure that humidification
is added to all continuous O2 therapy
Wound Care [134699]
Burn Care - Burn Care [NURWND0025] CONTINUOUS, Starting today, Routine
Burns Site:
Burns Treatment/Dressing (Must also enter separate
medication order to obtain drug):
Dressing Change Frequency:
Wash Wound:
Wound Airing:
Burn Care - Donor Site Care [NURWND0019] CONTINUOUS, Starting today, Routine
Donor Site Site:
Location:
Donor Site - Outer Dressing:
Donor Site - Outer Dressing Change Frequency:
Donor Site - Primary Dressing Change Frequency:
Burn Care - Meshed Graft Care [NURWND0020] CONTINUOUS, Routine
Meshed Graft Site:
Meshed Dressing:
Wash Wound:
Wound Airing:
Page 5 of 15
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:03:46 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Burn Care - Open Wound Care [NURWND0024] CONTINUOUS, Starting today, Routine
Wound Type:
Wound Site:
Wound Care Frequency:
Wash With:
Topical Therapy (Must also enter separate medication
order to obtain drug):
Primary Dressing:
Secondary Dressing:
Compression Layer:
Burn Care - Sheet Graft Care [NURWND0021] CONTINUOUS For Until specified, Routine
Sheet Graft Site:
Sheet Graft (Dry) Dressing:
Sheet Graft First Dressing Change:
Wound Airing:
Wound Vacuum [136891]
Wound Vacuum [NURWND0013] CONTINUOUS, Routine
Wound Vacuum Site:
Type of Suction:
DPC (Intermittent Suction) Frequency:
If VAC is leaking or alarming, and troubleshooting is
not effective, notify the service that is managing the
VAC. Per manufacturer recommendations, a VAC
dressing without active therapy for more than 2
hours should be removed. If managing service
verifies removal of VAC dressing, the dressing
should be removed, wound should be cleansed and
irrigated with NS, and a wet to dry dressing should
be applied. If active bleeding develops suddenly or
in large amounts during V.A.C. therapy or if frank
(bright red) blood is seen in the tubing or in the
canister immediately stop V.A.C therapy(clamp
tubing and turn therapy off), leave dressing in place
and notify managing service or covering physician,
as dressing will need to be removed and source of
bleeding must be controlled.
Vacuum Assisted Closure - KCI [EQP0030] CONTINUOUS, Routine
Measure Drain Output [NURTAD0005] EVERY 8 HOURS, Routine
Burn and Wound Topical Medications [231120]
silver sulfadiazine (SILVADENE) 1% cream
[42081]
Topical, 2 X DAILY PRN, Burn and Wound Care
Apply to open wounds as needed per wound care
orders
mafenide (SULFAMYLON) 5% topical packet
[59500]
50 g, Irrigation, EVERY 6 HOURS
Per wound care order
bacitracin ointment [49271] Topical, 2 X DAILY PRN, Open wounds as needed
Per wound care order
ointment base (HYDROPHOR) ointment [56186] Topical, 2 X DAILY PRN, Burn and Wound Care
Per wound care order
Intake and Output [22559]
hour = ICU level of care 1
hours = ICU or IMC level of care2
hours = IMC or General Care level of care4
hours = General Care level of care8
Measure Intake And Output [NURMON0005] EVERY 4 HOURS, Routine
Non-categorzied patient Care orders [187262]
Page 6 of 15
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12/2017CCKM@uwhealth.org

Monitor Distal Pulses and Capillary Refill of
Burned Extremities [NURMON0060]
SEE COMMENTS, Starting today For 24 Hours, Every
hour times 24 hours.
Measure Height [NURMON0052] ONCE, Starting today For 1 Occurrences, Routine,
Immediately upon admission.
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With?
Weigh when?
Measure weight immediately upon admission and
measure weight daily after wound care in dry
dressings
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
ONCE, Routine
Indication: Other (Comment Required)
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Functional Cardiac Defibrillator Present:
Feeding Tube Bedside Placement - Adult
[121915]
Feeding Tube Placement Request
[NURDIE0015]
ONCE, Routine
Feeding Tube Placement Reason:
Feeding Tube Placement:
Insertion Point:
Allow removal of existing orogastric or nasograstric
tube?
lidocaine-oxymetazoline 4%-0.05% (ADULT)
nasal spray [785081]
2 spray, Nasal, ONCE PRN For 36 Hours, feeding
tube placement
For numbing prior to feeding tube insertion.
Slowly spray the chosen nostril once, if required may
repeat x1 in opposite nostril. Angle toward back of
throat spraying the anterior nostril and wait 30-60
seconds before introducing more local
anesthetic into the nostril. Caution: Entire bottle
should not be used for insertion of tube. Discard
excess solution when procedure completed.
metoclopramide (REGLAN) injection [800059] 10 mg, Intravenous, ONCE PRN For 36 Hours,
peristalsis during feeding tube insertion
Maintain Enteral (Naso-) Tube [NURTAD0040] CONTINUOUS, Routine
Status:
Flush With: Water
Flush Volume (mL): 30 mL
Flush Frequency: EVERY 4 HOURS
Feedings may not be initiated in a newly placed
small bore feeding tube until physician radiograph
confirmation of placement is obtained via a written or
verbal report.
Flush with 30 mL of water per feeding tube every 4
hours and as needed to flush feeding tube after each
medication administration or alimentation. Refer to
policy 2.20 Enteral Feeding Tube.
Notify Feeding Tube Team [NURCOM0001] Provider to Notify: Other (Comment)
Notify based on: Other
Other: Feeding tube needs repositioning,Bridle
umbilical tape or clip needs to be changed,Viokase
unclogging kit is ineffective
Page 7 of 15
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:03:46 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

X-RAY ABDOMEN AP VIEW (KUB) [R74000] CONDITIONAL For 3 Days, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered
by this exam? Evaluate feeding tube placement
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date
in comment):
Transport Method: Floor Determined/Entered
If Conditional, What Condition? Evaluate feeding
tube placement
Consult Feeding Tube Team (Inpatient)
[CON0113]
ONCE For 1 Occurrences, Routine
Reason for Consult:
Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, Starting today, Routine, To
discontinue this order, enter a new order for
"Discontinue Urinary Catheter".
To modify this order, enter a new order for "Maintain
Urinary Catheter" and make the necessary changes in
the new order.
Type: Temperature Probe
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Using urimeter.
Urinary Catheter Removal Protocol does NOT apply to
Urology, Gynecology, spinal cord injured patients or
patients with catheters placed by Urology on prior
admission. Not appropriate for Pediatric patients.
Contingency Parameters [114417]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 180
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg): 100
If diastolic blood pressure < (mmHg): 40
If temperature > (C): 40
If temperature < (C): 36
If heart rate > (bpm): 150
If heart rate < (bpm): 50
If respiratory rate >: 30
If respiratory rate <: 8
If blood glucose > (mg/dL): 180
If blood glucose < (mg/dL): 50
If pain score >: 8
Pulse Oximetry < (%): 90
If urine output < (mL): 30 milliliter/hour or greater than
100 milliliter/hour
Other: Pain not controlled with ordered analgesics or
ordered interventions
Intravenous Therapy
Premedications for Needle Insertion [106310]
Page 8 of 15
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:03:46 AM
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Use lidocaine topical dressing kit for stable patient, no lidocaine allergies, have at least 30
minutes time prior to needing to use IV
Sodium chloride (bacteriostatic) 0.9% intradermal: Useful for patients requiring urgent IV
access; onset is immediate.
lidocaine (LMX) 4% topical dressing kit [66882] 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
sodium chloride (bacteriostatic) 0.9 % injection
[50585]
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.
IV Fluids [20126]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today For Until specified,
Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
lactated ringers infusion [38890] Intravenous, CONTINUOUS
Through fluid warmer for 8 hours post-burn. Titrate by
*** mL/hr (10% of baseline) every 1 hour as needed to
maintain urine output between 30-50 mL/hr. Minimum
total fluid rate *** mL/hr (calculated burn maintenance
rate). Discontinue with good oral intake.
Medications - Admission Specific
Vaccines - NOTE: Order for patients who have not received a tetanus containing vaccine within the last
5 years [185757]
tetanus-diphtheria toxoids ADULT (TENIVAC)
injection - NOTE: Order for patients who have not
received a tetanus containing vaccine within the
last 5 years [46712]
0.5 mL, Intramuscular, ONCE For 1 Doses
Do NOT give if patient has received a tetanus
containing vaccine within the last 5 years
Vitamin C [185758]
ascorbic acid (VITAMIN C) tab [43693] 500 mg, Oral, 2 X DAILY (AT MEALTIME)
Vitamins/Trace Mineral Supplementation [187526]
multivitamin with mineral tab [800240] 1 tab, Oral, 2 X DAILY (AT MEALTIME) Starting today
For 10 Doses
multivitamin with mineral tab [800240] 1 tab, Oral, 1 X DAILY Starting 12/14/17
Medications - General
Analgesics - Acetaminophen - Scheduled [233138]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 6 HOURS
Analgesics - Opioids - Oral - PRN [233139]
oxycodone tab RANGE [750032] 5-10 mg, Oral, EVERY 4 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
Analgesics - Opioids- Oral -Scheduled [20130]
MORPHine (MS CONTIN, ORAMORPH) ER tab
[156572]
Oral, EVERY 12 HOURS
Analgesics - Other (Single Response) [233140]
Gabapentin - Standard Therapy [239608]
Page 9 of 15
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:03:46 AM
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12/2017CCKM@uwhealth.org

gabapentin (NEURONTIN) cap [54258] 300 mg, Oral, 2 X DAILY (AM AND NOON)
gabapentin (NEURONTIN) cap [54258] 600 mg, Oral, 1 X DAILY (HS)
Gabapentin - Therapy for Elderly and Renal
Dysfunction Patients [239611]
gabapentin (NEURONTIN) cap [54258] 100 mg, Oral, 2 X DAILY (AM AND NOON)
gabapentin (NEURONTIN) cap [54258] 200 mg, Oral, 1 X DAILY (HS)
Note: No Gabapentin Ordered [950018] ONCE
Wound Care - Analgesics - Oral Opioids [242386]
oxycodone tab RANGE [750032] 10-20 mg, Oral, 2 X DAILY PRN, pain
For the prevention of pain associated with wound
care. Give one hour prior to wound care therapy, OK
to combine with PRN oxycodone dose.
Wound Care - Analgesics - IV - First Line (Single Response) [242399]
FENTanyl PF injection RANGE [750047] 25-100 mcg, Intravenous, EVERY 5 MINUTES PRN,
pain, For breakthrough pain at time of wound care or
therapy, for 1 Minutes
MORPHine PF injection RANGE [750057] 0.5-2 mg, Intravenous, EVERY 5 MINUTES PRN,
pain, For breakthrough pain at time of wound care or
therapy, for 4 Minutes
Wound Care - Analgesics - IV - Second Line [20138]
ketamine injection LOW DOSE ADULT BURN
PAIN [800191]
0.25 mg/kg, Intravenous, 2 X DAILY PRN, severe pain
with wound washing
Second line therapy for severe breakthrough pain with
wound washing
Administer 0.25 mg/kg initial dose prior to wound
washing and may repeat x 1 dose as needed for
morning dressing. Do not administer dose for evening
wound dressing change
Wound Care - Anti-Anxiety (Single Response) [189048]
midazolam (VERSED) injection RANGE [750056] 1-2 mg, Intravenous, EVERY 10 MINUTES PRN,
sedation, Anxiety at time of wound care therapy
midazolam (VERSED) injection RANGE - For
elderly adults and adults < 50 kg [750056]
0.5-1 mg, Intravenous, EVERY 10 MINUTES PRN,
sedation, Anxiety at time of wound care therapy
Note: No Midazolam Ordered for Wound Care
Therapy [950018]
4 X DAILY (NOTE ACKNOWLEDGE)
Reversal Agents [222975]
naloxone (NARCAN) injection [800199] 0.1 mg, Intravenous, PRN For 8 Doses, opioid
overdose, oversedation from opioids
Administer 0.1 mg every three minutes PRN up to 8
doses for respiratory rate less than 8 breaths/minute
or sedation score of 5 or greater. Max number of
doses = 8. Notify provider if administered
flumazenil (ROMAZICON) injection [104460] 0.2 mg, Intravenous, PRN For 5 Doses, oversedation
from benzodiazepines
Administer 0.2 mg over 15 seconds; repeat dose after
45 seconds (one minute intervals) PRN for sedation
reversal. Max number of doses = 5. Give naloxone
prior to flumazenil if opioids are given at the same
time. Notify provider if administered
If ordered IV: push over 15-30 seconds.
Anti-emetics [144258]
Adult - Standard - Anti-emetics [242359]
ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
4 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
Use first line
Page 10 of 15
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:03:46 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Use first line if unable to take medications by mouth
or enteral tube OR if immediate effect is needed.
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
Use second line if there is inadequate response to
first line anti-emetic within 30 minutes. If there is no
response to second line therapy within 30 minutes,
notify provider
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Use second line. Use if there is inadequate
response to first line anti-emetic within 30 minutes
and if unable to take medications by mouth or
enteral tube OR if immediate effect is needed. If
there is no response to second line therapy within 30
minutes, notify provider
Bowel Management [20136]
polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 1 X DAILY
Dissolve in 8 ounces of water
senna-docusate (SENOKOT-S) 8.6-50 mg per tab
[60530]
2 tab, Oral, 2 X DAILY
Hold for loose stools.
Bowel Management - As Needed - First Line [185760]
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, Oral, 1 X DAILY PRN, constipation, First Line
Agent
See Burn Patient Bowel Management Algorithm
bisacodyl EC (DULCOLAX) delayed release tab
[49076]
10 mg, Oral, EVERY 24 HOURS PRN, constipation,
First Line Agent
See Burn Patient Bowel Management Algorithm
Bowel Management - As Needed - Second Line [185761]
magnesium citrate soln [39309] 296 mL, Oral, 1 X DAILY PRN, constipation, Do not
give within 2 hours of first line therapy dose
See Burn Patient Bowel Management Algorithm
Bowel Management - As Needed - Third Line [185762]
function not prescribe in patients with impared renal Do
phosphate (FLEET) enema [37517] 1 enema, Rectal, 1 X DAILY PRN, constipation, Do
not give with 2 hours of second line therapy dose
See Burn Patient Bowel Management Algorithm
Bowel Management - As Needed - Fourth Line [233146]
Tap Water Enema [NURELM0020] 1X DAILY PRN For 1 Occurrences, Routine
Duration: Once
Fourth line bowel management as needed
See Burn Patient Bowel Management Algorithm
Protein Supplement [194895]
protein supplement (RESOURCE
BENEPROTEIN) oral packet [118845]
1-2 packet, Oral, EVERY 1 HOUR PRN, Protein
Supplementation, Choice of protein supplement per
patient preference
protein supplement no carb (PROSOURCE) soln
[140269]
1-2 packet, Oral, EVERY 1 HOUR PRN, Protein
Supplementation, Choice of protein supplement per
patient preference
Hypnotics [144257]
traZODONE (DESYREL) tab [720150] 50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see IPOC supplemental Sleep/Rest
Disturbance Adult)
Page 11 of 15
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Laboratory
Laboratory - Pregnancy Test [187228]
patient had pregnancy test if female between menarche & menopause and any of: (1) Obtain
patient says she "could" be pregnant. unprotected intercourse, (2) patient missed menses, (3)
Urine, Pregnancy Test [UPREG] STAT, 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?
Pre-Op Day Of Procedure
Draw On Admission [20344]
CBC WITHOUT DIFFERENTIAL [HEMO] NEXT DRAW, 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?
ELECTROLYTES [LYTE] NEXT DRAW, 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?
GLUCOSE [GLU] NEXT DRAW, 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?
BUN [BUN] NEXT DRAW, 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?
CREATININE [CRET] NEXT DRAW, 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?
CALCIUM [CA] NEXT DRAW, 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?
MAGNESIUM [MAG] NEXT DRAW, 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?
PHOSPHATE [PHOS] NEXT DRAW, 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?
ALBUMIN [ALB] NEXT DRAW, 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?
Page 12 of 15
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12/2017CCKM@uwhealth.org

BLOOD GASES AND O2 SATURATION
[HCBGASOS]
NEXT DRAW, Starting today For 1 Occurrences,
Routine
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALCOHOL [GM2440] NEXT DRAW, 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?
CARBON MONOXIDE [GM2350] NEXT DRAW, 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?
URINALYSIS, WITHOUT MICROSCOPY
[UACHEM]
ONCE, 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?
HEMOGLOBIN A1C [HA1C] NEXT DRAW, 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 Next AM [20345]
HEMATOCRIT [HCT] NEXT AM For 4 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
WHITE CELL COUNT [WBC] NEXT AM For 4 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] NEXT AM For 4 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
GLUCOSE [GLU] NEXT AM For 4 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BUN [BUN] NEXT AM For 4 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATININE [CRET] NEXT AM For 4 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CALCIUM [CA] NEXT AM For 4 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 13 of 15
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12/2017CCKM@uwhealth.org

ALBUMIN [ALB] NEXT AM For 4 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PHOSPHATE [PHOS] NEXT AM For 4 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
MAGNESIUM [MAG] NEXT AM For 4 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [20315]
ECG - 12 Lead [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
Disclaimer for University Hospital Only: A Stat status
for an ECG is in reference to the timing of the ECG.
The goal is to perform a STAT ECG within 10 minutes
of the order being placed. It is the responsibility of the
ordering provider to review the STAT ECGs. All ECGs
(stat or routine) will be formally reviewed within one
business day.
X-RAY CHEST PA & LAT VIEWS [R71020] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Radiology Specialty Area: GENERAL IMAGING
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?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
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? Bedside
Transport Method: Floor Determined/Entered
Consults
Consults [20316]
Behavioral Health Consults (select below)
[214751]
Page 14 of 15
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12/2017CCKM@uwhealth.org

amp, transplant), - adjustment, protocol (eg. burn, trauma, rehab, pre-Psychology Health
noncompliance, grief, pain
Addictive Disorders - alcohol or drug related problems (eg. treatment recommendations,
withdrawal mgmt)
Psychiatry - safety, agitation, capacity, med mgmt, psychotropic SE
ACE - 60 and older - delirium, dementia, depression, decisional capacity, sleep (also for non-
behavioral geriatric syndromes; overall geriatric evaluation, mobility/falls, functional decline,
social/caregiver issues, disposition, medication management)
Consult Health Psychology (Inpatient)
[CON0033]
ONCE, Routine, Please notify consulting provider if
patient needs to be seen same day (Monday-Friday)
or if special assessment needs.
Intent for Consult: Protocol: BURN, REHAB, PRE-
AMP, TRANSPLANT EVALUATION, TRAUMA
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis): Status
post large thermal burn
Consult Addictive Disorders (Inpatient)
[CON0003]
ONCE, Routine, This order is for ADULT patients.
Please use the Consult Adolescent/Pediatric AODA
Counselor order for adolescent/pediatric patients
instead.
Intent for Consult: Other
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis): Alcohol
or drug related burn admission
Consult Psychiatry (Inpatient) [CON0064] ONCE
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Call back number:
Consult Ace/Geriatric (Inpatient) [CON0001] ONCE, Routine
Reason for Consult:
Can this consult be done via video?
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Occupational Therapy Consult: ADL
Training
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult: Mobility
Training
BestPractice
No Hospital Problems have yet been identified. [107035]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing.
Page 15 of 15
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:03:46 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org