/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-97820-en.cckm

201712342

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100

UWHC,UWMF,

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

IP - Burn - Outpatient Short Stay - Adult - Admission [5730]

IP - Burn - Outpatient Short Stay - Adult - Admission [5730] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Burn


IP - Burn - Outpatient Short Stay - Adult - Admission [5730]
Admission Status
Level of Care (Single Response) [187515]
*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 [188721]
Admit To Outpatient Short Stay [ADT0003] Attending: FAUCHER, LEE D
Admitting Resident:
Requested Floor:
Service: BURN
Admission Status (Single Response) [188723]
Admit To Outpatient Short Stay [ADT0003] Attending: FAUCHER, LEE D
Admitting Resident:
Requested Floor:
Service: BURN
Anticipated Discharge [151652]
Anticipated Discharge Date [ADT0016] Anticipated Discharge Date:
Patient Care Orders
Vital Signs [134695]
Page 1 of 6
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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

Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
ONCE and PRN
Activity [134696]
Activity [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB: ad lib
AMBULATE:
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Nutrition [188727]
Diet [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:
Respiratory [134698]
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
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
ETCO2 Monitoring [RT0006] RT PRN, Starting today, Routine, For sedation
monitoring.
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:
Page 2 of 6
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:23:43 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Burn Care - Meshed Graft Care [NURWND0020] CONTINUOUS, Routine
Meshed Graft Site:
Meshed Dressing:
Wash Wound:
Wound Airing:
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 [231691]
silver sulfadiazine (SILVADENE) 1% cream
[42081]
Topical, 2 X DAILY PRN, Burn and Wound Care
Per wound care order
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
Per wound care order
Non-Categorized Patient Care Orders [188747]
Cardio-Respiratory Monitor - Adult
[NURMON0061]
INTERMITTENT, Routine
Contingency Parameters [188748]
Page 3 of 6
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:23:43 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

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,Notify Provider for apnea > 20
seconds
Intravenous Therapy
Premedications for Needle Insertion [106310]
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 [189687]
dextrose 5%-NaCl 0.2% infusion [51615] Intravenous, CONTINUOUS
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
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
Page 4 of 6
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:23:43 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Medications - General
Analgesics - Acetaminophen - PRN [189049]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain/fever
Temperature greater than 39 degrees Celsius. See
Pain Management Algorithm for the Selection of As-
Needed Analgesics
NOTE: Suggested dose 10-15 mg/kg (Maximum 650
mg/dose)
Analgesics - Opioids - Oral - PRN [231693]
oxycodone tab RANGE - NOTE: Suggested dose
5-10 mg [750032]
Oral, EVERY 4 HOURS PRN, pain, 1 hour prior to
wound care.
See Pain Management Algorithm for the Selection of
As-Needed Analgesic
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 (Single Response) [189050]
MORPHine PF injection RANGE - - NOTE:
Suggested dose 0.05 - 0.1 mg/kg (Maximum 2
mg/dose [750057]
1-2 mg, Intravenous, EVERY 5 MINUTES PRN, pain,
At time of wound care or therapy
See Pain Management Algorithm for the Selection of
As-needed Analgesics
for 4 Minutes
FENTanyl PF injection RANGE [750047] 25-100 mcg, Intravenous, EVERY 5 MINUTES PRN,
pain, At time of wound care or therapy
See Pain Management Algorithm for the Selection of
As-needed Analgesics
for 1 Minutes
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 - Oral (Single Response) [189688]
Page 5 of 6
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:23:43 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

ondansetron (ZOFRAN ODT) disintegrating tab -
NOTE: order on patients greater than 40 kg and
able to take tabs [64224]
4 mg, Oral, EVERY 6 HOURS PRN, nausea/vomiting,
Give IV if unable to tolerate po
NOTE: Suggested dose 0.1 mg/kg/dose (Maximum 4
mg/dose)
Anti-emetics - IV [189692]
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 12 HOURS PRN,
nausea/vomiting
Consults
Consults [188751]
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:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Routine
Reason for Occupational Therapy Consult:
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Routine
Reason for Physical Therapy Consult:
Consult Social Work (Inpatient) [CON0076] ONCE, Routine
Reason for Consult:
Is this a STAT consult?
Can this consult be done via video?
Page 6 of 6
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:23:43 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org