/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/cardiologyct-surgery/,

/clinical/cckm-tools/content/order-sets/inpatient/cardiologyct-surgery/name-115399-en.cckm

201704100

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Cardiology/CT Surgery

IP - Left Atrial Appendage Closure - Adult - Preprocedure [6307]

IP - Left Atrial Appendage Closure - Adult - Preprocedure [6307] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Cardiology/CT Surgery


IP - Left Atrial Appendage Closure - Adult - Preprocedure [6307]
for Adult Patients OnlyIntended
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) [221447]
Page 1 of 9
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor: F4/5
Service: CARDIOVASCULAR CATH PROCEDURE
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:
Admission Status (Single Response) [119354]
Admit To Inpatient Status [ADT0001] Attending:
Admitting Resident:
Requested Floor: F4/5
Service: CARDIOVASCULAR CATH PROCEDURE
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 Status [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [150158]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
High Bleed Risk with Any 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:
VTE Prophylaxis (Single Response) [130129]
Caprini VTE Risk Assessment URL:
Page 2 of 9
Printed by LIND, JANNA S [JSL237] at 4/7/2017 11:38:16 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
High Bleed Risk with Any 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 [121555]
Vital Signs [NURMON0013] EVERY 8 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Patient Monitoring [119369]
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting today, 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?
Glucose, POC [IPGLUCOSE] EVERY 6 HRS IF NPO/ CONT. TUBE FEEDING/ OR
TPN, Starting today, 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?
ACTIVATED CLOTTING TIME, POC
[HCACTPOC]
ONCE, Routine
If Conditional, What Condition?
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
CONTINUOUS, Starting today, Routine
Notify Provider: Symptomatic Change in Rhythm
Functional Cardiac Defibrillator Present:
Discontinue telemetry on-call to OR
Activity [119524]
Page 3 of 9
Printed by LIND, JANNA S [JSL237] at 4/7/2017 11:38:16 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

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 [119355]
NPO - Except Medications [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
Respiratory [119357]
Oxygen Therapy [RT0032] CONTINUOUS, Starting today, 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
Pulse Oximetry [NURMON0009] ONCE For 1 Occurrences, Routine
Intake and Output [119358]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today, Routine
Non-Categorized [119359]
Measure Height [NURMON0052] ONCE, Starting today For 1 Occurrences, Routine,
On admission
Measure Weight [NURMON0015] ONCE For 1 Occurrences, Routine
Weigh With?
Weigh when?
On admission
Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, 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:
Indication for Placement: Monitor Volume in ICU
Patient and Unable to Use Alternative Methods
Initiate Urinary Catheter Removal Protocol? (NP/PA
Must Select "No"):
Details: To Dependent Drainage
Does this need to be inserted/placed?
Please use Coude catheter for patient over age 50.
Urinary Catheter Removal Protocol does NOT apply
to Urology, Gynecology, spinal cord injured patients,
patients with catheters placed by Urology on prior
admission, or to patients with chronic Foley catheters.
Not appropriate for Pediatric patients.
Contingency Parameters [119368]
Page 4 of 9
Printed by LIND, JANNA S [JSL237] at 4/7/2017 11:38:16 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] CONTINUOUS
Provider to Notify: Provider
If systolic blood pressure > (mmHg): 160
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 39
If temperature < (C):
If heart rate > (bpm): 110
If heart rate < (bpm): 50
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
If pain score >:
Pulse Oximetry < (%): 92%
If urine output < (mL): 30
Other: Patient is having chest pain
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 within 1 minute. Choice of medication should be based on patient’s previous
experience/preference, history of lidocaine allergy and ease of access.
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
lidocaine (XYLOCAINE) 1% injection [39034] 0.1-0.4 mL, Intradermal, PRN, peripheral line
insertion - see Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge
needle to inject solution and create a wheal. Wait 30
seconds to 1 minute then insert IV catheter into
center of wheal. Use if IV is needed within 30
minutes. Choice of medication should be based on
patient’s previous experience/preference, history of
lidocaine allergy and ease of access
sodium chloride (bacteriostatic) 0.9 % injection
[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. Choice of medication should be based on
patient’s previous experience/preference, history of
lidocaine allergy and ease of access
IV Fluids [120302]
sodium chloride 0.9% infusion [64367] Intravenous, CONTINUOUS
sodium chloride 0.45% infusion [42187] Intravenous, CONTINUOUS
Page 5 of 9
Printed by LIND, JANNA S [JSL237] at 4/7/2017 11:38:16 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV - Second Line
[NURVAD0013]
CONTINUOUS, Starting today For Until specified,
Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
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?
Second Line
Medications - General
Medications [221494]
aspirin chew tab [720164] 81 mg, Oral, ONCE For 1 Doses
Give prior to procedure.
atropine injection [800178] 0.5 mg, Intravenous, PRN Starting today,
bradycardia, Heart rate less than 50 beats/min and
systolic blood pressure less than 90mmHg
Over 1 minute
Medications - Preprocedure
Preprocedure - Steriods (Single Response) [221495]
prednisone (DELTASONE) tab [41277] 50 mg, Oral, ON CALL For 1 Doses
hydrocortisone sod suc in sodium chloride 0.9%
injection [800189]
100 mg, Intravenous, ON CALL For 1 Doses
Give 1 hour prior to OR
Preprocedure - Antihistamines (Single Response) [221496]
diphenhydramine (BENADRYL) cap [36791] 25 mg, Oral, ON CALL For 1 Doses
Give 1 hour prior to OR
diphenhydramine (BENADRYL) injection
[800106]
25 mg, Intravenous, ON CALL For 1 Doses
Give 1 hour prior to OR
diphenhydramine (BENADRYL) cap [36791] 50 mg, Oral, ON CALL For 1 Doses
Give 1 hour prior to OR.
diphenhydramine (BENADRYL) injection
[800106]
50 mg, Intravenous, ON CALL For 1 Doses
Give 1 hour prior to OR.
Preprocedure - Antacids [221489]
ranitidine (ZANTAC) tab [720131] 150 mg, Oral, ON CALL For 1 Doses
Give 1 hour prior to OR.
Medications - Anti-infectives
First Line (Single Response) [152817]
Patients who are 40-120 kg [222298]
cefuroxime (ZINACEF) intraVENOUS [800030] 1.5 g, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 120 kg [138959]
cefuroxime (ZINACEF) intraVENOUS [800030] 3 g, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies: [119530]
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Laboratory
Laboratory [212665]
Page 6 of 9
Printed by LIND, JANNA S [JSL237] at 4/7/2017 11:38:16 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

AST/SGOT [AST] 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?
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?
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?
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?
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL - RN COLLECT, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Stat every time blood
glucose monitoring (bedside) is less than 40 or
greater than 400 mg/dL.
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?
PROTHROMBIN TIME/INR [PT] 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?
PTT [PTT] 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?
PROTEIN, URINE [UTPR] 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?
Page 7 of 9
Printed by LIND, JANNA S [JSL237] at 4/7/2017 11:38:16 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

URINALYSIS WITH MICROSCOPY [UA] 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?
Blood Bank
Tests [119526]
TYPE AND SCREEN [HCTS] NEXT DRAW, Starting today For 1 Occurrences,
Routine, As good clinical practice and for patient
safety, the Transfusion Service will automatically
crossmatch 2 packed RBCs on all patients with
antibodies to ensure blood would be available in the
event it is needed. If you would like to opt out of this
automatic order for this patient please contact the
UWHC Blood Bank at (608) 263-8367 or The
American Center Lab at (608) 234-6600 as
appropriate.
Blood Products
Blood Products [12026]
Red Blood Cells (Adult) [BLB0006] 1 UNIT, Starting today For 1 Occurrences, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Plasma (Adult) [BLB0003] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Page 8 of 9
Printed by LIND, JANNA S [JSL237] at 4/7/2017 11:38:16 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Platelets (Adult) [BLB0004] 1 SINGLE, Starting today For 1 Occurrences, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Cryoprecipitate (Adult) [BLB0005] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Fibrin Glue, mLs Needed:
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [212690]
ECG - 12 Lead - Pre-Operative [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: PRE-OPERATIVE
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 9 of 9
Printed by LIND, JANNA S [JSL237] at 4/7/2017 11:38:16 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org