/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-98404-en.cckm

201712342

page

100

UWHC,UWMF,

Tools,

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

IP - Esophagectomy - Adult - Postoperative [2958]

IP - Esophagectomy - Adult - Postoperative [2958] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Cardiology/CT Surgery


IP - Esophagectomy - Adult - Postoperative [2958]
for Adult Patients OnlyIntended
Admission Status
Level of Care (Single Response) [187485]
*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:
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 [120757]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: THORACIC SURGERY
Rationale for LOS greater than 2 midnights:
Post-Op/Phase II
Page 1 of 22
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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

Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admission Status [120766]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: THORACIC SURGERY
Rationale for LOS greater than 2 midnights:
Post-Op/Phase II
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [131999]
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
Post-Op/Phase II
Moderate VTE Risk with Low Bleed Risk (Single
Response) [209954]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Post-Op/Phase II
High VTE with Low Bleed Risk [211018]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 8 HOURS, Post-
Op/Phase II
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
Page 2 of 22
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 10:30:28 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

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:
Post-Op/Phase II
VTE Prophylaxis (Single Response) [150176]
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
Post-Op/Phase II
Moderate VTE Risk with Low Bleed Risk (Single
Response) [209954]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Post-Op/Phase II
High VTE with Low Bleed Risk [211018]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Post-Op/Phase II
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:
Post-Op/Phase II
PACU Normoglycemia Management
Normoglycemia Management (Single Response) [217140]
Patients withOUT Diabetes and NOT on Insulin
Infusion [228192]
Page 3 of 22
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 10:30:28 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

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 [228194]
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]
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
Page 4 of 22
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 10:30:28 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@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), 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
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
Page 5 of 22
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 10:30:28 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@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
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 12/16/17 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 [228199]
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 22
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 10:30:28 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@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 [228200]
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 22
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 10:30:28 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@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 22
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 10:30:28 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@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 12/16/17 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 [91213]
Vital Signs [NURMON0013] EVERY 1 HOUR, Starting today For 8 Hours, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Post-Op/Phase II
Patient Monitoring [91214]
Refer to Policy 1.11 for Arterial Catheter Insertion,
Maintenance, Blood Drawing, and Discontinuation
[NURMON0060]
CONTINUOUS, Starting today For Until specified,
Refer to Policy 1.11 for Arterial Catheter Insertion,
Maintenance, Blood Drawing, and Discontinuation
(Adults & Pediatrics), Post-Op/Phase II
Measure Arterial Line Pressure [NURVAD0001] CONTINUOUS, Starting today, Routine
Flush Solution:
Post-Op/Phase II
Measure Central Venous Pressure - Continuous
[NURMON0002]
CONTINUOUS, Starting today, Routine, Post-
Op/Phase II
Measure Central Venous Pressure - Every 4
Hours [NURMON0002]
EVERY 4 HOURS, Starting today For Until specified,
Routine, Post-Op/Phase II
Activity [91215]
Page 9 of 22
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 10:30:28 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Elevate Head Of Bed Greater Than 30 Degrees
and Elevate Foot Of Bed [NURACT0002]
Equal to (degrees):
Greater than (degrees): 30
Less than (degrees):
Other options: At all times
Routine, CONTINUOUS, Starting today, Patient is not
to lie flat. Elevate head of bed greater than 30
degrees and elevate foot of bed., Post-Op/Phase II
Post Sign at Bedside - "Patient is not to lie
flat" [NURACT0011]
CONTINUOUS, Starting today, Post-Op/Phase II
Chair Four Times Daily [NURACT0008] CONTINUOUS, Starting tomorrow, Routine
AD LIB:
AMBULATE:
CHAIR: 4x daily
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Post-Op/Phase II
Ambulate [NURACT0008] CONTINUOUS, Starting tomorrow, Routine
AD LIB:
AMBULATE: 4x 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. Advance to goal of 5
times a day., Post-Op/Phase II
Nutrition [91216]
Strict NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: Strict NPO
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
Respiratory [91217]
Oxygen Therapy [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 90
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, Routine, While
awake, Post-Op/Phase II
Incentive Spirometry [NURTRT0018] CONTINUOUS, Starting today, Routine, While awake
every 10 minutes, Post-Op/Phase II
No CPAP, BIPAP, or IPV [RT0073] CONTINUOUS, Starting today, Routine, Post-
Op/Phase II
Page 10 of 22
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 10:30:28 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Respiratory Therapy per Protocol [RT0035] Routine
Protocol Type:
Post-Op/Phase II
Chest Tube Care [91218]
Maintain Chest Tube -20 cm Wall Suction
[NURTAD0001]
CONTINUOUS, Starting today For Until specified,
Routine
Location: Right Pleura
Position: N/A - Single Location
Drainage Options: -20 cm wall suction
Site Assessment Frequency: EVERY 8 HOURS
Care Frequency: SEE COMMENTS
Wash With:
Primary Dressing:
Secondary Dressing:
Secondary dressing change every 24 hours
postoperatively, then every 24 hours or as needed.
No showering for 48 hours following chest tube
removal., Post-Op/Phase II
Maintain Chest Tube to Water Seal
[NURTAD0001]
CONTINUOUS, Starting today For Until specified,
Routine
Location: Right Pleura
Position: N/A - Single Location
Drainage Options: To water seal
Site Assessment Frequency: EVERY 8 HOURS
Care Frequency: SEE COMMENTS
Wash With:
Primary Dressing:
Secondary Dressing:
Secondary dressing change every 24 hours
postoperatively, then every 24 hours or as needed.
No showering for 48 hours following chest tube
removal., Post-Op/Phase II
Chest Tube to Portable Suction During
Ambulation or When Patient Off Floor
[NURTAD0046]
CONTINUOUS, Starting today For Until specified,
Chest tube to portable suction during ambulation or
when patient off floor, Post-Op/Phase II
Nasogastric Tube Care [91219]
Maintain Nasogastric Tube [NURTAD0014] CONTINUOUS, Starting today, Routine
Options: Low, Continuous Suction
Flush with: Normal saline (30cc)
Flush Frequency: EVERY 4 HOURS
Clamp NG Tube:
Check Residual:
Does this need to be inserted/placed?
Device Status: Ready For Use
Flush sump port with 30mL of air every 4 hours. DO
NOT administer medication via nasogastric tube.,
Post-Op/Phase II
Do Not Reposition/Manipulate Nasogastric Tube
[NURTAD0046]
CONTINUOUS, Starting today, Post-Op/Phase II
Do Not Use Antireflux Valve [NURTAD0046] CONTINUOUS, Starting today, Post-Op/Phase II
Drain/Tube Care [91220]
Page 11 of 22
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Maintain Drain [NURTAD0003] CONTINUOUS, Starting today, Routine
Type: Closed Suction (Jackson-Pratt)
Site: Head/Neck
Location: Left
Drainage Options: Bulb
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For: Other (Comment)
Dressing Change Frequency: SEE COMMENTS
Dressing Type: Gauze
Assess drain site every 8 hours. Dressing change 24
hours postoperatively, then every 48 hours and as
needed. Split sterile 4x4 Dry Gauze, Sterile 4x4 Dry
Gauze. Strip every 4 hours for duration of drain.,
Post-Op/Phase II
Maintain Drain [NURTAD0003] CONTINUOUS, Routine
Type: Closed Suction (Jackson-Pratt)
Site: Chest
Location: Left
Drainage Options: Bulb
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For: Other (Comment)
Dressing Change Frequency: SEE COMMENTS
Dressing Type: Gauze
Assess drain site every 8 hours. Dressing change 24
hours postoperatively, then every 48 hours and as
needed. Split sterile 4x4 Dry Gauze, Sterile 4x4 Dry
Gauze. Strip every 4 hours for duration of drain.,
Post-Op/Phase II
Maintain Jejunostomy Tube [NURTAD0012] CONTINUOUS, Starting today, Routine
Tube Indications: Drainage
Drainage Options: Dependent Drainage
Flush With: Water (warm water)
Flush Volume (mL): 30 mL
Flush Frequency: SEE COMMENTS (in addition to
meds)
Site Assessment Frequency: EVERY 4 HOURS
Care Frequency: SEE COMMENTS
Wash With: Other (Comment)
Primary Dressing: Other (Comment) (Split Sterile 4x4
Dry Gauze.)
Secondary Dressing: Other (Comment) (Sterile 4x4
Dry Gauze)
Flush every 4 hours with 30mL water. Also flush
before and after tube feeds.
NO CRUSHED MEDICATIONS (liquid only) unless
discussed with MD.
Dressing change 24 hours postoperatively, then every
24 hours and as needed., Post-Op/Phase II
Intake and Output [91221]
Measure Intake And Output [NURMON0005] EVERY 2 HOURS, Starting today, Routine, Post-
Op/Phase II
Page 12 of 22
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Measure Intake And Output [NURMON0005] SEE COMMENTS, Starting today For Until specified,
Routine, Every 2 hours times 4, then every 4 hours,
Post-Op/Phase II
Measure Drain Output [NURTAD0005] EVERY 8 HOURS, Starting today, Routine, Post-
Op/Phase II
Non-Categorized Patient Care Orders [91222]
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With?
Weigh when?
Post-Op/Phase II
Measure Weight - On Admission [NURMON0015] ONCE, Starting today For 1 Occurrences, Routine
Weigh With?
Weigh when?
Post-Op/Phase II
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: Indwelling Single Lumen
Indication for Placement: Postoperative Requirements
of Specific Procedure
Initiate Urinary Catheter Removal Protocol? (NP/PA
Must Select "No"):
Details: To Dependent Drainage
Does this need to be inserted/placed?
Post-Op/Phase II
Please Begin J Tube and Drain Care Teaching to
the Patient and Their Family Beginning on POD
#1 [NURCOM0022]
ONCE For 1 Occurrences, Post-Op/Phase II
Contingency Parameters [91223]
Page 13 of 22
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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):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 60
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
If pain score >:
Pulse Oximetry < (%): 88% Patient put on non-
rebreather face mask at 100% oxygen
If urine output < (mL): 30 mL/hour for 2 consecutive
hours
Other: Chest Tube/Drain Output Greater Than 200 mL
In 1 Hour,Patient requires greater than 4L/min oxygen
per nasal cannula to keep saturation greater than or
equal to 90%,Patient needs 60% oxygen,Serum
magnesium less than 1.0 mg/dL,Serum potassium
less than 3.0 or greater than 5.0 mmol/L,If JP drain
does not hold suction
Post-Op/Phase II
Intravenous Therapy
Premedications for Needle Insertion [106327]
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.
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Post-Op/Phase II
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
Post-Op/Phase II
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.
Post-Op/Phase II
IV Fluids (Single Response) [91225]
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS, Post-Op/Phase II
Page 14 of 22
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dextrose 5%-lactated ringers infusion [44897] at 125 mL/hr, Intravenous, CONTINUOUS, Post-
Op/Phase II
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L
infusion [44910]
at 150 mL/hr, Intravenous, CONTINUOUS, Post-
Op/Phase II
Medications - Anti-infectives
First Line (Single Response) [146215]
cefoxitin (MEFOXIN) intraVENOUS - Note: For
patients who are 40-120 kg [800022]
2 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
cefoxitin (MEFOXIN) intraVENOUS - Note: For
patients who are greater than 120 kg [800022]
3 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
MRSA/Documented MRSA History (Single Response) [146229]
Patients who are 40-120 kg [228416]
cefoxitin (MEFOXIN) intraVENOUS [800022] 2 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Patients who are greater than 120 kg [228418]
cefoxitin (MEFOXIN) intraVENOUS [800022] 3 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Immediate/Severe Reaction to Penicillin or Known Cephalosporin Allergies (Single Response) [146251]
Patients who are 40-160 kg [228734]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Patients who are greater than 160 kg [228736]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Medications - General
Analgesics - Acetaminophen - As Needed [91227]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Jejunostomy Tube, EVERY 6 HOURS PRN
Starting 12/11/17, pain
See Pain management Algorithm for the Selection of
As-needed Analgesics.
Post-Op/Phase II
Analgesics - NSAIDs - Scheduled [206177]
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 For 72 Hours,
Post-Op/Phase II
Anti-emetics [91228]
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 24 HOURS PRN,
nausea/vomiting, Administer first line, Post-Op/Phase
II
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting, Administer second line when there is
no response to first line antiemetic within 30 minutes.
If ordered IV: push slowly, max rate 5 mg/minute.
Post-Op/Phase II
Bowel Management [91229]
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docusate sodium (COLACE) soln [74449] 100 mg, Jejunostomy Tube, 2 X DAILY Starting
12/11/17
Begin POD 3, follow by 20 mL water flush.
Post-Op/Phase II
sennosides (SENNA) 8.8 MG/5ML syrup [50880] 10 mL, Jejunostomy Tube, 2 X DAILY Starting
12/11/17
For administration with docusate sodium solution.
Post-Op/Phase II
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal, 1 X DAILY PRN, constipation,
Constipation or when there is a need for immediate
laxation, Post-Op/Phase II
Beta Blockers [146270]
metoprolol (LOPRESSOR) injection [800274] 5 mg, Intravenous, EVERY 6 HOURS
Hold dose if heart rate < 60 bpm or systolic blood
pressure < 90 mmHg
Flushes [91233]
sodium chloride 0.9% flush 10 mL injection
[785055]
Flush, PRN, flush/line care
Flush per VAD guidelines
Post-Op/Phase II
sodium chloride 0.9 % infusion [64367] at 4 mL/hr, Other, CONTINUOUS
Per intraflow for arterial line and central venous
pressure distal port
Post-Op/Phase II
Gastric [91234]
pantoprazole (PROTONIX) injection [800119] 40 mg, Intravenous, 1 X DAILY, Post-Op/Phase II
Potassium Supplementation (Single Response) [87702]
potassium chloride 20 mEq/ 50 mL bag
CENTRAL LINE ONLY [46256]
20 mEq, Intravenous, PRN, Potassium
Supplementation
For potassium level between 3.8 - 4.0 mmol/L give 20
mEq x1
For potassium level between 3.5 - 3.7 mmol/L give 20
mEq x2
For potassium level between 3.2 - 3.4 mmol/L give 20
mEq x3
for 60 Minutes, Post-Op/Phase II
potassium chloride 10 mEq/100 mL bag - NOTE:
Order for patients with renal impairment (CrCl
less than 30 mL/min) [46253]
10 mEq, Intravenous, PRN - NOTIFY PHARMACY
WHEN NEEDED, potassium supplementation - See
Administration Instructions
For potassium level between 3.5 - 3.7 mmol/L give 10
mEq x1
For potassium level between 3.2 - 3.4 mmol/L give 10
mEq x2
Order for patients with renal impairment (CrCl less
than 30 mL/min)
for 60 Minutes, Post-Op/Phase II
Magnesium Supplementation (Single Response) [87703]
Page 16 of 22
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Magnesium Supplemental Scale [950039] PRN - NOTIFY PHARMACY WHEN NEEDED, PRN
comment: magnesium supplementation - See
Administration Instructions
Non-cardiac patients: For serum magnesium 1.6-1.8
mg/dL - do not replace
Cardiac patients: For serum magnesium 1.6-1.8
mg/dL give 0.05 g/kg IV x1
For serum magnesium 1.0-1.5 mg/dL give 0.1 g/kg IV
x1
For serum magnesium less than 1 mg/dL give 0.15
g/kg IV x1
Administer each 2 gram bag over 3 hours at a
frequency of one bag every 4 hours.
Maximum 6 grams per replacement dose
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
Post-Op/Phase II
Magnesium Supplemental Scale - NOTE: Order in
patients with RENAL impairment (CrCl <30
mL/min) [950039]
PRN - NOTIFY PHARMACY WHEN NEEDED, PRN
comment: magnesium supplementation - See
Administration Instructions
Non-cardiac patients: For serum magnesium 1.6-1.8
mg/dL - do not replace
Cardiac patients: For serum magnesium 1.6-1.8
mg/dL give 0.025 g/kg IV x1
For serum magnesium 1.0-1.5 mg/dL give 0.05 g/kg IV
x1
For serum magnesium less than 1 mg/dL give 0.075
g/kg IV x1
Administer each 2 gram bag over 3 hours at a
frequency of one bag every 4 hours.
Maximum 6 grams per replacement dose
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
NOTE: Order in patients with RENAL impairment
(CrCl < 30 mL/min)
Post-Op/Phase II
Phosphate SODIUM (Single Response) [193032]
phosphate-potassium & sodium (PHOS-NAK) oral
packet - For normal renal function [112317]
2 packet, Oral, PRN, phosphate supplementation -
See Admin Instructions
For serum phosphate 1.6 - 2.4 mg/dL, give 2 packets
every 4 hours while awake x 3 doses;
For serum phosphate 1.0 - 1.5 mg/dL, give 2 packets
every 4 hours while awake x 4 doses
For serum phosphate less than 1.0 mg/dL, call
provider for IV dosing.
Post-Op/Phase II
phosphorus (K-PHOS NEUTRAL) tab - For renal
dysfunction [45503]
1 tab, Oral, PRN, phosphate supplementation - See
Admin Instructions
For serum phosphate 1.6 - 2.4 mg/dL give 1 tablet
every 4 h while awake x 3 doses
For serum phosphate 1.0 - 1.5 mg/dL give 1 tablet
every 4 h while awake x 4 doses
For serum phosphate less than 1.0 mg/dL, call
provider
Post-Op/Phase II
Page 17 of 22
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Non-Categorized Medications [121022]
lidocaine (STERILE UROJECT) 2 % gel [785049] Topical, PRN For 1 Doses, PRN - Bedside
Bronchoscopes
Doses to be directed by provider
Post-Op/Phase II
lidocaine 1 % vial [39034] 10 mL, ONCE PRN For 1 Doses, PRN-Bedside
Bronchoscopes
Doses to be directed by provider
Post-Op/Phase II
Bronchodilators (Single Response) [146272]
ipratropium-albuterol (DUO-NEB) 0.5-2.5 mg/3
mL neb soln [67220]
3 mL, Nebulization, EVERY 4 HOURS PRN, dyspnea,
Post-Op/Phase II
albuterol 2.5 mg/0.5 mL neb soln [34315] 2.5 mg, Nebulization, EVERY 2 HOURS PRN,
dyspnea, wheezing, shortness of breath, Post-
Op/Phase II
ipratropium (ATROVENT) neb soln - Note: For
patients with COPD/asthma [47883]
500 mcg, Nebulization, EVERY 4 HOURS PRN,
dyspnea
Note: For patients with COPD/asthma
Post-Op/Phase II
Laboratory
PACU [91237]
CBC WITHOUT DIFFERENTIAL [HEMO] 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?
PACU
BUN [BUN] 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?
PACU
MAGNESIUM [MAG] 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?
PACU
ELECTROLYTES [LYTE] 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?
PACU
CREATININE [CRET] 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?
PACU
CALCIUM [CA] 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?
PACU
GLUCOSE [GLU] 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?
PACU
Page 18 of 22
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PHOSPHATE [PHOS] 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?
PACU
Postoperative Day 1 [91238]
CBC WITHOUT DIFFERENTIAL [HEMO] NEXT AM, Starting tomorrow For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
BUN [BUN] SPECIFIC TIME, Starting tomorrow at 5:00 AM For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
GLUCOSE [GLU] SPECIFIC TIME, Starting tomorrow at 5:00 AM For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
CREATININE [CRET] SPECIFIC TIME, Starting tomorrow at 5:00 AM For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
ELECTROLYTES [LYTE] SPECIFIC TIME, Starting tomorrow at 5:00 AM For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
Conditional Labs [90310]
MAGNESIUM [MAG] CONDITIONAL, Starting today For 4 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw AM Following
completion of infusion. Daily while patient on diuretics,
if patient experiences arrhythmias.
Post-Op/Phase II
POTASSIUM [K] CONDITIONAL, Starting today For 4 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw 1 hour after IV
replacement and 4 hours after oral replacement. Daily
while patient on diuretics, if patient experiences
arrhythmias.
Post-Op/Phase II
Page 19 of 22
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PHOSPHATE [PHOS] CONDITIONAL, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw 4 hours after last
phosphate dose, Daily while patient on diuretics, if
patient experiences arrhythmias
Post-Op/Phase II
Diagnostic Tests and Imaging
Radiology [91242]
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, STAT
Current signs and symptoms? postoperative
esophageal surgery
What specific question(s) would you like answered by
this exam? postoperative esophageal surgery
Relevant recent/past history? esophageal disorder
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
On arrival to PACU, if not done in Operating Room,
PACU
X-RAY CHEST AP VIEW [R71010] ONCE-ON SPECIFIC DATE, Starting tomorrow at
5:00 AM For 1 Occurrences, Routine
Current signs and symptoms? postoperative
esophageal surgery
What specific question(s) would you like answered by
this exam? postoperative esophageal surgery
Relevant recent/past history? esophageal disorder
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Post-Op/Phase II
Consults
Consults [91244]
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
Page 20 of 22
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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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):
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, Starting tomorrow For 1 Occurrences, Routine
Reason for Occupational Therapy Consult:
Post-Op/Phase II
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting tomorrow For 1 Occurrences, Routine
Reason for Physical Therapy Consult:
Post-Op/Phase II
Consult Nutrition (Inpatient) [CON0043] ONCE, Starting tomorrow For 1 Occurrences, Routine
Reason for Consult:
Delegate to Initiate and Manage Tube Feeding:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
Can this consult be done via video?
Post-Op/Phase II
Page 21 of 22
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 10:30:28 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Respiratory Therapy per Protocol [RT0035] Routine
Protocol Type:
Post-Op/Phase II
BestPractice
No Hospital Problems have yet been identified [107363]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing., Post-Op/Phase II
Page 22 of 22
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 10:30:28 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org