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IP – Impella – Ventricular Assist Device – Adult – Postopertaive [2954]

IP – Impella – Ventricular Assist Device – Adult – Postopertaive [2954] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Cardiology/CT Surgery


IP - Impella - Ventricular Assist Device - Adult - Postoperative [2954]
Intended for Adult Patients Only
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 [127581]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: CARDIOLOGY
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:
Page 1 of 10
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
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Post-Op/Phase II
Admission Status [127580]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: CARDIOLOGY
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) [150164]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
High VTE Risk with Low Bleed Risk [206298]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 HOURS
Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
High VTE Risk with High Bleed Risk (Single Response)
[129757]
Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Post-Op/Phase II
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: Receiving Therapeutic
Anticoagulation
VTE Prophylaxis (Single Response) [131949]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
High VTE Risk with Low Bleed Risk [206296]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 HOURS
Page 2 of 10
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2016CCKM@uwhealth.org

Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? 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
High VTE Risk with High Bleed Risk (Single Response)
[129757]
Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Post-Op/Phase II
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: Receiving Therapeutic
Anticoagulation
Patient Care Orders
Vital Signs [91115]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Post device implantation: after 15 minutes then every hour
until stable then every 2 hours.
Post device removal: every 15 minutes times 4, then every 30
minutes times 4, then every hour times 4, then every 2 hours.,
Post-Op/Phase II
Patient Monitoring [90000]
Measure Arterial Line - Continuous [NURMON0019] CONTINUOUS, Starting today, Routine
BP Source: Invasive (Arterial Line)
BP Location:
BP Position:
BP Restrictions:
Post-Op/Phase II
Measure Hemodynamic Parameters [NURMON0023] SEE COMMENTS, Starting today, Routine
Pulmonary Artery Systolic Pressure (mmHg): Other
(Comment)
Pulmonary Artery Diastolic Pressure (mmHg): Other
(Comment)
Pulmonary Artery Mean Pressure (mmHg): Other (Comment)
Pulmonary Artery Wedge Pressure (mmHg):
Central Venous Pressure (mmHg):
Central Venous Pressure (mmH2O):
Cardiac Output: Every 4 hours
Cardiac Output Method: Thermodilution
Cardiac Index: Every 4 hours
Systemic Vascular Resistance: Every 4 hours
Pulmonary Vascular Resistance: Every 4 hours
Pulmonary Vascular Resistance Index:
Stroke Volume (mL/beat):
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2016CCKM@uwhealth.org

Stroke Volume Index:
Systemic Vascular Resistance Index:
Left Cardiac Work Index:
Right Cardiac Work Index:
Left Ventricular Stroke Work Index:
Right Ventricular Stroke Work Index:
Pulmonary Capillary Wedge Pressure (mmHg):
Measure with FloTrac? No
Measure pulmonary artery systolic pressure, pulmonary
artery diastolic pressure and pulmonary artery mean pressure
CONTINUOUS. Measure cardiac output, cardiac index,
systemic vascular resistance, and pulmonary vascular
resistance EVERY 4 HOURS., Post-Op/Phase II
Neurovascular Checks [NURMON0045] EVERY 1 HOUR, Starting today, Routine, Post-Op/Phase II
Assess Neurologic Status [NURMON0006] EVERY 1 HOUR, Starting today, Routine, Post-Op/Phase II
Measure Central Venous Pressure - Every 4 Hours
[NURMON0002]
EVERY 4 HOURS, Starting today, Routine, Post-Op/Phase II
Measure Central Venous Pressure - Continuous
[NURMON0002]
CONTINUOUS, Starting today, Routine, Post-Op/Phase II
Glucose, POC [IPGLUCOSE] EVERY 6 HRS IF NPO/ CONT. TUBE FEEDING/ OR TPN,
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?
Activity [91117]
Bedrest with Log Roll Precautions [NURACT0008] CONTINUOUS, Starting today For Until specified, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: strict logroll
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
Reposition [NURACT0011] SEE COMMENTS, Starting today, Reposition every 2 hours.,
Post-Op/Phase II
No Waist Flexion Greater than 30 Degrees
[NURACT0011]
CONTINUOUS, Starting today, Post-Op/Phase II
Apply Brace/Splint, Lower Body - Knee Immobilizer
[NURTRT0009]
CONTINUOUS, Starting today, Routine, If ordering a Bledsoe
Boot or Hip Abduction Brace, please contact the cast room
technician at 265-0746.
Type: Knee Immobilizer
Left/Right/Bilateral?
Wearing schedule:
Post-Op/Phase II
Elevate Head of bed to 15 degress [NURACT0002] Equal to (degrees):
Greater than (degrees):
Less than (degrees): 15
Other options:
Routine, CONTINUOUS, Starting today, Post-Op/Phase II
Nutrition [90002]
NPO Except Medications [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: NPO except Medications
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2016CCKM@uwhealth.org

Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
Respiratory [91119]
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today, Routine, Post-Op/Phase II
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
Post-Op/Phase II
Suction Airway [NURTAD0017] PRN, Starting today, Routine
Location: Tracheal
Suction endotracheal tube as needed for removal of
secretions., Post-Op/Phase II
Mechanical Ventilation - Adult [117146]
Provide Manual Resuscitator at Bedside [RT0039] CONTINUOUS, Routine, Post-Op/Phase II
Mechanical Ventilation [RT0028] CONTINUOUS, Routine, For ADULT patients order
chlorihexidene gluconate (PERIDEX) 0.12% soln 15 mL to
swab oral cavity 2x daily while on ventilation.
Ventilator Management: Adult Vent Management Protocol
Wean: Per Cardiothoracic Surgery Protocol
Mode:
Set Rate/Min:
Tidal Volume Multiplier: 6
PEEP (cmH2O):
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Pressure Support:
Pressure Control:
P High (cmH20):
P Low (PEEP) (cmH20):
T High (sec):
T Low (T PEEP) (sec):
PS above P High (cmH2O):
PS above PEEP (cmH2O):
NAVA Level (µV):
Tidal Volume (mL) (4-6 mL/kg of Ideal Body Weight for
neonatal):
Refer to "Cardiothoracic Surgery Extubation Protocol" for
ventilator weaning, Post-Op/Phase II
chlorhexidine (PERIDEX) 0.12 % soln MULTIDOSE
[792004]
15 mL, Mouth/Throat, 2 X DAILY Starting today
Use to swab oral cavity. D/C when patient no longer on
ventilation.
Post-Op/Phase II
Respiratory Therapy per Protocol [RT0035] CONTINUOUS, Starting today, Routine
Protocol Type:
Post extubation, Post-Op/Phase II
Cough And Deep Breathe [NURTRT0019] EVERY 1 HOUR, Starting today, Routine, Post extubation.,
Post-Op/Phase II
Incentive Spirometry [NURTRT0018] EVERY 1 HOUR, Starting today, Routine, Post extubation.,
Post-Op/Phase II
Ventricular Assist Device Care [91120]
Ventricular Assist Device Checks - Impella
[NURVENT0009]
CONTINUOUS, Starting today For Until specified, Routine
Goal Flow (L/min):
Performance Level (P0 - P9):
Record Device Flow (Liters/Minute): Every hour for 24 hours,
then every 2 hours
Record Device Performance Level (P2-P9): Every hour for 24
hours, then every 2 hours
Record Device Motor Current Level (Amps): Every hour for 24
Page 5 of 10
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
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hours, then every 2 hours
Record Device Placement: Every hour for 24 hours, then
every 2 hours
Record Device Purge Solution Infusion Rate (mL/Hour):
Every hour for 24 hours, then every 2 hours
Record Device Purge Pressure (mmHg): Every hour for 24
hours, then every 2 hours
Post-Op/Phase II
Ventricular Assist Device Care [NURVENT0010] CONTINUOUS, Starting today, Routine, Post-Op/Phase II
Ventricular Assist Device Emergency Care
[NURVENT0011]
CONTINUOUS, Starting today, Routine, Post-Op/Phase II
Change Impella Infusion Tubing [NURVENT0017] SEE COMMENTS, Starting tomorrow, Every 24 hours., Post-
Op/Phase II
Device Weaning (Single Response) [91121]
Rapid Weaning [NURTRT0048] SEE COMMENTS, Starting today, Decrease pump
performance in 2-level steps at intervals of several minutes.
Do not decrease performance level below P2 as long as
pump is in the ventricle. When performance level has been
reduced to P2, then maintain patient on this level of support
for at least 10 minutes. Call Cath Lab Attending Physician to
patient room for device removal., Post-Op/Phase II
Slow Weaning [NURTRT0048] SEE COMMENTS, Starting today, Decrease pump
performance in 2-level steps at intervals over 2 to 3 hours.
Do not decrease performance level below P2 as long as
pump is in the ventricle. When performance level has been
reduced to P2, then maintain patient on this level of support
for 2 to 3 hours. Call Cath Lab Attending Physician to patient
room for device removal., Post-Op/Phase II
Wound/Procedure Site Care [91123]
Refer to "Vascular Access (Venous and Arterial) Policy
8.18" for Groin Cannulation Site Care [NURWND0018]
SEE COMMENTS, Starting today, Refer to "Vascular Access
(Venous and Arterial) Policy 8.18" for Groin Cannulation Site
Care., Post-Op/Phase II
Assess Groin Site [NURMON0036] SEE COMMENTS, Starting today For Until specified, Routine,
Every 15 minutes times 4, then every 30 minutes times 4,
then every hour times 4, then every 2 hours., Post-Op/Phase
II
Intake and Output [91124]
Measure Intake And Output [NURMON0005] EVERY 1 HOUR, Starting today, Routine, Post-Op/Phase II
Non-Categorized Patient Care Orders [91125]
Refer to "Diabetes Management Supplemental Order Set" for all glucose monitoring and insulin therapy.
Refer to "Insulin Infusion - Adult Supplemental Order Set" for patients on insulin infusion.
Measure Weight [NURMON0015] 1X DAILY, Starting today, 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:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Post-Op/Phase II
Contingency Parameters [91126]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg):
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If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 90
If urine output < (mL):
Other: Hemoglobin decreases by more than 2 g/dL from
baseline,Platelet count less than 100 k/uL,Platelet count
decreases by more than 1/3 of baseline value,Any signs of
bleeding,Any deterioration in neurological status,Mean arterial
pressure less than 60 or greater than 90 mmHg
Post-Op/Phase II
Notify Cardiology Fellow [NURCOM0022] CONTINUOUS, Starting today For Until specified, Activated
Clotting Time less than 120 or greater than 220 seconds;
Activated partial thromboplastin time less than 36 or greater
than 66 seconds; Baseline international normalized ratio
(INR) is greater than 1.2; Baseline activated partial
thromboplastin time is greater than 34 seconds; Ventricular
Assist Device failure; Change of Ventricular Assist Device
flows greater than 1 L/min; Ventricular Assist Device flow rate
less than *** L/min; Change in Ventricular Assist Device
Motor Current Level; Change in cardiac rhythm ; Ventricular
Assist Device Purge Pressure Alarm unresponsive to titration
of purge solution or requiring drip rates less than 4 or greater
than 20 mL/hour; Patient not meeting goal flow., Post-
Op/Phase II
Notify Cath Lab Attending for Changes in Catheter
Position (Positioning Alarm) [NURCOM0022]
CONTINUOUS, Starting today For Until specified, 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 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
Post-Op/Phase II
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
Page 7 of 10
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
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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. Choice of medication should be
based on patient’s previous experience/preference, history of
lidocaine allergy and ease of access
Post-Op/Phase II
IV Fluids [91128]
sodium chloride 0.9% infusion [64367] at 5 mL/hr, Intravenous, CONTINUOUS
To central venous port of the pulmonary artery catheter
Post-Op/Phase II
sodium chloride 0.9% BOLUS [730003] 500 mL, Intravenous, CONTINUOUS
Pressure bag 300 mmHg to the peripheral Ventricular Assist
Device (PVAD).
Post-Op/Phase II
Medications
Analgesics [90016]
FENTanyl (50 mcg/mL) 1250 mcg in 25 mL infusion
syringe [785178]
Intravenous, CONTINUOUS, Post-Op/Phase II
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain/fever,
temperature greater than 38.5 degrees Celsius, Post-
Op/Phase II
acetaMINOPHEN (TYLENOL) suppository [43994] 650 mg, Rectal, EVERY 4 HOURS PRN, pain/fever,
temperature greater than 38.5 degrees Celsius, Post-
Op/Phase II
Ventricular Assist Device Purge Solution [91130]
(IMPELLA VAD) heparin 25,000 units in dextrose 5%
500 mL infusion [794035]
Other, CONTINUOUS
Administer Impella Motor purge solution via the Impella
Controller.
Post-Op/Phase II
Activated Clotting Time (ACT) [91131]
ACTIVATED CLOTTING TIME, POC [HCACTPOC] CONDITIONAL - RN COLLECT, Starting today, Routine
If Conditional, What Condition? Every hour until 2 consecutive
readings within goal, then every 2 hours.
Goal range *** to *** seconds., Post-Op/Phase II
ACTIVATED CLOTTING TIME, POC [HCACTPOC] CONDITIONAL - RN COLLECT For 4 Days, Routine
If Conditional, What Condition? Every hour for postoperative
patients who have received fresh frozen plasma (FFP),
platelets or cryoprecipitate.
Post-Op/Phase II
Anticoagulants [127583]
heparin 1000 Units/mL injection CUSTOM [45303] 70 Units/kg, Intravenous, ONCE For 1 Doses
Maximum dose 7000 units
Post-Op/Phase II
heparin 25,000 units in dextrose 5% 500 mL infusion
[51597]
5-20 Units/kg/hr, Intravenous, CONTINUOUS
Start heparin infusion at 15 units/kg/hr when ACT *** seconds
AND postoperative bleeding is controlled.
Maximum weight for dose calculations is 100 kg.
If ACT is less than 140 seconds: increase rate by 5
units/kg/hr
If ACT 140-159 seconds: increase rate by 3 units/kg/hr
If ACT 160-179 seconds: no change
If ACT 180-199 seconds: decrease rate by 3 units/kg/hr
If ACT is 200 seconds or greater: decrease rate by 5
units/kg/hr
Page 8 of 10
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2016CCKM@uwhealth.org

Post-Op/Phase II
Anti-anxiety [90023]
midazolam (VERSED) injection RANGE [750056] 1-2 mg, Intravenous, EVERY 6 HOURS PRN, agitation or
anxiety while on ventilator, Post-Op/Phase II
midazolam (VERSED) 100 mg in dextrose 5 % 100 mL
infusion [700236]
1-10 mg/hr, Intravenous, CONTINUOUS, Post-Op/Phase II
Gastric (Single Response) [90022]
pantoprazole (PROTONIX) injection [800119] 40 mg, Intravenous, 1 X DAILY, Post-Op/Phase II
pantoprazole (PROTONIX) susp [780113] 40 mg, Oral, 1 X DAILY, Post-Op/Phase II
Potassium Supplementation (Single Response) [89899]
potassium chloride 20 mEq/ 100 mL bag [46255] 20 mEq, Intravenous, PRN, potassium supplementation - See
Admin Instructions
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: Renal
dosing [46253]
10 mEq, Intravenous, PRN, 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
for 60 Minutes
NOTE: Renal dosing
Post-Op/Phase II
Magnesium Supplementation (Single Response) [89900]
Magnesium Supplemental Scale [950039] PRN - NOTIFY PHARMACY WHEN NEEDED, magnesium
supplementation - See Administation Instructions
For serum magnesium 1.6-1.8 mg/dL give 0.05 g/kg IV x1
over 12 hours
For serum magnesium 1.0-1.5 mg/dL give 0.1 g/kg IV x1 over
24 hours
For serum magnesium less than 1 mg/dL give 0.15 g/kg IV x1
over 24 hours
Post-Op/Phase II
Magnesium Supplemental Scale - NOTE: Order for
RENAL Dosing [950039]
PRN - NOTIFY PHARMACY WHEN NEEDED, magnesium
supplementation - See Administation Instructions
For serum magnesium 1.6-1.8 mg/dL give 0.025 g/kg IV x1
over 12 hours
For serum magnesium 1.0-1.5 mg/dL give 0.05 g/kg IV x1
over 24 hours
For serum magnesium less than 1 mg/dL give 0.075 g/kg IV
x1 over 24 hours
NOTE: Order for RENAL Dosing
Post-Op/Phase II
Laboratory
Prior to Heparin Administration [91134]
PROTHROMBIN TIME/INR [PT] CONDITIONAL - RN COLLECT For 4 Days, STAT
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? Prior to heparin administration
Post-Op/Phase II
HEMOGLOBIN [HGB] CONDITIONAL - RN COLLECT For 4 Days, STAT
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? Stat baseline prior to heparin
administration; and every other day starting in 48 hours.
Post-Op/Phase II
PLATELET COUNT [PLT] CONDITIONAL - RN COLLECT For 4 Days, STAT
If add on test, what should lab do if unable to add test to
Page 9 of 10
Printed by LIND, JANNA S [JSL237] at 7/7/2016 9:51:46 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2016CCKM@uwhealth.org

previous specimen?
If Conditional, What Condition? Stat baseline prior to heparin
administration; and every other day, starting in 48 hours.
Post-Op/Phase II
Diagnostic Tests
Diagnostic Tests and Imaging [91136]
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? Postoperative Ventricular Assist Device placement
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Transport Method: Floor Determined/Entered
Upon arrival to ICU., Post-Op/Phase II
ECG - 12 Lead [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: CHEST PAIN
ECG - 12 Lead [EKG0008] PRN, STAT
Reason for exam:
Chest Pain or Rhythm Change
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 10 of 10
Printed by LIND, JANNA S [JSL237] at 7/7/2016 9:51:46 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2016CCKM@uwhealth.org