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/clinical/cckm-tools/content/order-sets/inpatient/cardiologyct-surgery/name-98412-en.cckm

201712341

page

100

UWHC,UWMF,

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

IP - Pacemaker/Defibrillator Implant - Adult - Postoperative [901]

IP - Pacemaker/Defibrillator Implant - Adult - Postoperative [901] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Cardiology/CT Surgery


IP - Pacemaker/Defibrillator Implant - Adult - Postoperative [901]
Admission Status
Level of Care (Single Response) [187516]
*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 [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 [88521]
Page 1 of 8
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: CARDIOVASCULAR
ELECTROPHYSIOLOGY
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:
Anticipated Discharge Date:
Post-Op/Phase II
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service: CARDIOVASCULAR
ELECTROPHYSIOLOGY
Post-Op/Phase II
Admission Status (Single Response) [146780]
Admit To Inpatient Status [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 Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Discharge Status [150833]
Confirmed Discharge Date/Time [ADT0013] Confirmed Discharge Date:
Confirmed Discharge Time:
Conditions for Discharge:
Provider to be Present at Discharge?
Patient Care Orders
Vital Signs [9657]
Page 2 of 8
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Vital Signs [NURMON0013] SEE COMMENTS, Starting today with First
Occurrence As Scheduled, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Assess every 15 minutes times 4, then every 30
minutes times 4, then every 1 hour times 4, then every
8 hours.
Activity [9658]
Apply Arm Sling [NURTRT0001] ONCE, Starting today For 1 Occurrences, Routine, If
ordering a Shoulder Immobilizer - Adult, please
contact the cast room technician at 265-0746.
Type: Simple Sling - Adult
Left/Right/Bilateral?
Wearing schedule: Continuous
Bedrest For 3 Hours [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: with bathroom privileges
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Bedrest for 3 hours, then up as tolerated prior to
discharge.
Bedrest For 4 Hours [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: with bathroom privileges
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Bedrest for 4 hours, then up as tolerated prior to
discharge.
Nutrition [9659]
Low Fat/Low Cholesterol/No Added Salt Diet
[NUT9999]
EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Heart Healthy
Heart Healthy Options: Custom
Sodium: NAS (2400 mg)
Fat:
Fluid Restriction Total mLs/24H (IV/PO):
Caffeine:
Bedside Meal Instructions:
Room Service Class:
Page 3 of 8
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:01:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Diabetes Meal Plan [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Diabetes
Bedside Meal Instructions:
Room Service Class:
Restrict Fluids - Must Indicate Restriction
[NUT9999]
EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Fluid Restriction
Fluid Restriction Total mLs/24H (IV/PO):
Bedside Meal Instructions:
Room Service Class:
Wound/Procedure Site Care [9660]
May Remove Dressing after 72 Hours
[NURWND0018]
ONCE, Starting today For 1 Occurrences, May
Remove Dressing after 72 Hours. Do NOT remove
Steri Strips.
Assess Incision Site [NURWND0018] SEE COMMENTS, Starting today For Until specified,
Assess every 15 minutes times 4, then every 30
minutes times 4, then every 1 hour times 4, then every
8 hours.
Intake and Output [9661]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today, Routine
Non-Categorized Patient Care Orders (Single Response) [9662]
For Pacemaker Dependent Patients ONLY
[117951]
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
CONTINUOUS, Starting today, Routine
Indication: Other (Comment Required)
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Functional Cardiac Defibrillator Present:
Do not place electrode pad for telemetry on left
chest.
Escort patient while off unit for x-ray
[NURCOM0052]
ONCE, Starting today For 1 Occurrences, Routine
Order Name (Only necessary if something other than
"Nursing Communcation" is preferred.):
Escort patient while off unit for x-ray.
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
INTERMITTENT (MAY REMOVE WHEN OFF
UNIT/BATHING), Routine
Indication: Other (Comment Required)
Notify Provider: Symptomatic Change in
Rhythm,Pacemaker Malfunction,Serious Arrhythmia
Functional Cardiac Defibrillator Present:
Do not place electrode pad for telemetry on left chest.
Contingency Parameters [9663]
Page 4 of 8
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:01:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 150
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Any delivered shocks from ICD or non-
capture/non-sensing
Intravenous Therapy
IV Fluids [12831]
sodium chloride 0.9 % infusion [64367] Intravenous, CONTINUOUS, Post-Op/Phase II
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Post-Op/Phase II
Surgical Prophylaxis
First Line (Single Response) [145946]
cefuroxime (ZINACEF) intraVENOUS - Note:
Patients who are 40-120 kg [800030]
1.5 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
cefuroxime (ZINACEF) intraVENOUS - Note:
Patients who are 121 kg and greater [800030]
3 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
MRSA/Documented MRSA History OR High Risk for MRSA (Implanted Device) (Single Response)
[145951]
Patients who are 40-120 kg [228653]
cefuroxime (ZINACEF) intraVENOUS [800030] 1.5 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS
[800084]
15 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Patients who are 121 kg and greater [228654]
cefuroxime (ZINACEF) intraVENOUS [800030] 3 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS
[800084]
15 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Patients with Immediate/Severe Reaction to Penicillin or Known Cephalosporin Allergies (Single
Response) [145947]
vancomycin (VANCOCIN) intraVENOUS [800084] 15 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Medications - General
Analgesics - Non-Opioid [12833]
acetaMINOPHEN (TYLENOL) tab RANGE
[750000]
325-650 mg, Oral, EVERY 4 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
Post-Op/Phase II
Page 5 of 8
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:01:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Analgesics - Opioid (Single Response) [99784]
hydrocodone-acetaMINOPHEN (NORCO) 5-325
MG per tab RANGE [750021]
1-2 tab, Oral, EVERY 4 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
Post-Op/Phase II
oxycodone-acetaMINOPHEN (PERCOCET)
5-325 MG per tab RANGE [750033]
1-2 tab, Oral, EVERY 4 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
Post-Op/Phase II
Anti-emetics [186192]
ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
4 mg, Oral, EVERY 24 HOURS PRN,
nausea/vomiting, Post-Op/Phase II
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 24 HOURS PRN,
nausea/vomiting, If unable to take orally., Post-
Op/Phase II
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [9664]
X-RAY CHEST AP VIEW - Next Available
[R71010]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms? Routine S/P device
implant
What specific question(s) would you like answered by
this exam? Rule out pneumothorax
Relevant recent/past history? S/P generator implant
and lead system
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Patient to not raise affected arm over shoulder level.
X-Ray Chest PA & LAT Views [R71020] ONCE-ON SPECIFIC DATE, Starting today at 9:00
PM For 1 Occurrences, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? Routine S/P device
implant
What specific question(s) would you like answered by
this exam? Rule out pneumothorax
Relevant recent/past history? S/P generator implant
and lead system
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Instruct patient to move arm out of x-ray field but do
NOT raise affected arm over shoulder level.
Page 6 of 8
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:01:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

ECG - 12 Lead [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
Disclaimer for University Hospital Only: A Stat status
for an ECG is in reference to the timing of the ECG.
The goal is to perform a STAT ECG within 10 minutes
of the order being placed. It is the responsibility of the
ordering provider to review the STAT ECGs. All ECGs
(stat or routine) will be formally reviewed within one
business day.
ECG - 12 Lead [EKG0008] ONCE, Starting tomorrow For 1 Occurrences, Routine
Reason for exam: Other (enter comments)
Comment:
Disclaimer for University Hospital Only: A Stat status
for an ECG is in reference to the timing of the ECG.
The goal is to perform a STAT ECG within 10 minutes
of the order being placed. It is the responsibility of the
ordering provider to review the STAT ECGs. All ECGs
(stat or routine) will be formally reviewed within one
business day.
Post device implant
Laboratory
Draw in AM [9665]
HEMOGLOBIN [HGB] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
BUN [BUN] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
CREATININE [CRET] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
POTASSIUM [K] NEXT 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?
MAGNESIUM [MAG] NEXT AM, 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?
B-TYPE NATRIURETIC PEPTIDE [XBNP] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
PROTHROMBIN TIME/INR [PT] NEXT 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?
Non-Categorized Orders
Consults [145292]
Consult Pacemaker / ICD (Inpatient) [CARD0015] ONCE, Starting tomorrow For 1 Occurrences, Routine,
Consults are performed Monday-Friday 0700-1700.
For after hours, weekends and holidays, contact the
Cardiology Fellow on call.
Reason for consult:
Specify programming changes (if needed):
Type of device:
Device company:
Page 7 of 8
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:01:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult: Mobility
Training
Do not lift/exert pressure greater than 10 pounds or
raise arm over shoulder level.
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Occupational Therapy Consult: ADL
Training
Do not lift/exert pressure greater than 10 pounds or
raise arm over shoulder level.
Device Follow-Up (Single Response) [9666]
Schedule Appointment for 2 Week Wound Check
in Device Clinic [NURCOM0026]
Reason for Hospital Follow Up Appointment: Two
week wound check in device clinic
When do you want appointment: Schedule
appointment for 2 weeks from discharge
Which Clinic or Specialty: Device Clinic. Call 263-1530
to schedule appointment for wound check
Which Provider (Optional):
Education [9667]
Post-Defibrillator/Pacer Implant Teaching
[NURCOM0022]
ONCE, Starting today For 1 Occurrences, Patient
and/or family to view video and receive HFFY for
implanted device.
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 8 of 8
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:01:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org