/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-98423-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 – Ventricular Assist Device – Adult – Readmission [2578]

IP – Ventricular Assist Device – Adult – Readmission [2578] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Cardiology/CT Surgery


IP - Ventricular Assist Device - Adult - Readmission [2578]
for Adult Patients OnlyIntended
Admission Status
Transplant Cardiology if a on Cardiac Transplant service if a surgeon is admitting patient. Place on Admit
patient. heart failure attending is admitting
Level of Care (Single Response) [186484]
*An admit patient order has already been written, but the level of care at which the patient
should be placed still needs to be identified.
Place Patient on General Care [ADT0018] General Care, has already been signed. This order
will ensure that the patient is placed at the appropriate
level of care.
Place Patient on Intermediate Care (IMC)
[ADT0018]
Intermediate Care, has already been signed. This
order will ensure that the patient is placed at the
appropriate level of care.
Place Patient on Intensive Care (ICU) [ADT0018] Intensive Care, has already been signed. This order
will ensure that the patient is placed at the appropriate
level of care.
Admit to Inpatient (Single Response) [188296]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-
only surgery, or a previously-authorized inpatient
stay. Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status [7248]
Page 1 of 16
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Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-only
surgery, or a previously-authorized inpatient stay.
Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status (Single Response) [82665]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-only
surgery, or a previously-authorized inpatient stay.
Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Venous Thromboembolism (VTE) Prophylaxis
Anticoagulation Ventricular Assist Device Heparin -patient Order Set 4999 -to InRefer
VTE Prophylaxis (Single Response) [130119]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response) [129777]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
Page 2 of 16
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12/2017CCKM@uwhealth.org

heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE Risk [129757]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
VTE Prophylaxis (Single Response) [150156]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response) [129777]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE Risk [129757]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Patient Care Orders
Vital Signs [83880]
Vital Signs [NURMON0013] EVERY 4 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
While awake.
Page 3 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:30:01 AM
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Vital Signs [NURMON0013] EVERY 1 HOUR, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With?
Weigh when?
Patient Monitoring [144617]
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
CONTINUOUS, Starting today, Routine
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Functional Cardiac Defibrillator Present:
Activity [82541]
Ad Lib [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB: ad lib
AMBULATE:
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Bedrest [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: other (comment)
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Chair [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB:
AMBULATE:
CHAIR: other (comment)
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Page 4 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:30:01 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Ambulate [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB:
AMBULATE: other (comment)
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Nutrition [7422]
Strict NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: Strict NPO
Bedside Meal Instructions:
Room Service Class:
Sodium Controlled 2000 mg [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Sodium Controlled
Sodium: 2000 mg
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:
Heart Healthy - Custom [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Heart Healthy
Sodium: NAS (2400 mg)
Heart Healthy Options: Custom
Fat: Low Saturated Fat/Low Cholesterol
Fluid Restriction Total mLs/24H (IV/PO):
Caffeine: Low Caffeine
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): 2000 mL
Bedside Meal Instructions:
Room Service Class:
POC Glucose and Hypoglycemia Management [82551]
monitoring Supplemental" Order Sets for all glucose -Adult -to "Diabetes Management Refer
and insulin therapy.
BOTH orders when ordering. Select
Page 5 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:30:01 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Glucose, POC [IPGLUCOSE] BEFORE MEALS AND BEDTIME, Starting today,
Routine, Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia management
and monitoring as indicated in the Hypoglycemia
Management (Adult) panel.
If Conditional, What Condition?
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?
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)
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
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.
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.
Page 6 of 16
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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.
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.
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
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
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
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.
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting 12/15/17 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.
Respiratory [83881]
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:
Attempt to Wean Off Oxygen?
Pulse Oximetry [NURMON0009] EVERY 4 HOURS, Starting today, Routine
Pulse Oximetry [NURMON0009] EVERY 1 HOUR, Starting today For Until specified,
Routine
Wound/Procedure Site Care [194860]
Page 7 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:30:01 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Wound Care [NURWND0015] CONTINUOUS, Routine
Wound Type: Other (Comment)
Wound Site: Abdomen
Wound Location: Anterior
Assess Frequency: EVERY 24 HOURS
Care Frequency:
Wash With:
Irrigate/Rinse With: Do Not Irrigate
Apply (Must also enter separate medication order to
obtain drug):
Primary Dressing:
Secondary Dressing:
Follow dressing change process as outlined in the
Mechanical Circulatory Device Guideline.
Intake and Output [82550]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today, Routine
Ventricular Assist Device Care [94967]
Ventricular Assist Device Care [NURVENT0010] CONTINUOUS, Starting today, Routine
Ventricular Assist Device Emergency Care
[NURVENT0011]
CONTINUOUS, Starting today, Routine
Ventricular Assist Device Checks - HeartMate II
[NURVENT0001]
CONTINUOUS, Starting today, Routine
Mode: Fixed
Record Mode: Every hour for 24 hours, then every 2
hours while in ICU status, then every 4 hours while in
IMC / General Care status.
Fixed Speed (RPM):
Record Speed (RPM): Every hour for 24 hours, then
every 2 hours while on ICU status, then every 4 hours
while in IMC/general care status
Record Flow (Liters/Minutes): Every hour for 24 hours,
then every 2 hours while on ICU status, then every 4
hours while in IMC/general care status
Record Power (Watts): Every hour for 24 hours, then
every 2 hours while on ICU status, then every 4 hours
while in IMC/general care status
Record Pulsatility Index (PI): Every hour for 24 hours,
then every 2 hours while on ICU status, then every 4
hours while in IMC/general care status
Page 8 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:30:01 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

RIGHT Ventricular Assist Device Checks - TLC II
[NURVENT0004]
CONTINUOUS, Starting today For Until specified,
Routine
Select Mode:
Record Mode: Every hour for 24 hours, then every 2
hours while on ICU status, then every 4 hours while in
IMC/general care status
Low Beat Rate (BPM):
Beat Rate (BPM):
Record Beat Rate:
Record Low Rate:
Record Accumulator Pressure (mmHg):
Accumulator Pressure (mmHg):
Eject Time (msec):
Vacuum (mmHg):
Record Eject Time:
Record Flow (L/min): Every hour for 24 hours, then
every 2 hours while on ICU status, then every 4 hours
while in IMC/general care status
Record Rate (BPM): Every hour for 24 hours, then
every 2 hours while on ICU status, then every 4 hours
while in IMC/general care status
Record Vacuum:
Record Flash Test or Flashing Empty Light on Signal
Processor: Every hour for 24 hours, then every 2
hours while on ICU status, then every 4 hours while in
IMC/general care status
Record Fill Light Status: Every hour for 24 hours, then
every 2 hours while on ICU status, then every 4 hours
while in IMC/general care status
Page 9 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:30:01 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

LEFT Ventricular Assist Device Checks - TLC II
[NURVENT0012]
CONTINUOUS, Starting today For Until specified,
Routine
Select Mode:
Record Mode: Every hour for 24 hours, then every 2
hours while on ICU status, then every 4 hours while in
IMC/general care status
Low Beat Rate (BPM):
Beat Rate (BPM):
Record Beat Rate:
Record Low Rate:
Record Accumulator Pressure (mmHg):
Accumulator Pressure (mmHg):
Eject Time (msec):
Vacuum (mmHg):
Record Eject Time:
Record Flow (L/min): Every hour for 24 hours, then
every 2 hours while on ICU status, then every 4 hours
while in IMC/general care status
Record Rate (BPM): Every hour for 24 hours, then
every 2 hours while on ICU status, then every 4 hours
while in IMC/general care status
Record Vacuum:
Record Flash Test or Flashing Empty Light on Signal
Processor: Every hour for 24 hours, then every 2
hours while on ICU status, then every 4 hours while in
IMC/general care status
Record Fill Light Status: Every hour for 24 hours, then
every 2 hours while on ICU status, then every 4 hours
while in IMC/general care status
Ventricular Assist Device Checks - Heartware
[144451]
Mean Arterial Pressure [NURVENT0017] ONCE, Starting today For 1 Occurrences, Keep
MAP 65-85
Hematocrit Setting [NURVENT0017] ONCE, Starting today For 1 Occurrences, Change
hematocrit setting in Heartware monitor with every
hematocrit value
Note: Warfarin Dosing Per Pharmacy [950044] 1 X DAILY (HS) Starting tomorrow
INR goal 2-3
Page 10 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:30:01 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

LEFT Ventricular Assist Device Checks -
Heartware [NURVENT0024]
CONTINUOUS, Starting today, Routine
Speed (rpm) Set speed to keep CI > 2.5:
Document Speed: Every hour for 24 hours, then
every 2 hours while on ICU status, then every 4
hours while in IMC/general care status
Document Flow (L\Min): Every hour for 24 hours,
then every 2 hours while on ICU status, then every 4
hours while in IMC/general care status
Document Power (w): Every 2 hours while on ICU
status, then every 4 hours while in IMC/general care
status
Document High Power Alarm Setting: Every 4 hours
Low Flow Alarm Setting: Every 4 hours
Assess VAD Waveforms: Every hour for 24 hours,
then every 2 hours while on ICU status, then every 4
hours while in IMC/general care status
-Change high power and low flow alarm value with
every speed change.
-Set high power limit 2 points higher than patient
average value.
-Set low flow value 2 points lower than patient
average value with the lowest possible low flow
alarm value of 2.
-Notify Provider: If abnormal flow waveforms,
abnormal power waveforms, VAD stopped alarm,
low flow alarm, high watts alarm, suction detection
alarm, blank display alarm.
RIGHT Ventricular Assist Device Checks -
Heartware [NURVENT0025]
CONTINUOUS, Starting today, Routine
Speed (rpm) Set speed to keep CI > 2.5:
Document Speed: Every hour for 24 hours, then
every 2 hours while on ICU status, then every 4
hours while in IMC/general care status
Document Flow (L\Min): Every hour for 24 hours,
then every 2 hours while on ICU status, then every 4
hours while in IMC/general care status
Document Power (w): Every 2 hours while on ICU
status, then every 4 hours while in IMC/general care
status
Document High Power Alarm Setting: Every 4 hours
Low Flow Alarm Setting: Every 4 hours
Assess VAD Waveforms: Every hour for 24 hours,
then every 2 hours while on ICU status, then every 4
hours while in IMC/general care status
-Change high power and low flow alarm value with
every speed change.
-Set high power limit 2 points higher than patient
average value.
-Set low flow value 2 points lower than patient
average value with the lowest possible low flow
alarm value of 2.
-Notify Provider: If abnormal flow waveforms,
abnormal power waveforms, VAD stopped alarm,
low flow alarm, high watts alarm, suction detection
alarm, blank display alarm.
Ventricular Assist Device3 Care - PANEL - Vent
Assist Device Checks - HeartMate 3 [240438]
Page 11 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:30:01 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Hematocrit Setting [NURVENT0017] CONTINUOUS, Starting today, Change hematocrit
setting in HeartMate 3 monitor with every hematocrit
value.
Call VAD Coordinator with communication fault,
system controller hardware fault, LVAD fault,
driveline power fault, driveline communication
fault, red heart alarm, VAD failure.
[NURCOM0022]
CONTINUOUS, Starting today
Do not change modular driveline without
discussion with attending physician and VAD
coordinator [NURCOM0022]
CONTINUOUS, Starting today
Contingency Parameters [82552]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.3
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 50 and symptomatic; otherwise
40
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
If pain score >:
Pulse Oximetry < (%): 92
If urine output < (mL): 30 mL/hr times 2 hours or less
than 240 mL over 8 hours.
Other: Unexpected change in cardiac
rhythm,Automatic internal cardiac defibrillator (AICD)
firings,Pulsatility Index greater than 8,Power greater
than 8 (watts),Any anti-arryhthmia pacings,Runs of
ventricular tachycardia,Potassium less than 3.5
mmol/L,Magnesium less than 1.5 mg/dL,Increasing
supplemental oxygen requirements,Inability to fill or
empty Ventricular Assist Device,Flow less than 3.5
(L/min),PuIsatility Index less than 3,MAP as measured
by Doppler less than 60 or greater than 85
Intravenous Therapy
Premedications for Needle Insertion [106310]
Use lidocaine topical dressing kit for stable patient, no lidocaine allergies, have at least 30
minutes time prior to needing to use IV
Sodium chloride (bacteriostatic) 0.9% intradermal: Useful for patients requiring urgent IV
access; onset is immediate.
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, peripheral line
insertion - see Admin Instructions
Do NOT apply to area greater than 200 square
centimeters (maximum 2.5 g/site; maximum 4 sites
per hour, 6 times per day). Do NOT leave on longer
than 2 hours. Use for stable patient, no allergies to
lidocaine, with at least 30 minutes time prior to IV use
Page 12 of 16
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12/2017CCKM@uwhealth.org

sodium chloride (bacteriostatic) 0.9 % injection
[50585]
0.05-0.1 mL, Intradermal, PRN, peripheral line
insertion - see Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge
needle to inject solution and create a wheal. Wait 30
seconds to 1 minute then insert IV catheter into center
of wheal. Use if IV is needed within 30 minutes.
IV Fluids [12306]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed? Yes
Laboratory
General Laboratory Tests [82553]
ALBUMIN [ALB] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALKALINE PHOSPHATASE [ALKP] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALT/SGPT [ALT] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
AST/SGOT [AST] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BILIRUBIN, TOTAL [TBIL] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BUN [BUN] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CALCIUM [CA] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CBC WITH DIFFERENTIAL [CBC] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CBC WITHOUT DIFFERENTIAL [HEMO] NEXT 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?
Page 13 of 16
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

CREATININE [CRET] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
GLUCOSE [GLU] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
LD, TOTAL [LDH] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
MAGNESIUM [MAG] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PHOSPHATE [PHOS] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PREALBUMIN [XPRALB] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTEIN, TOTAL [TP] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTHROMBIN TIME/INR [PT] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
POTASSIUM [K] CONDITIONAL, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? 4 hours after IV
MAGNESIUM [MAG] CONDITIONAL, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? 4 hours after IV
Page 14 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:30:01 AM
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C REACTIVE PROTEIN [CRPN] 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?
Conditional Laboratory Tests [145118]
GLUCOSE [GLU] 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 if blood glucose
is less than 40 or greater than 400 mg/dL.
Draw if blood glucose is less than 40 or greater than
400 mg/dL.
Consults
Consults [82555]
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult:
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Occupational Therapy Consult:
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
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):
Page 15 of 16
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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?
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?
Consult Nutrition [CON0043] ONCE, Starting today 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?
Consult Cardiac Rehab/Preventive Cardiology
[CON0010]
ONCE, Starting today For 1 Occurrences, Routine
Reason for consult: Other (Comment) (Assessment
and education.)
BestPractice
No Hospital Problems have yet been identified. [107035]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing.
Page 16 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:30:01 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org