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/clinical/cckm-tools/content/order-sets/inpatient/emergency-medicine/name-101163-en.cckm

20180109

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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Emergency Medicine

ED - Intubation - Adult - Supplemental [5113]

ED - Intubation - Adult - Supplemental [5113] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Emergency Medicine


ED - Intubation - Adult - Supplemental [5113]
Intubation Assessment
Airway Timeout [197538]
Airway Timeout [RT0126] ONCE, Routine
Was airway timeout completed?
Was airway checklist completed?
Laboratory
Laboratory [189904]
BLOOD GASES AND O2 SATURATION
[HCBGASOS]
CONDITIONAL - RN COLLECT, Starting today For 3
Days, STAT
Indicate FIO2: FiO2 Per RN
If add on test, what should lab do if unable to add test
to previous specimen? Cancel
If Conditional, What Condition? Draw 30 minutes
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [186358]
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
STAT
Current signs and symptoms? Intubated
What specific question(s) would you like answered by
this exam? Evaluate ET Tube
Relevant recent/past history? S/P Intubation
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method:
Perform 30 minutes after order is signed
Intravenous Bolus Therapy
IV Fluids (Single Response) [153055]
sodium chloride 0.9% IV BOLUS [730003] Intravenous, ONCE For 1 Doses
lactated ringers IV BOLUS [730001] Intravenous, ONCE For 1 Doses
Medications - Intubation
Pre-Induction Agents [189905]
FENTanyl PF injection RANGE [750047] 50-200 mcg, Intravenous, ONCE PRN For 1 Doses,
pain, analgesia for intubation, for 1 Minutes
lidocaine PF 2 % injection [140345] 100 mg, Intravenous, ONCE For 1 Doses
Give 3-5 minutes prior to intubation
Induction Agents (Single Response) [186372]
etomidate (AMIDATE) 2 mg/mL 10mL vial
STOCK VIAL [790016]
0.15-0.3 mg/kg, Intravenous, ONCE PRN For 2 Hours,
sedation for intubation induction, for 1 Minutes
ketAMINE injection [800191] 1-2 mg/kg, Intravenous, ONCE PRN For 2 Hours,
sedation for intubation induction
propofol (DIPRIVAN) 10 mg/mL IV BOLUS
[730017]
0.5-1 mg/kg, Intravenous, ONCE PRN For 2 Hours,
sedation for intubation induction
Paralytics (Single Response) [153058]
succinylcholine (ANECTINE) 20 mg/mL 10 mL
STOCK vial [790064]
1-2 mg/kg, Intravenous, ONCE PRN For 2 Hours,
Paralysis
rocuronium (ZEMURON) injection [800213] 0.6-1 mg/kg, Intravenous, ONCE PRN For 2 Hours,
Paralysis
Post Intubation Analgesia/Sedation
paralyzed use if paralysis with succinylcholine or currently not Appropriate
Pain (Single Response) [189898]
Page 1 of 8
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 1:17:36 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Fentanyl PRN with Option for Continuous
Infusion (STANDARD DOSE) - NOTE: order if
SBP greater than or equal to 110 [189900]
FENTanyl PF injection RANGE - NOTE: order if
SBP greater than or equal to 110 [750047]
25-100 mcg, Intravenous, EVERY 15 MINUTES
PRN, pain
NOTE: order if SBP greater than or equal to 110
for 1 Minutes
FENTanyl (50 mcg/mL) infusion [800264] 25-50 mcg/hr, Intravenous, CONTINUOUS
Start infusion if persistent pain despite 3 or more
intermittent doses administered within 1 hour
Start continuous infusion if moderate to severe
pain persists after 3 or more bolus doses in 1
hour [NURCOM0022]
ONCE, Do NOT start analgesic continuous infusion
unless 3 or more intermittent doses have been used
within one hour
Fentanyl PRN with Options for Continuous
Infusion (LOW DOSE) - NOTE: order if SBP less
than 110 [189899]
FENTanyl PF injection RANGE - NOTE: order if
SBP less than 110 [750047]
25-50 mcg, Intravenous, EVERY 15 MINUTES PRN,
pain, for 1 Minutes
FENTanyl (50 mcg/ml) infusion [800264] 25-200 mcg/hr, Intravenous, CONTINUOUS
Initiate, titrate and bolus by Adult ICU Pain,
Agitation, Delirium Protocol
Start continuous infusion if moderate to severe
pain persists after 3 or more bolus doses in 1
hour [NURCOM0022]
ONCE, Do NOT start analgesic continuous infusion
unless 3 or more intermittent doses have been used
within one hour
Agitation (Single Response) [153185]
OptionsInfusion
Propofol-line 1st
Midazolam-line 2nd
Propofol Infusion [153187]
propofol (DIPRIVAN) 10 mg/mL infusion [800260] 10-70 mcg/kg/min, Intravenous, CONTINUOUS
Initiate/Titrate/Bolus per Assessment and Treatment
of Pain, Agitation, and Delirium in Mechanically
Ventilated Adult Intensive Care Patient to achieve
RASS score of 0 to -2
propofol (DIPRIVAN) 10 mg/mL IV BOLUS
[730017]
0.25-0.75 mg/kg, Intravenous, PRN, sedation
Use only if propofol being initiated or dose increased
Goal RASS Score [NURCOM0022] CONTINUOUS, Initiate/Titrate/Bolus per
Assessment and Treatment of Pain, Agitation, and
Delirium in Mechanically Ventilated Adult Intensive
Care Patient to achieve ordered goal RASS score of
-1
Midazolam PRN with Option for Propofol Infusion
(STANDARD DOSE) - NOTE: order for SBP
greater than or equal to 110 [153186]
midazolam (VERSED) injection RANGE - NOTE:
order for SBP greater than or equal to 110
[750056]
1-4 mg, Intravenous, EVERY 15 MINUTES PRN,
agitation
NOTE: order for SBP greater than or equal to 110
propofol (DIPRIVAN) 10 mg/mL infusion [46335] 10-70 mcg/kg/min, Intravenous, CONTINUOUS
Initiate, titrate and bolus by Adult ICU Pain,
Agitation, Delirium Protocol
propofol (DIPRIVAN) 10 mg/mL IV BOLUS
[730017]
0.25-0.75 mg/kg, Intravenous, PRN, sedation
Use only if propofol being initiated or dose increased
Goal RASS Score [NURCOM0022] CONTINUOUS, Initiate/Titrate/Bolus per
Assessment and Treatment of Pain, Agitation, and
Delirium in Mechanically Ventilated Adult Intensive
Care Patient to achieve ordered goal RASS score of
-1
Page 2 of 8
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 1:17:36 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Start continuous infusion if RASS score greater
than goal after 3 or more midazolam bolus doses
in 1 hour [NURCOM0022]
CONTINUOUS
Midazolam PRN with Option for Propofol Infusion
(LOW DOSE) - NOTE: order for SBP less than
110 [190481]
midazolam (VERSED) injection RANGE - NOTE:
order for SBP greater less or equal to 110
[750056]
1-2 mg, Intravenous, EVERY 15 MINUTES PRN,
agitation
propofol (DIPRIVAN) 10 mg/mL infusion [800260] 10-70 mcg/kg/min, Intravenous, CONTINUOUS
Initiate, titrate and bolus by Adult ICU Pain,
Agitation, Delirium Protocol
propofol (DIPRIVAN) 10 mg/mL IV BOLUS
[730017]
0.25-0.75 mg/kg, Intravenous, PRN, sedation
Use only if propofol being initiated or dose increased
Goal RASS Score [NURCOM0022] CONTINUOUS, Initiate/Titrate/Bolus per
Assessment and Treatment of Pain, Agitation, and
Delirium in Mechanically Ventilated Adult Intensive
Care Patient to achieve ordered goal RASS score of
-1
Start continuous infusion if RASS score greater
than goal after 3 or more midazolam bolus doses
in 1 hour [NURCOM0022]
CONTINUOUS
Midazolam PRN with Option for Midazolam
Infusion (STANDARD DOSE) - NOTE: order for
SBP greater than or equal to 110 [193348]
midazolam (VERSED) injection RANGE [750056] 1-4 mg, Intravenous, EVERY 15 MINUTES PRN,
agitation
If patient fails to respond after 3 doses in an hour
consider starting continuous infusion
midazolam (VERSED) 50 mg in dextrose 5 % 50
mL infusion [700236]
1-10 mg/hr, Intravenous, CONTINUOUS
Initiate, titrate and bolus by Adult ICU Pain,
Agitation, Delirium Protocol
Goal RASS Score [NURCOM0022] CONTINUOUS, Initiate/Titrate/Bolus per
Assessment and Treatment of Pain, Agitation, and
Delirium in Mechanically Ventilated Adult Intensive
Care Patient to achieve ordered goal RASS score of
-1
Start continuous infusion if RASS score greater
than goal after 3 or more bolus doses in 1 hour
[NURCOM0022]
CONTINUOUS
Midazolam PRN with Option for Midazolam
Infusion (LOW DOSE) - NOTE: order for SBP
less than 110 [190491]
midazolam (VERSED) injection RANGE [750056] 1-2 mg, Intravenous, EVERY 15 MINUTES PRN,
agitation
If orderd IV: push rate 1 mg/minute.
If patient fails to respond after 3 doses in an hour
consider starting continuous infusion
midazolam (VERSED) 50 mg in dextrose 5 % 50
mL infusion [700236]
1-10 mg/hr, Intravenous, CONTINUOUS
Initiate, titrate and bolus by Adult ICU Pain,
Agitation, Delirium Protocol
Goal RASS Score [NURCOM0022] CONTINUOUS, Initiate/Titrate/Bolus per
Assessment and Treatment of Pain, Agitation, and
Delirium in Mechanically Ventilated Adult Intensive
Care Patient to achieve ordered goal RASS score of
-1
Page 3 of 8
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 1:17:36 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Start continuous infusion if RASS score greater
than goal after 3 or more midazolam bolus doses
in 1 hour [NURCOM0022]
CONTINUOUS
Extended Chemical Paralysis - Post Intubation Analgesia/Sedation
vecuroniumfor use if paralysis with rocuronium or Appropriate
Pain (Single Response) [189901]
Fentanyl Scheduled Bolus [189454]
FENTanyl PF injection RANGE [750047] 25-50 mcg, Intravenous, EVERY 20 MINUTES PRN
For 4 Doses, pain/agitation
Hold if SBP < 90. Use if scheduled dose not
controlling pain
for 1 Minutes
FENTanyl PF injection [800187] 50 mcg, Intravenous, EVERY 20 MINUTES For 4
Doses
Admin Inst: Hold for SBP <90. If patient
spontaneously moving hold scheduled doses if pain
controlled
Fentanyl Continuous Infusion [191209]
FENTanyl PF injection [800187] 50 mcg, Intravenous, ONCE For 1 Doses
Give prior to initiation of infusion. Hold for SBP less
than 90
FENTanyl (50 mcg/mL) infusion [800264] 25-200 mcg/hr, Intravenous, CONTINUOUS
Initiate, titrate and bolus by Adult ICU Pain,
Agitation, Delirium Protocol
Agitation (Single Response) [189897]
Midazolam Scheduled Bolus (STANDARD
DOSE) - NOTE: order for SBP greater than or
equal to 110 [186345]
midazolam (VERSED) injection [800197] 2 mg, Intravenous, EVERY 20 MINUTES For 4
Doses
If patient spontaneously moving hold scheduled
doses if sedate
midazolam (VERSED) injection RANGE - NOTE:
order for SBP greater than or equal to
110" [750056]
1-4 mg, Intravenous, EVERY 20 MINUTES PRN For
4 Doses, agitation
Use if scheduled dose not adequately sedating
patient. NOTE: order for SBP greater than or equal
to 110
Nursing Communication [NURCOM0022] ONCE, If patient NOT spontaneously
moving/responding 90 minutes after administration
of paralytic perform Train of 4 testing. If less than 4
twitches contact MD for further orders
Midazolam Scheduled Bolus (LOW DOSE) -
NOTE: order for SBP less than 110 [193353]
midazolam (VERSED) injection [800197] 2 mg, Intravenous, EVERY 20 MINUTES For 4
Doses
If patient spontaneously moving hold scheduled
doses if sedated
midazolam (VERSED) injection RANGE - NOTE:
order for SBP less than 110 [750056]
1-2 mg, Intravenous, EVERY 20 MINUTES PRN For
4 Doses, agitation
If orderd IV: push rate 1 mg/minute.
Use if scheduled dose not adequately sedating
patient
Nursing Communication [NURCOM0022] ONCE, If patient NOT spontaneously
moving/responding 90 minutes after administration
of paralytic perform Train of 4 testing. If less than 4
twitches contact MD for further orders
Page 4 of 8
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 1:17:36 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Midazolam Infusion [189451]
midazolam (VERSED) injection [800197] 2 mg, Intravenous, ONCE For 1 Doses
Prior to initiation of infusion
midazolam (VERSED) 50 mg in dextrose 5 % 50
mL infusion [700236]
1-10 mg/hr, Intravenous, CONTINUOUS
Initiate, titrate and bolus by Adult ICU Pain,
Agitation, Delirium Protocol
Comfort with Paralysis [NURCOM0022] ONCE, Initiate/Titrate/Bolus per Assessment and
Treatment of Pain, Agitation, and Delirium in
Mechanically Ventilated Adult Intensive Care Patient
to achieve RASS score of -1, or Paralyzed patient
Propofol Infusion [153180]
propofol (DIPRIVAN) 10 mg/mL IV BOLUS
[730017]
Intravenous, PRN, For initiation prior to infusion and
as needed for sedation
propofol (DIPRIVAN) 10 mg/mL infusion [800260] 10-70 mcg/kg/min, Intravenous, CONTINUOUS
Initiate/Titrate/Bolus per Assessment and Treatment
of Pain, Agitation, and Delirium in Mechanically
Ventilated Adult Intensive Care Patient to achieve
RASS score of 0 to -1
Comfort with Paralysis [NURCOM0022] ONCE, Initiate/Titrate/Bolus per Assessment and
Treatment of Pain, Agitation, and Delirium in
Mechanically Ventilated Adult Intensive Care Patient
to achieve RASS score of -1, or Paralyzed patient
Ketamine Scheduled Bolus - Paralyzed
Hypotensive Patients [189448]
ketAMINE injection [800191] 1.5 mg/kg, Intravenous, ONCE For 1 Doses
ketAMINE injection [800191] 0.5 mg/kg, Intravenous, EVERY 20 MINUTES For 4
Doses
ketAMINE injection [800191] 0.25-0.5 mg/kg, Intravenous, EVERY 20 MINUTES
PRN For 4 Doses, Sedation/Agitation
Nursing Communication [NURCOM0022] ONCE, If patient NOT spontaneously
moving/responding 90 minutes after administration
of paralytic perform Train of 4 testing. If less than 4
twitches contact MD for further orders
Patient Care Orders
Activity [186360]
Elevate Head Of Bed [NURACT0002] Equal to (degrees): 30
Greater than (degrees):
Less than (degrees):
Other options: At all times
Routine, CONTINUOUS
Cervical Spine Precautions [PRECAU0005] CONTINUOUS, Routine, Cervical Spine Precautions:
Cervical collar at all times.
No pillow behind head.
No lifting anything greater than 10 pounds.
No lifting of arms over head.
Thoracic/Lumbar Spine Precautions
[PRECAU0009]
CONTINUOUS, Routine, Thoracic/Lumbar Spine
Precautions:
Head of bed less than 30 degrees unless otherwise
stated.
Head of bed flat for log rolling side to side.
Non-Categorized Patient Care Orders [152478]
Mechanical Ventilation - Adult [216836]
Page 5 of 8
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 1:17:36 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Provide Manual Resuscitator at Bedside
[RT0039]
CONTINUOUS, Routine
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.
Is this a modification to a current vent order?
Ventilator Management: Adult Vent Management
Protocol,Adult Vent Management Protocol
Wean:
Set Rate/Min:
PEEP (cmH2O):
Mode:
Tidal Volume Multiplier: 6
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):
Patient's @FLOWDATETIME[2000004@
Tidal Volume
6-8 mL/kg of ideal body weight.
chlorhexidine (PERIDEX) 0.12 % soln
MULTIDOSE [792004]
15 mL, Swish & Spit, 2 X DAILY Starting today
Use to swab oral cavity. D/C when patient no longer
on ventilation.
OG Tube Placement - Adult [120995]
Insert and Maintain Orogastric Tube
[NURTAD0015]
CONTINUOUS, Routine
Options:
Flush with:
Flush Frequency: EVERY 8 HOURS
Check Residual:
Does this need to be inserted/placed?
Device Status:
Refer to Policy 2.20AP Care & Maintenance of
Enteral Tubes (Adult & Pediatric)
Recommendations for flush quantity:
For adult patients, 30 mLs of fluid should be
sufficient.
Page 6 of 8
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 1:17:36 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

X-RAY ABDOMEN AP VIEW (KUB) [R74000] ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? Orogastric tube
placement
What specific question(s) would you like answered
by this exam? Evaluate orogastric tube placement
Relevant recent/past history? Cardiac Surgery
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
If Conditional, What Condition? Evaluate orogastric
tube placement. The location of orogastric tube
should be confirmed prior to the instillation of fluids,
medications, or feedings. Refer to Policy 2.20
Enteral Tubes Used for Instillation of Fluids,
Medications, or Feeding
NG Tube Placement - Adult [120994]
Insert and Maintain Nasogastric Tube
[NURTAD0014]
CONTINUOUS, Routine
Options:
Flush with:
Flush Frequency: EVERY 8 HOURS
Clamp NG Tube:
Check Residual:
Does this need to be inserted/placed?
Device Status:
Refer to Policy 2.20 Enteral Tubes Used for
Instillation of Fluids, Medications, or Feeding
Recommendations for flush quantity:
For adult patients, 30 mLs of fluid should be
sufficient.
lidocaine-oxymetazoline 4%-0.05% (ADULT)
nasal spray [785081]
2 spray, Nasal, ONCE For 1 Doses
For numbing prior to feeding tube insertion.
Slowly spray the chosen nostril once, if required may
repeat x1 in opposite nostril. Angle toward back of
throat spraying the anterior nostril and wait 30-60
seconds before introducing more local
anesthetic into the nostril. Caution: Entire bottle
should not be used for insertion of tube. Discard
excess solution when procedure completed.
Page 7 of 8
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 1:17:36 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

X-RAY ABDOMEN AP VIEW (KUB) [R74000] ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered
by this exam? Evaluate nasogastric tube placement
Relevant recent/past history?
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
If Conditional, What Condition? Evaluate nasogastric
tube placement. The location of nasogastric tube
should be confirmed prior to the instillation of fluids,
medications, or feedings. Refer to Policy 2.20
Enteral Tubes Used for Instillation of Fluids,
Medications, or Feeding
ETCO2 Monitoring [RT0006] CONTINUOUS, Routine, Continuous monitoring after
ETT placement
Page 8 of 8
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 1:17:36 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org