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ED - CLINICAL DECISION UNIT - MINOR HEAD TRAUMA - ADULT [6045]

ED - CLINICAL DECISION UNIT - MINOR HEAD TRAUMA - ADULT [6045] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Emergency Medicine


SmartSet: ED - CLINICAL DECISION UNIT - MINOR HEAD TRAUMA - ADULT
(ID:6045)
General Information
Display name: ED - Clinical Decision Unit - Minor Head Trauma - Adult
Type: General
Merge priority:
Version comment:
Content source:
Synonyms: 1. ed cdu
2. observation
3. adult
4. ed
5. clinical decicion unit
SmartSet notes:
Description: Inclusion Criteria for this Order Set:
1. Patients with normal CT scans of brain and with complaints consistent with
head injury. These complaints may include headache, dizziness, transient
vomiting, amnesia to the event causing the injury, and reported loss of
consciousness.
2. Patients taking anticoagulants who present to the Emergency Department with
history of head trauma and subsequently have normal CT scans of the brain.
3. Patients who may have other injuries provided that they have been managed
prior to transfer to the CDU and are stable.
Exclusion Criteria for this Order Set:
1. Patients with head trauma and abnormal levels of consciousness not
associated with alcohol or drug intoxication.
- Intoxicated patients are not exclused if they are cooperative.
2. Patients who are uncooperative.
3. Patients with focal neurological abnormalities.
4. Patients with abnormal vital signs (HR > 110, SBP < 100 or Oxygen Saturation
less than 93%.)
Web information: Title URL
1.
Questionnaire:
Configuration
Page 1 of 5
Printed by STRAKA, KEVIN F [KFS1] at 12/22/2016 2:30:15 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Admission Status
Admission Status
Admit to CDU (ED Observation) Patient Class: Observation
Accommodation Code, if IMC request, please enter
Comments in field to the right: OSS/OBS
Will the patient require special placement due to
ISOLATION Precautions?
Could this patient have ACS/MI?
Does the patient require CARDIAC MONITORING for
transport?
Admitting Provider?
Attending Provider?
CDU Protocol: Minor Head Trauma
Family History:
Expected Treatment/Procedures:
Medications
Analgesics - Acetaminophen PRN
acetaMINOPHEN (TYLENOL) tab 325-650 mg, Oral, EVERY 4 HOURS PRN, pain/fever
Mild to moderate pain
Analgesics - NSAIDS - PRN
ibuprofen (MOTRIN) tab 200-400 mg, Oral, EVERY 6 HOURS PRN, pain
Mild to moderate pain
Analgesics - Opioid - Oral PRN
hydrocodone-acetaMINOPHEN (NORCO) 5-325
MG per tab
1-2 tab, Oral, EVERY 4 HOURS PRN, pain
Severe pain
oxycodone tab 5-10 mg, Oral, EVERY 4 HOURS PRN, pain
Severe pain
Analgesics - Opioid - Injection PRN
MORPHine PF injection 1-2 mg, Intravenous, EVERY 2 HOURS PRN, pain
Severe pain if unable to tolerate oral medications
HYDROmorphone PF (DILAUDID) injection 0.2-0.4 mg, Intravenous, EVERY 2 HOURS PRN,
pain
Severe pain if unable to tolerate oral medications
Antiemetics
ondansetron (ZOFRAN ODT) disintegrating tab 4 mg, Oral, EVERY 24 HOURS PRN,
nausea/vomiting
Administer first line as needed when able to tolerate
oral medications.
ondansetron (ZOFRAN) injection 4 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Administer first line as needed when unable to
tolerate oral medications.
prochlorperazine (COMPAZINE) tab 10 mg, Oral, EVERY 6 HOURS PRN, nausea
Administer second line if there is no response to first
line antiemetic within 30 minutes.
Page 2 of 5
Printed by STRAKA, KEVIN F [KFS1] at 12/22/2016 2:30:15 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

prochlorperazine (COMPAZINE) injection 10 mg, Intravenous, EVERY 6 HOURS PRN, nausea
Administer second line if there is no response to first
line antiemetic within 30 minutes.
promethazine (PHENERGAN) tab 12.5-25 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
promethazine (PHENERGAN) injection 12.5-25 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Patient Care Orders
Vital Signs
Vital Signs SEE COMMENTS, Starting S, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
EVERY 1 HOUR x 2, then EVERY 2 hours X 2, then
EVERY 4 HOURS
Activity
Activity CONTINUOUS, Routine
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:
Nutrition
Diet - Custom EFFECTIVE NOW, Starting S, Routine
Patient Type: Adult
Room Service Class:
Diet Type: Diet Modifications
Diet Modifications:
Bedside Meal Instructions:
Diet - General EFFECTIVE NOW, Starting S, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Diet - NPO Except Medications EFFECTIVE NOW, Starting S, Routine
Patient Type: Adult
Diet Type: NPO
NPO: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
Page 3 of 5
Printed by STRAKA, KEVIN F [KFS1] at 12/22/2016 2:30:15 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

Diet - Adult Renal EFFECTIVE NOW, Starting S, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Renal
Sodium:
Potassium:
Phosphorus:
Fluid Restriction Total mLs/24H (IV/PO):
Protein:
Bedside Meal Instructions:
Room Service Class:
Patient Monitoring
Neurovascular Checks SEE COMMENTS, Routine, EVERY 1 HOUR x 2,
then EVERY 2 hours X 2, then EVERY 4 HOURS
Contingency Parameters
Notify Provider Provider to Notify: Provider
If systolic blood pressure > (mmHg): 180
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg): 95
If diastolic blood pressure < (mmHg): 60
If temperature > (C): 38
If temperature < (C): 36
If heart rate > (bpm): 120
If heart rate < (bpm): 50
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): 300
If blood glucose < (mg/dL): 80
If pain score >:
Pulse Oximetry < (%): 92
If urine output < (mL):
Other:
Consults
Consult Speech Therapy (Inpatient) Eval and
Treat
ONCE For 1 Occurrences, Routine
Patient Type: Adult
Reason for Speech Therapy Consult: Other
Disposition Criteria
Home
Disposition Criteria - Home CONTINUOUS, 1. Normal serial neurological exams.
2. Vital signs are acceptable.
Hospital
Disposition Criteria - Hospital CONTINUOUS, 1. Deterioration in clnical condition.
- Admitted patient should have repeated CT Head.
Criteria
Suggestions: LOOKUP LOCATOR-HEAD INJURY TREATMENT UWHC ED (RFV)[538]
Page 4 of 5
Printed by STRAKA, KEVIN F [KFS1] at 12/22/2016 2:30:15 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

UWIP C LOGIN DEPT UWH ED OR TAC ED[30001972]
Filter: RESTRICTION LOCATOR - UWHC ED[486]
Restrict SmartSet:
Settings
Discontinue action:
Deselect sections for
Pended/Held orders:
Pended/Held orders
display:
Release date: Use System Definitions Setting
Disallow user override:
Page 5 of 5
Printed by STRAKA, KEVIN F [KFS1] at 12/22/2016 2:30:15 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org