/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/ent/,

/clinical/cckm-tools/content/order-sets/inpatient/ent/name-98348-en.cckm

201712342

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,ENT

IP - Composite Resection With Flap Reconstruction And Trach - Adult - Postoperative [2818]

IP - Composite Resection With Flap Reconstruction And Trach - Adult - Postoperative [2818] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, ENT


IP - Composite Resection With Flap Reconstruction And Trach - Adult -
Postoperative [2818]
for Adult Patients OnlyIntended
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 [102176]
Page 1 of 25
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12/2017CCKM@uwhealth.org

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 [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
Admission Status [84059]
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 [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) [150176]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Low VTE Risk [130084]
Page 2 of 25
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
Post-Op/Phase II
Moderate VTE Risk with Low Bleed Risk (Single
Response) [209954]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Post-Op/Phase II
High VTE with Low Bleed Risk [211018]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Post-Op/Phase II
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
High Bleed 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
Post-Op/Phase II
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Post-Op/Phase II
VTE Prophylaxis (Single Response) [131999]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
Post-Op/Phase II
Moderate VTE Risk with Low Bleed Risk (Single
Response) [209954]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Post-Op/Phase II
High VTE with Low Bleed Risk [211018]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 8 HOURS, Post-
Op/Phase II
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Page 3 of 25
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:10:50 AM
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12/2017CCKM@uwhealth.org

Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
High Bleed 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
Post-Op/Phase II
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Post-Op/Phase II
PACU Normoglycemia Management
Normoglycemia Management (Single Response) [217140]
Patients withOUT Diabetes and NOT on Insulin
Infusion [228192]
Glucose, POC [IPGLUCOSE] ONCE For 1 Occurrences, 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?
PACU
If Glucose POC 200 mg/dL or Greater Initiate
Perioperative Normoglycemia for Surgical
Patients Adult Delegation Protocol
[NURMON0167]
CONTINUOUS For 24 Hours, Routine, Use order set
Perioperative Normoglycemia for Surgical Patients
Delegation Protocol order set [6133] to place orders,
PACU
Patients WITH Diabetes and NOT on Insulin
Infusion [228194]
Glucose, POC [IPGLUCOSE] ONCE For 1 Occurrences, 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?
PACU
If Glucose POC is 180 mg/dL or Greater Initiate
Perioperative Normoglycemia for Surgical
Patients Adult Delegation Protocol
[NURMON0167]
ONCE For 1 Occurrences, Routine, Use order set
Perioperative Normoglycemia for Surgical Patients
Delegation Protocol order set [6133] to place orders,
PACU
Patient ON Insulin Infusion [217180]
insulin infusionSupplemental order set [1345] to order -Adult -Insulin Infusion -IP Use
Confirm Time and Value of Last Glucose POC
and Insulin Infusion Column [NURCOM0022]
ONCE, PACU
Hypoglycemia Management [216855]
URL:
Hypoglycemia Management (Adult) [191576]
Page 4 of 25
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:10:50 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

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?
PACU
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), PACU
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
PACU
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., PACU
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., PACU
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.
PACU
Page 5 of 25
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:10:50 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

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.
PACU
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
PACU
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
PACU
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
PACU
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.
PACU
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting 12/16/17 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.
PACU
Post-OP Normoglycemia Management
Normoglycemia Management (Single Response) [216839]
Patients withOUT Diabetes and NOT on Insulin
Infusion [228199]
Glucose, POC [IPGLUCOSE] CONDITIONAL For 8 Hours, 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?
Check once on arrival if PACU Glucose POC is >/=
180 mg/dL
Recheck in 4 hours if initial floor Glucose POC is
180-199 mg/dL, Post-Op/Phase II
Page 6 of 25
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:10:50 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Glucose Monitoring and Response
[NURCOM0022]
ONCE For 1 Occurrences, If Glucose POC obtained
on arrival is:
< 180 mg/dL - no further action needed.
180-199 mg/dL - recheck and contact provider to
order the following: if patient is NPO, provider to
order glucose POC every 6 hours; if eating glucose
POC before meals and at bedtime. Provider should
order an A1c if not performed in the last 90 days.
200 mg/dL or greater - initiate Perioperative
Normoglycemia Delegation Protocol, Post-Op/Phase
II
If Glucose POC is 200 mg/dL or Greater Initiate
Perioperative Normoglycemia for Surgical
Patients Adult Delegation Protocol
[NURMON0167]
CONTINUOUS For 24 Hours, Routine, Use order set
Perioperative Normoglycemia for Surgical Patients
Delegation Protocol order set [6133] to place orders,
Post-Op/Phase II
Patients WITH Diabetes and NOT on Insulin
Infusion [228200]
Glucose, POC [IPGLUCOSE] ONCE For 1 Occurrences, 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?
Post-Op/Phase II
Glucose Monitoring and Response
[NURCOM0022]
ONCE For 1 Occurrences, If Glucose POC obtained
on arrival is:
<180 mg/dL - contact provider to order the following:
if patient is NPO, provider to order glucose POC
every 6 hours; if eating glucose POC before meals
and at bedtime. Provider should order an A1c if not
performed in the last 90 days.
180 mg/dL or greater - initiate Perioperative
Normoglycemia Delegation Protocol, Post-Op/Phase
II
If Glucose POC 180 mg/dL or Greater Initiate
Perioperative Normoglycemia for Surgical
Patients Adult Delegation Protocol
[NURMON0167]
CONTINUOUS, Routine, Use order set Perioperative
Normoglycemia for Surgical Patients Delegation
Protocol order set [6133] to place orders, Post-
Op/Phase II
Patient ON Insulin Infusion [217180]
insulin infusionSupplemental order set [1345] to order -Adult -Insulin Infusion -IP Use
Confirm Time and Value of Last Glucose POC
and Insulin Infusion Column [NURCOM0022]
ONCE, Post-Op/Phase II
Hypoglycemia Management [217170]
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?
Post-Op/Phase II
Page 7 of 25
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:10:50 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

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), Post-Op/Phase II
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
Post-Op/Phase II
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., Post-Op/Phase II
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., Post-Op/Phase II
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.
Post-Op/Phase II
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.
Post-Op/Phase II
Page 8 of 25
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:10:50 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

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
Post-Op/Phase II
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
Post-Op/Phase II
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
Post-Op/Phase II
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.
Post-Op/Phase II
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting 12/16/17 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.
Post-Op/Phase II
Patient Care Orders
Vital Signs [87573]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every hour times 2 then Every 2 hours times 2 then
Every 4 hours, Post-Op/Phase II
Patient Monitoring [87574]
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
CONTINUOUS, Starting today, Routine
Indication: ICU/PACU patient
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Functional Cardiac Defibrillator Present:
Post-Op/Phase II
Activity [87575]
Page 9 of 25
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:10:50 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Bedrest [NURACT0008] SEE COMMENTS, Starting today For 24 Hours,
Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: strict bedrest
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Strict bedrest for day of procedure, Post-Op/Phase II
Elevate head of bed 30 degrees [NURCOM0022] CONTINUOUS, Starting today For Until specified,
Post-Op/Phase II
Chair [NURACT0008] CONTINUOUS, Starting tomorrow 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:
With assistance on postoperative day 1, Post-
Op/Phase II
Ambulate 3x daily [NURACT0008] CONTINUOUS, Routine
AD LIB:
AMBULATE: 3x daily
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Starting postoperative Day 2, Post-Op/Phase II
Activity For Patients Getting Fibula Free FLap [111652]
Activity [NURACT0008] CONTINUOUS, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS: Other (Comment)
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Post-Op/Phase II
Nutrition [87576]
Page 10 of 25
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:10:50 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Tube Feeding with NPO except Medications
[NUT9999]
EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Tube Feed
Tube Feed Diet: Tube Feed with NPO Except Meds
Tube Feed Route: NG/OG Tube
NG/OG Frequency: Continuous
Infusion Instructions:
Gastric Feeding Patient Monitoring:
Gastric Feeding Residual Guidelines:
Hold Gastric Tube Feeding:
Tube Feed Product:
Bedside Meal Instructions:
Room Service Class:
Begin when Dobhoff tube cleared for use., Post-
Op/Phase II
Respiratory [87577]
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today For Until specified,
Routine, Post-Op/Phase II
Oxygen Therapy [RT0032] CONTINUOUS, Starting today For Until specified,
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
Apply Heated Trach Mask [117145]
Apply Heated Trach Mask [RT0044] Routine
Titrate oxygen to maintain O2 sat at (%): 92
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Apply heated humidified trach mask, Post-Op/Phase
II
Provide Manual Resuscitator at Bedside
[RT0039]
CONTINUOUS, Routine, Post-Op/Phase II
Wound Care [87578]
Maintain Drain [NURTAD0003] CONTINUOUS, Starting today For Until specified,
Routine
Type: Evacuator (RELIOVAC)
Site: Head/Neck
Location:
Drainage Options: Low Continuous Wall
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip: EVERY 2 HOURS (and as needed)
Strip For:
Dressing Change Frequency:
Dressing Type:
Measure drain output: every 8 hours. Cleanse with
sodium chloride 0.9% 2 times a day for drain site
care., Post-Op/Phase II
Page 11 of 25
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Maintain Drain [NURTAD0003] CONTINUOUS, Starting today For Until specified,
Routine
Type: Evacuator (RELIOVAC)
Site: Head/Neck
Location:
Drainage Options: Low Continuous Wall
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip: EVERY 2 HOURS (and as needed)
Strip For:
Dressing Change Frequency:
Dressing Type:
Measure drain output: every 8 hours. Cleanse with
sodium chloride 0.9% 2 times a day for drain site
care., Post-Op/Phase II
Maintain Drain [NURTAD0003] CONTINUOUS, Starting today For Until specified,
Routine
Type: Evacuator (RELIOVAC)
Site: Extremity
Location:
Drainage Options: Low Continuous Wall
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip: EVERY 2 HOURS (and as needed)
Strip For:
Dressing Change Frequency:
Dressing Type:
Measure drain output: every 8 hours. Cleanse with
sodium chloride 0.9% 2 times a day for drain site
care., Post-Op/Phase II
Maintain Drain [NURTAD0003] CONTINUOUS, Routine
Type:
Site:
Location:
Drainage Options:
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For:
Dressing Change Frequency:
Dressing Type:
Post-Op/Phase II
Maintain Enteral (Naso-) Tube [NURTAD0040] CONTINUOUS, Routine
Status: Feeding Tube Not Ready for Use
Flush With: Water
Flush Volume (mL):
Flush Frequency:
Post-Op/Phase II
Page 12 of 25
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Suture Line Care [NURWND0015] CONTINUOUS, Starting today For Until specified,
Routine
Wound Type: Closed - Incision (Suture Line)
Wound Site: Head/Neck
Wound Location:
Assess Frequency: EVERY 24 HOURS
Care Frequency: 2X DAILY
Wash With:
Irrigate/Rinse With:
Apply (Must also enter separate medication order to
obtain drug): Other (Comment)
Primary Dressing:
Secondary Dressing:
Apply ointment twice daily after gently cleaning the
incision with warm water., Post-Op/Phase II
Suture Line Care [NURWND0015] CONTINUOUS, Starting today For Until specified,
Routine
Wound Type: Closed - Incision (Suture Line)
Wound Site:
Wound Location:
Assess Frequency: EVERY 24 HOURS
Care Frequency: 2X DAILY
Wash With:
Irrigate/Rinse With:
Apply (Must also enter separate medication order to
obtain drug): Other (Comment)
Primary Dressing:
Secondary Dressing:
Apply ointment twice daily after gently cleaning the
incision with warm water., Post-Op/Phase II
Flap Monitoring [87579]
Assess Color, Doppler and Capillary Refill
[NURCOM0022]
SEE COMMENTS, Starting today, Every hour times
24, then every 2 hours times 12, then every 4 hours,
Post-Op/Phase II
Doppler Evaluation of Vein and Artery Flow
[NURCOM0022]
SEE COMMENTS, Starting today, Every hour times
24, then every 2 hours times 12, then every 4 hours,
Post-Op/Phase II
Flap Care [NURWND0015] CONTINUOUS, Starting today, Routine
Wound Type: Flap
Wound Site: Head/Neck
Wound Location:
Assess Frequency: EVERY 1 HOUR
Care Frequency: 2X DAILY
Wash With:
Irrigate/Rinse With:
Apply (Must also enter separate medication order to
obtain drug):
Primary Dressing:
Secondary Dressing:
Assess Frequency: every hour times 24, then every 2
hours for 24 hours , then every four hours., Post-
Op/Phase II
Implantable Doppler [NURCOM0022] SEE COMMENTS, Starting today, Continuous
Monitoring of Venous signal with every 1 hour checks
of artery. Please page care team if signal changes.,
Post-Op/Phase II
Skin Graft Donor Site Care [87580]
Page 13 of 25
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Wound Vacuum [136891]
Wound Vacuum [NURWND0013] CONTINUOUS, Starting today For Until specified,
Routine
Wound Vacuum Site:
Type of Suction:
DPC (Intermittent Suction) Frequency:
If VAC is leaking or alarming, and troubleshooting is
not effective, notify the service that is managing the
VAC. Per manufacturer recommendations, a VAC
dressing without active therapy for more than 2
hours should be removed. If managing service
verifies removal of VAC dressing, the dressing
should be removed, wound should be cleansed and
irrigated with NS, and a wet to dry dressing should
be applied. If active bleeding develops suddenly or
in large amounts during V.A.C. therapy or if frank
(bright red) blood is seen in the tubing or in the
canister immediately stop V.A.C therapy(clamp
tubing and turn therapy off), leave dressing in place
and notify managing service or covering physician,
as dressing will need to be removed and source of
bleeding must be controlled., Post-Op/Phase II
Vacuum Assisted Closure - KCI [EQP0030] CONTINUOUS, Starting today, Routine, Post-
Op/Phase II
Measure Drain Output [NURTAD0005] EVERY 8 HOURS, Routine
Skin Graft Donor Site Care [NURWND0015] CONTINUOUS, Starting today For Until specified,
Routine
Wound Type: Donor Site
Wound Site:
Wound Location:
Assess Frequency: EVERY 8 HOURS
Care Frequency: 2X DAILY
Wash With:
Irrigate/Rinse With:
Apply (Must also enter separate medication order to
obtain drug):
Primary Dressing:
Secondary Dressing:
Post-Op/Phase II
Tracheotomy Care Orders [87581]
Obturator and additional tracheotomy tube at
bedside [NURCOM0022]
CONTINUOUS, Starting today For Until specified,
Post-Op/Phase II
Respiratory Therapy to Check Cuff Pressure and
Adjust Accordingly [RT0073]
RT PRN, Starting today, Routine, Post-Op/Phase II
Drain sponge may be placed around the tube to
collect secretions [NURCOM0022]
CONTINUOUS, Starting today For Until specified,
Post-Op/Phase II
Do not move/manipulate/cut trach ties or sutures
[NURCOM0022]
CONTINUOUS, Starting today For Until specified,
First tracheotomy change will be done on
postoperative day 5, Post-Op/Phase II
NO TRACH TIES OR BANDS AROUND NECK
[NURCOM0022]
CONTINUOUS, Starting today For Until specified,
Post-Op/Phase II
Provide Trach Care [NURTAD0019] 3X DAILY, Starting today, Routine, Provide trach care
3 times daily and as needed for secretions., Post-
Op/Phase II
Page 14 of 25
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Suction Airway (tracheal suction) [NURTAD0017] PRN, Routine
Location: Tracheal
Post-Op/Phase II
Assess Skin on Neck for Breakdown
[NURCOM0022]
SEE COMMENTS, Starting today, Every 8 hours.,
Post-Op/Phase II
Irrigate Airway with 5 mL Normal Saline [RT0073] SEE COMMENTS, Starting today For Until specified,
Routine, Irrigate airway every 8 hrs and PRN.
Remove inner cannula and clean or replace with each
irrigation., Post-Op/Phase II
Intake and Output [87582]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today For Until specified,
Routine, Post-Op/Phase II
Measure Drain Output - STRICT [NURTAD0005] EVERY 8 HOURS, Starting today For Until specified,
Routine, Post-Op/Phase II
Measure wound vacuum output [NURTAD0005] EVERY 8 HOURS, Starting today For Until specified,
Routine, Post-Op/Phase II
Non-Categorized Patient Care Orders [87583]
No Oral Suctioning; No Oral Rinses; No
Toothettes; No Oral Temperatures
[NURCOM0022]
CONTINUOUS, Starting today For Until specified,
Post-Op/Phase II
Assess Neck for Hematoma [NURCOM0022] SEE COMMENTS, Starting today For Until specified,
Every hour times 2, then every 2 hours times 2, then
every 4 hours times 2, then every 8 hours, Post-
Op/Phase II
Assess Characteristics of Drainage from Wound
Site [NURCOM0022]
SEE COMMENTS, Starting today For Until specified,
Every hour times 2, then every 2 hours times 2, then
every 4 hours times 2, then every 8 hours, Post-
Op/Phase II
Maintain Urinary Catheter [NURELM0013] CONTINUOUS, 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 Triple Lumen
Indication for Placement: Postoperative Requirements
of Specific Procedure
Initiate Urinary Catheter Removal Protocol? (NP/PA
Must Select "No"): Yes
Details: To Dependent Drainage
Does this need to be inserted/placed?
Post-Op/Phase II
Initiate Bladder Management Protocol
[NURELM0014]
CONTINUOUS, Routine, Post-Op/Phase II
Measure Weight Daily [NURMON0015] 1X DAILY For Until specified, Routine
Weigh With?
Weigh when?
Post-Op/Phase II
Contingency Parameters [87584]
Page 15 of 25
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Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 160
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg): 90
If diastolic blood pressure < (mmHg): 60
If temperature > (C): 38 (axillary) 38.5 (oral)
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 60
If respiratory rate >: 30
If respiratory rate <: 8
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 90
If urine output < (mL): 240 for 8 hours
Other: Pain not controlled with ordered analgesics or
ordered interventions,Capillary refill is less than 2 or
greater than 3 seconds,Treatment area has dark color,
congested appearance,Treatment area has significant
cooling,Treatment area has marked swelling,Doppler
signal cannot be obtained or is substantially
changed,NECK SWELLING
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 immediate.
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Post-Op/Phase II
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
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.
Post-Op/Phase II
IV Fluids [87586]
Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Post-Op/Phase II
Page 16 of 25
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sodium chloride flush 0.9% 10 mL injection
[785055]
Flush, PRN, flush/line care
Flush per VAD guidelines
Post-Op/Phase II
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS, Post-Op/Phase II
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L
infusion [44910]
Intravenous, CONTINUOUS, Post-Op/Phase II
sodium chloride 0.45% infusion [42187] Intravenous, CONTINUOUS, Post-Op/Phase II
Limit Total Intravenous Fluids [NURVAD0022] Limit Total IV Fluids To (mL/hr):
Device Status: Ready For Use
IV Fluids + Meds+ Tube Feeds (once Started), Post-
Op/Phase II
Surgical Prophylaxis
First Line (Single Response) [148958]
ampicillin/sulbactam (UNASYN) intraVENOUS -
NOTE: Patients who are 40 - 120 kg [800010]
1.5 g, Intravenous, EVERY 6 HOURS For 3 Doses,
Post-Op/Phase II
ampicillin/sulbactam (UNASYN) intraVENOUS -
NOTE: Patients who are 121 kg and greater
[800010]
3 g, Intravenous, EVERY 6 HOURS For 3 Doses,
Post-Op/Phase II
cefazolin (ANCEF) intraVENOUS - NOTE:
Patients who are 40 - 80 kg [800000]
1 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
cefazolin (ANCEF) intraVENOUS - NOTE:
Patients who are 81 - 120 kg [800000]
2 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
cefazolin (ANCEF) intraVENOUS - NOTE:
Patients who are 121 kg and greater [800000]
3 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
metRONIDazole (FLAGYL) intraVENOUS -
NOTE: Patients who are 40-160 kg- Order with
Cefazolin if indicated [800062]
500 mg, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
metRONIDazole (FLAGYL) intraVENOUS -
NOTE: Patients who are greater than 160 kg-
Order with Cefazolin if indicated [800062]
750 mg, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
MRSA/Documented MRSA History (Single Response) [148967]
Patients who are 40-120 kg [228794]
ampicillin/sulbactam (UNASYN) intraVENOUS
[800010]
1.5 g, Intravenous, EVERY 6 HOURS For 3 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 [228796]
ampicillin/sulbactam (UNASYN) intraVENOUS
[800010]
3 g, Intravenous, EVERY 6 HOURS For 3 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 40-80 kg [228798]
cefazolin (ANCEF) intraVENOUS [800000] 1 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 81-120 kg [228799]
cefazolin (ANCEF) intraVENOUS [800000] 2 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 or greater [228800]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
Page 17 of 25
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vancomycin (VANCOCIN) intraVENOUS
[800084]
15 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Immediate/Severe Reactions to Pencillin or Known Cephalosporin Allergies (Single Response) [208461]
URL:
clindamycin (CLEOCIN) intraVENOUS - NOTE for
patients who are 40-80 kg [800033]
600 mg, Intravenous, EVERY 8 HOURS For 1 Doses,
Post-Op/Phase II
clindamycin (CLEOCIN) intraVENOUS - NOTE:
for patients 81-160 kg [800033]
900 mg, Intravenous, EVERY 8 HOURS For 1 Doses,
Post-Op/Phase II
clindamycin (CLEOCIN) intraVENOUS - NOTE:
for patients greater than 160 kg [800033]
1,200 mg, Intravenous, EVERY 8 HOURS For 1
Doses, Post-Op/Phase II
Medications - General
Analgesics [193945]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Dobhoff Tube, EVERY 4 HOURS PRN, pain
Do NOT use until feeding tube is cleared for use.
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
acetaMINOPHEN (TYLENOL) suppository
[34153]
650 mg, Rectal, EVERY 4 HOURS PRN, pain
Use when unable to take orally or by feeding tube.
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 [205031]
Adult - Standard - Anti-emetics [242181]
ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
4 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
Use first line
Post-Op/Phase II
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Use first line if unable to take medications by mouth
or enteral tube OR if immediate effect is needed.
Post-Op/Phase II
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
Use second line if there is inadequate response to
first line anti-emetic within 30 minutes. If there is no
response to second line therapy within 30 minutes,
notify provider
Post-Op/Phase II
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Use second line. Use if there is inadequate
response to first line anti-emetic within 30 minutes
and if unable to take medications by mouth or
enteral tube OR if immediate effect is needed. If
there is no response to second line therapy within 30
minutes, notify provider
Post-Op/Phase II
Anti-hypertensives [149091]
Adult - Standard - Hypertension [242183]
Page 18 of 25
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Give lowest dose of range for initial administration. If there is inadequate response, give highest
dose of range for subsequent administrations.
labetalol injection RANGE [750053] 10-20 mg, Intravenous, EVERY 1 HOUR PRN,
Hypertension
Use if systolic blood pressure greater than *** mmHg
OR if diastolic blood pressure greater than *** mmHg
and heart rate is greater than or equal to *** beats
per minute prior to administration. If hydralazine was
given previously, give at least 1 hour after last
hydralazine dose. If persistent blood pressure
elevation after *** hours, contact provider for
evaluation.
for 2 Minutes, Post-Op/Phase II
hydrALAZINE (APRESOLINE) injection RANGE
[750049]
10-20 mg, Intravenous, EVERY 1 HOUR PRN,
hypertension
Use if systolic blood pressure greater than 160
mmHg OR diastolic blood pressure greater than ***
mmHg and heart rate is less than 60 beats per
minute. If labetalol was given previously, give at
least 1 hour after previous labetalol dose. If
persistent blood pressure elevation after *** hours,
contact provider for evaluation.
Post-Op/Phase II
Bowel Management Scheduled [149283]
docusate sodium (COLACE) soln [74449] 100 mg, Dobhoff Tube, 2 X DAILY
Do NOT administer until feeding tube is cleared for
use. Hold for loose stool or suspected obstruction.
Use rescue therapy after first 48 hours if inadequate
response to scheduled bowel management.
Post-Op/Phase II
sennosides (SENNA) 8.8 MG/5ML syrup [50880] 10 mL, Dobhoff Tube, 2 X DAILY
Do NOT administer until feeding tube is cleared for
use. Hold for loose stool or suspected obstruction.
Use rescue therapy after first 48 hours if inadequate
response to scheduled bowel management.
Post-Op/Phase II
Bowel Management - As Needed [205032]
Adult - Bowel Management - As Needed
[242185]
polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Dobhoff Tube, 1 X DAILY PRN, constipation
First Line Therapy
Post-Op/Phase II
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, Dobhoff Tube, 1 X DAILY PRN, constipation
Second line therapy, if no response to first line
therapy within 12 hours
Post-Op/Phase II
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal, 1 X DAILY PRN, constipation
If unable to take medications by mouth or enteral
tube OR if need immediate laxation OR if failure of
second line agent after 6 hours
Gastric [103711]
famotidine (PEPCID) suspension [106408] 20 mg, Dobhoff Tube, 2 X DAILY, Post-Op/Phase II
famotidine (PEPCID) intraVENOUS [800279] 20 mg, Intravenous, EVERY 12 HOURS, Post-
Op/Phase II
Page 19 of 25
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pantoprazole (PROTONIX) injection [800119] 40 mg, Intravenous, 1 X DAILY
Notify Pharmacy-Convert IV pantoprazole to solution
via feeding tube when tube feeds initiated.
Post-Op/Phase II
pantoprazole (PROTONIX) susp [780113] 40 mg, Dobhoff Tube, 1 X DAILY, Post-Op/Phase II
Incision Care [149288]
bacitracin ointment [49271] Topical, 2 X DAILY
Apply to suture line and drain site
Post-Op/Phase II
white petrolatum gel [108509] Topical, 2 X DAILY
Apply to suture line and drain site
Post-Op/Phase II
Aspirin - NOTE: For patients with free flap [87595]
aspirin chew tab - NOTE: To start on
postoperative day 1 [720014]
81 mg, Dobhoff Tube, 1 X DAILY Starting today with
First Dose Include Now
Do NOT administer until feeding tube is cleared for
use.
Post-Op/Phase II
Non-categorized [204915]
naloxone (NARCAN) injection [800199] 0.1 mg, Intravenous, PRN, opioid overdose
Administer every 3 minutes times 4 doses as needed
for respiratory rate less than 8 breaths/minute or
sedation score of 5 or greater. Notify MD if naloxone
administered.
Post-Op/Phase II
Electrolyte Supplementation
Magnesium Sulfate [121755]
Magnesium Supplemental Scale [950039] PRN - NOTIFY PHARMACY WHEN NEEDED,
magnesium supplementation - see Admin Instructions
Non-cardiac patients: For serum magnesium 1.6-1.8
mg/dL - do not replace
Cardiac patients: For serum magnesium 1.6-1.8
mg/dL give 0.05 g/kg IV x1
For serum magnesium 1.0-1.5 mg/dL give 0.1 g/kg IV
x1
For serum magnesium less than 1 mg/dL give 0.15
g/kg IV x1
Administer each 2 gram bag over 3 hours at a
frequency of one bag every 4 hours.
Maximum 6 grams per replacement dose
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
Post-Op/Phase II
Potassium Chloride [121756]
Page 20 of 25
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potassium chloride 10 mEq/100 mL bag [46253] 10 mEq, Intravenous, PRN - NOTIFY PHARMACY
WHEN NEEDED, potassium supplementation - See
Admin Instruction
For serum K between 3.6 - 3.9 mmol/L give 10 mEq
x2;
For serum K between 3.1 - 3.5 mmol/L give 10 mEq
x4;
For serum K less than or equal to 3.0 mmol/L give 10
mEq x6
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable.
for 60 Minutes, Post-Op/Phase II
Phosphate SODIUM (Single Response) [112675]
phosphate-potassium & sodium (PHOS-NAK) oral
packet - For normal renal function [112317]
2 packet, Oral, PRN, phosphate supplementation -
See Admin Instructions
For serum phosphate 1.6 - 2.4 mg/dL, give 2 packets
every 4 hours while awake x 3 doses;
For serum phosphate 1.0 - 1.5 mg/dL, give 2 packets
every 4 hours while awake x 4 doses
For serum phosphate less than 1.0 mg/dL, call
provider for IV dosing.
Post-Op/Phase II
phosphorus (K-PHOS NEUTRAL) tab - For renal
dysfunction [45503]
1 tab, Oral, PRN, phosphate supplementation - See
Admin Instructions
For serum phosphate 1.6 - 2.3 mg/dL give 1 tablet
every 4 h while awake x 3 doses
For serum phosphate 1.0 - 1.5 mg/dL give 1 tablet
every 4 h while awake x 4 doses
For serum phosphate less than 1.0 mg/dL, call
provider
Post-Op/Phase II
Laboratory
Postoperative Day 1 [87601]
CBC WITHOUT DIFFERENTIAL [HEMO] 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?
Post-Op/Phase II
ELECTROLYTES [LYTE] 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?
Post-Op/Phase II
BUN [BUN] 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?
Post-Op/Phase II
CREATININE [CRET] 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?
Post-Op/Phase II
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GLUCOSE [GLU] 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?
Post-Op/Phase II
CALCIUM [CA] 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?
Post-Op/Phase II
MAGNESIUM [MAG] 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?
Post-Op/Phase II
PHOSPHATE [PHOS] 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?
Post-Op/Phase II
TSH [TSH] 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?
Post-Op/Phase II
Postoperative Day 2 [87602]
ELECTROLYTES [LYTE] NEXT AM, Starting 12/10/17 For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
BUN [BUN] NEXT AM, Starting 12/10/17 For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
CREATININE [CRET] NEXT AM, Starting 12/10/17 For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
GLUCOSE [GLU] NEXT AM, Starting 12/10/17 For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
CALCIUM [CA] NEXT AM, Starting 12/10/17 For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
Page 22 of 25
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12/2017CCKM@uwhealth.org

MAGNESIUM [MAG] NEXT AM, Starting 12/10/17 For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
PHOSPHATE [PHOS] NEXT AM, Starting 12/10/17 For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
HEMATOCRIT [HCT] 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?
Post-Op/Phase II
Post-Electrolyte Supplementation [108694]
POTASSIUM [K] CONDITIONAL For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw 1 hour after IV
replacement and 4 hours after oral replacement
Post-Op/Phase II
MAGNESIUM [MAG] CONDITIONAL For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw AM following
completion of infusion
Post-Op/Phase II
PHOSPHATE [PHOS] CONDITIONAL For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw 1 hour after IV
replacement
Post-Op/Phase II
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [87604]
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms? Status post composite
resection, tracheotomy
What specific question(s) would you like answered by
this exam? Verify trach tube position
Relevant recent/past history? Status post composite
resection, tracheotomy
Is patient pregnant?
If being performed remotely, where? Bedside
Transport Method: Floor Determined/Entered
In PACU, PACU
Page 23 of 25
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12/2017CCKM@uwhealth.org

X-RAY ABDOMEN AP VIEW (KUB) [R74000] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? Status post composite
resection, tracheotomy
What specific question(s) would you like answered by
this exam? Verify Dobhoff tube position, desire tube
placed in stomach.
Relevant recent/past history? Status post composite
resection, tracheotomy
Is patient pregnant?
If being performed remotely, where? Bedside
Transport Method: Floor Determined/Entered
In PACU, PACU
Consults
Consults [87606]
Consult Nutrition (Inpatient) [CON0043] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Nutrition Assessment w/
Recommendations
Delegate to Initiate and Manage Tube Feeding:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
Tube feed recommendations for both continuous
(including peptide 1.5) and bolus feeding, Post-
Op/Phase II
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult: Mobility
Training
Post-Op/Phase II
Consult Case Management (Inpatient) [CON0013] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: DURABLE MEDICAL
EQUIPMENT
Home humidification if patient goes home with new
tracheotomy (or stoma)., Post-Op/Phase II
Consult Orthotics / Prosthetics (Inpatient)
[CON0051]
ONCE, Starting today For 1 Occurrences, Routine
Do you need Orthotics or Prosthetics? Orthotics
Reason for Consult: PRAFO Boot
Post-Op/Phase II
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today, Routine
Reason for Consult: DISCHARGE PLANNING
Can this consult be done via video?
Post-Op/Phase II
Consults for Patients with Laryngectomy Performed [118161]
Consult Swallow Therapy (Inpatient) [CON0079] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
May the Speech Pathologist and Registered Dietician
place diet orders on your behalf? No
Is this a potential new stroke patient?
Indication Electrolarynx. When patient is transferred
out of ICU. To be performed by the Swallow Service.,
Post-Op/Phase II
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 24 of 25
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Page 25 of 25
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:10:50 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org