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IP - Ear Surgery/Cochlear Implant - Pediatric - Postoperative [2837]

IP - Ear Surgery/Cochlear Implant - Pediatric - Postoperative [2837] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, ENT


IP - Ear Surgery/Cochlear Implant - Pediatric - Postoperative [2837]
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 [103186]
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:
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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
Patient Care Orders
Vital Signs [88248]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, 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
Activity [88249]
Ambulate with Assistance Day of Surgery
[NURACT0008]
CONTINUOUS, Starting today For 1 Days, Routine
AD LIB:
AMBULATE: with assistance
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Day of surgery., Post-Op/Phase II
Ad Lib Starting Postoperative Day 1 [NURACT0008] CONTINUOUS, Starting tomorrow, Routine
AD LIB: ad lib
AMBULATE:
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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 1., Post-Op/Phase II
Nutrition [88250]
General Diet [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet: GENERAL;
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail):
Tube Feeding Management:
Room Service Class:
Post-Op/Phase II
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
Respiratory [103996]
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today, Routine, Post-Op/Phase II
Oxygen Therapy [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%):
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
Wound Care [88251]
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Wound Care [NURWND0015] CONTINUOUS, Starting today, Routine
Wound Type: Closed - Incision
Wound Site: Head/Neck
Wound Location: Other (Comment) (Affected Ear(s))
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:
Reinforce dressing as needed., Post-Op/Phase II
If Mastoid Dressing in place may adjust or reinforce
dressing if needed [NURCOM0022]
ONCE, If Mastoid Dressing in place may adjust or reinforce
dressing if needed., Post-Op/Phase II
Intake and Output [88252]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today, Routine, Post-Op/Phase II
Non-Categorized Patient Care Orders [88253]
Measure Weight [NURMON0015] 1X DAILY, Starting today For Until specified, Routine
Weigh With?
Weigh when?
Post-Op/Phase II
No Nose Blowing [NURCOM0022] CONTINUOUS, Starting today, Post-Op/Phase II
No Popping of Ears (Valsalva) [NURCOM0022] CONTINUOUS, Starting today, Post-Op/Phase II
Sneeze with Mouth Open [NURCOM0022] CONTINUOUS, Starting today, Post-Op/Phase II
Contingency Parameters for Patients Less than 6 Months Old [88254]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 100
If systolic blood pressure < (mmHg): 65
If diastolic blood pressure > (mmHg): 65
If diastolic blood pressure < (mmHg): 45
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 180
If heart rate < (bpm): 90
If respiratory rate >: 50
If respiratory rate <: 25
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 90
If urine output < (mL):
Other: Pain not controlled with ordered analgesics or ordered
interventions,Mastoid dressing is soaked or loose
Post-Op/Phase II
Contingency Parameters for Patients 7 Months through 2 Years Old [88255]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 118
If systolic blood pressure < (mmHg): 85
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 160
If heart rate < (bpm): 80
If respiratory rate >: 40
If respiratory rate <: 20
If blood glucose > (mg/dL):
Page 4 of 8
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org

If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 90
If urine output < (mL):
Other: Pain not controlled with ordered analgesics or ordered
interventions,Mastoid dressing is soaked or loose
Post-Op/Phase II
Contingency Parameters for Patients 3 through 6 Years Old [88256]
Notify [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 118
If systolic blood pressure < (mmHg): 87
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 140
If heart rate < (bpm): 75
If respiratory rate >: 30
If respiratory rate <: 18
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 90
If urine output < (mL):
Other: Pain not controlled with ordered analgesics or ordered
interventions,Mastoid dressing is soaked or loose
Post-Op/Phase II
Contingency Parameters for Patients 7 through 10 Years Old [88257]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 125
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 70
If respiratory rate >: 24
If respiratory rate <: 14
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 90
If urine output < (mL):
Other: Pain not controlled with ordered analgesics or ordered
interventions,Mastoid dressing is soaked or loose
Post-Op/Phase II
Contingency Parameters for Patients 11 Years and Older [88258]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 140
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 110
If heart rate < (bpm): 60
If respiratory rate >: 22
If respiratory rate <: 12
Page 5 of 8
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org

If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 90
If urine output < (mL):
Other: Pain not controlled with ordered analgesics or ordered
interventions,Mastoid dressing is soaked or loose
Post-Op/Phase II
IV Fluids
Premedication for Needle Insertion [84317]
Lidocaine [152737]
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, prior to needle sticks to
reduce pain. See "LMX Use Instructions" order in Active
Orders report or the Admin Instructions for application
details
FOR PATIENTS 5 Kg OR LESS: Do NOT apply to area
greater than 100 square centimeters. (maximum 1 g/site;
maximum 1 site per hour, 6 times per day).
FOR PATIENTS 5.1-10 Kg: Do NOT apply to area greater
than 100 square centimeters. (maximum 1 g/site;
maximum 2 sites per hour, 6 times per day).
FOR PATIENTS GREATER THAN 10 Kg: Do NOT apply
to area greater than 200 square centimeters. (maximum
2.5 g/site; maximum 4 sites per hour, 6 times per day).
For patients less than 1 year old do NOT leave on longer
than 1 hour. For patients 1 year or older do NOT leave on
longer than 2 hours
Post-Op/Phase II
LMX Use Instructions for Premedication Prior to Needle
Insertion [NURCOM0095]
Post-Op/Phase II
IV Fluids [194893]
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS, Post-Op/Phase II
dextrose 5%-lactated ringers infusion [44897] Intravenous, CONTINUOUS, Post-Op/Phase II
sodium chloride 0.9% infusion [64367] Intravenous, CONTINUOUS, Post-Op/Phase II
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Post-Op/Phase II
sodium chloride flush 0.9% 10 mL injection [785055] Flush, PRN, flush/line care
Flush per VAD guidelines
Post-Op/Phase II
Discontinue IV Fluids and Cap Line When Adequate
Oral Intake [NURVAD0053]
CONTINUOUS, Starting today For Until specified, Post-
Op/Phase II
Medications - Anti-infectives
First Line (Single Response) [88266]
cefuroxime (ZINACEF) intraVENOUS - Patients who are
less than 40 kg [800030]
50 mg/kg, Intravenous, EVERY 8 HOURS For 2 Doses, Post-
Op/Phase II
cefuroxime (ZINACEF) intraVENOUS- Patients who are
40-80 kg [800030]
1.5 g, Intravenous, EVERY 8 HOURS For 2 Doses, Post-
Op/Phase II
MRSA/Documented MRSA History (Single Response) [149002]
Patients who are less than 40 kg [204579]
cefuroxime (ZINACEF) intraVENOUS [800030] 50 mg/kg, Intravenous, ONCE For 1 Doses, Post-
Op/Phase II
vancomycin (VANCOCIN) intraVENOUS [800084] 15 mg/kg, Intravenous, ONCE For 1 Doses, Post-
Op/Phase II
Patients who are 40 - 80 kg [204580]
cefuroxime (ZINACEF) intraVENOUS [800030] 1.5 g, Intravenous, ONCE For 1 Doses, Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS [800084] 15 mg/kg, Intravenous, EVERY 8 HOURS For 2 Doses,
Page 6 of 8
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Post-Op/Phase II
Immediate/Severe Reactions to Pencillin or Known Cephalosporin Allergies [149005]
vancomycin (VANCOCIN) intraVENOUS [800084] 15 mg/kg, Intravenous, ONCE For 1 Doses, Post-Op/Phase II
Medications
Analgesics - Non-opioids (Scheduled) [87754]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 15 mg/kg
(Maximum 650 mg/dose) [800005]
15 mg/kg, Oral, EVERY 6 HOURS For 12 Doses
NOTE: Suggested dose 15 mg/kg (Maximum 650 mg/dose)
Post-Op/Phase II
acetaMINOPHEN (TYLENOL) suppository - NOTE:
Suggested dose 15 mg/kg (Maximum 650 mg/dose)
[43994]
Rectal, EVERY 6 HOURS For 12 Doses
Administer if patient unable to take oral formulation
No more than 4 grams acetaminophen per 24 hours for adults
or 15 mg/kg per dose for peds <40 kg
NOTE: Suggested dose 15 mg/kg (Maximum 650 mg/dose)
Post-Op/Phase II
ibuprofen (MOTRIN) 100 mg/5 mL susp - NOTE:
Suggested dose 10 mg/kg (Maximum 600 mg/dose)
[45376]
10 mg/kg, Oral, EVERY 6 HOURS For 12 Doses
NOTE: Suggested dose 10 mg/kg (Maximum 600 mg/dose)
Post-Op/Phase II
Analgesics - Non-opioids (PRN) [143985]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 15 mg/kg
(Maximum 650 mg/dose) [800005]
15 mg/kg, Oral, EVERY 6 HOURS PRN Starting 5/30/16,
pain/fever, For temperature greater than 38.2 degrees
Celsius, or mild to moderate pain or multimodal therapy. Give
with ibuprofen
NOTE: Suggested dose 15 mg/kg (Maximum 650 mg/dose)
Post-Op/Phase II
acetaMINOPHEN (TYLENOL) suppository - NOTE:
Suggested dose 15 mg/kg (Maximum 650 mg/dose)
[43994]
Rectal, EVERY 6 HOURS PRN Starting 5/30/16, pain/fever,
For temperature greater than 38.2 degrees Celsius, or mild to
moderate pain or multimodal therapy. Give if unable to
tolerate orally
NOTE: Suggested dose 15 mg/kg (Maximum 650 mg/dose)
Post-Op/Phase II
ibuprofen (MOTRIN) 100 mg/5 mL susp - NOTE:
Suggested dose 10 mg/kg (Maximum 600 mg/dose)
[45376]
10 mg/kg, Oral, EVERY 6 HOURS PRN Starting 5/30/16,
pain, For temperature greater than 38.2 degrees Celsius, or
mild to moderate pain, or multimodal therapy. Give with
acetaminophen
NOTE: Suggested dose 10 mg/kg (Maximum 600 mg/dose)
Post-Op/Phase II
Analgesics - Opioids [87755]
Note: No Opiods [950013] 4 X DAILY (NOTE ACKNOWLEDGE), Post-Op/Phase II
MORPHine PF injection - NOTE: Suggested dose 0.05 -
0.1 mg/kg (Maximum 2 mg/dose) [800122]
0.05-0.1 mg/kg, Intravenous, EVERY 2 HOURS PRN, pain,
For moderate to severe pain and unable to take oral opioid
NOTE: Suggested dose 0.05 - 0.1 mg/kg (Maximum 2
mg/dose)
Post-Op/Phase II
oxycodone soln - NOTE: Suggested dose 0.1 - 0.2
mg/kg (Maximum 5 mg/dose) [45975]
0.1-0.2 mg/kg, Oral, EVERY 4 HOURS PRN, pain, For
moderate to severe pain
NOTE: Suggested dose 0.1 - 0.2 mg/kg (Maximum 5
mg/dose)
Post-Op/Phase II
Anti-emetics [141870]
ondansetron (ZOFRAN) injection - NOTE: Suggested
dose 0.1 mg/kg/dose (Maximum 4 mg/dose) [800202]
0.1 mg/kg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Administer as first line therapy
NOTE: Suggested dose 0.1 mg/kg (Maximum 4 mg/dose)
Post-Op/Phase II
diphenhydramine (BENADRYL) injection [800106] 0.5 mg/kg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting, Administer as second line therapy when
Page 7 of 8
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unresponsive to first line therapy within 30 minutes, Post-
Op/Phase II
Anti-emetics - 2nd Line - For Patients 2 Years or Older [87757]
promethazine (PHENERGAN) injection CUSTOM -
NOTE: Suggested dose 0.25-1 mg/kg/dose (Maximum
25 mg/dose) [800112]
Intravenous, EVERY 6 HOURS PRN, nausea/vomiting
NOTE: Suggested dose 0.25-1 mg/kg/dose (Maximum 25
mg/dose)
Post-Op/Phase II
promethazine (PHENERGAN) rectal suppository -
NOTE: Suggested dose 12.5 or 25 mg (Maximum 25
mg/dose) [46328]
Rectal, EVERY 6 HOURS PRN, nausea/vomiting
NOTE: Suggested dose 12.5 or 25 mg (Maximum 25
mg/dose)
Post-Op/Phase II
Sucrose for Oral Analgesia [110668]
sucrose (SWEET-EASE) 24% buccal soln [794009] Oral, PRN, pain, mild pain or potentially painful procedures.
See Admin Instructions, Post-Op/Phase II
Anti-infectives [148616]
ofloxacin (OCUFLOX) 0.3 % ophthalmic soln [55774] 3 drop, 3 X DAILY For 3 Doses
Give ophthalmic soln via otic route
Instill three drops in operated ear following tube placement
three times daily for three days
Post-Op/Phase II
Diagnostic Tests and Imaging - Cochlear Implants
Radiology [88269]
X-RAY SKULL < 4 VIEWS [R70250] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by this
exam? Evaluate device placement
Relevant recent/past history? Bilateral deafness status post
cochlear implant
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
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 8 of 8
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
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