/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-98351-en.cckm

201710291

page

100

UWHC,UWMF,

Tools,

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

IP – Laryngectomy – Without Free Flap – Adult – Postoperative [2820]

IP – Laryngectomy – Without Free Flap – Adult – Postoperative [2820] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, ENT


IP - Laryngectomy - Without Free Flap - Adult - Postoperative [2820]
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 [103409]
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Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-only
surgery, or a previously-authorized inpatient stay.
Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
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) [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]
Page 2 of 20
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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 PF 5000 UNIT/0.5ML injection [156571] 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 PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 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) [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]
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 PF 5000 UNIT/0.5ML injection [156571] 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 PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Post-Op/Phase II
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Page 3 of 20
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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 [231555]
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 [231558]
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 20
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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 20
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10/2017CCKM@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 10/19/17 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 [231573]
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 20
Printed by STRAKA, KEVIN F [KFS1] at 10/11/2017 7:39:52 PM
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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 [231576]
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 20
Printed by STRAKA, KEVIN F [KFS1] at 10/11/2017 7:39:52 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@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 20
Printed by STRAKA, KEVIN F [KFS1] at 10/11/2017 7:39:52 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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10/2017CCKM@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 10/19/17 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 [87642]
Vital Signs [NURMON0013] EVERY 2 HOURS, Starting today For 2 Occurrences,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 2 hours times 2, then every 4 hours., Post-
Op/Phase II
Activity [87643]
Elevate Head Of Bed [NURACT0002] Equal to (degrees): 30
Greater than (degrees):
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting today, Post-
Op/Phase II
Page 9 of 20
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Chair With Assistance [NURACT0008] CONTINUOUS, Starting today, 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:
Post-Op/Phase II
Ambulate With Assistance [NURACT0008] CONTINUOUS, Starting tomorrow, Routine
AD LIB:
AMBULATE: with assistance,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:
Post-Op/Phase II
NPO Except Medications by Feeding Tube [87644]
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:
Post-Op/Phase II
Respiratory [87645]
Deep Breathe [NURTRT0019] EVERY 2 HOURS, Starting today For Until specified,
Routine, Post-Op/Phase II
Pulse Oximetry [NURMON0009] SEE COMMENTS, Starting today, Routine,
Continuous for first 24 hours postop, then every 4
hours., 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
Page 10 of 20
Printed by STRAKA, KEVIN F [KFS1] at 10/11/2017 7:39:52 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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10/2017CCKM@uwhealth.org

Respiratory Therapist to Discontinue Heated
Trach Mask Once the LaryTube is Placed and
Heat and Moisture Exchanger is Being Utilized
[NURCOM0022]
ONCE, Post-Op/Phase II
Maintain HME Valve [NURCOM0022] ONCE, Change the HME every 24 hours or more
frequently if significant soiling occurs. Clean the
LaryTube per manufacturer's instructions. Secure the
LaryTube with neck strap and place HME in LaryTube.
HME can be worn 24 hours a day., Post-Op/Phase II
Wound Care [87646]
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: 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, 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 20
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Suture Line Care [NURWND0015] CONTINUOUS, Starting today For Until specified,
Routine
Wound Type: Closed - Incision (Suture Line Care)
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
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
Stoma/Tracheotomy Care Orders [87647]
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
Suction Airway (tracheal suction) [NURTAD0017] PRN, Routine
Location: Tracheal
Post-Op/Phase II
Provide Stoma Care [NURTAD0019] 2X DAILY PRN, Starting today For Until specified,
Routine, Every 8 hours and as needed, 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 with 5 mL Normal Saline and suction
airway every 8 hrs and as needed for thick mucous
with suctioning for airway clearance. Remove inner
cannula and clean or replace with each irrigation.,
Post-Op/Phase II
Intake and Output [87648]
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
Non-Categorized Patient Care Orders [87649]
Page 12 of 20
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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, Starting today, 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 Single 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?
Discontinue on postoperative day 1
Urinary Catheter Removal Protocol does NOT apply to
Urology, Gynecology, spinal cord injured patients or
patients with catheters placed by Urology on prior
admission. Not appropriate for Pediatric patients.,
Post-Op/Phase II
Measure Weight [NURMON0015] 1X DAILY For Until specified, Routine
Weigh With?
Weigh when?
Post-Op/Phase II
Initiate Bladder Management Protocol
[NURELM0014]
CONTINUOUS, Routine, Post-Op/Phase II
Contingency Parameters [87650]
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,Neck swelling,Complains of
dyspnea
Post-Op/Phase II
Intravenous Therapy
Page 13 of 20
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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 within 1 minute. Choice of medication should be based on patient’s previous
experience/preference, history of lidocaine allergy and ease of access.
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
lidocaine (XYLOCAINE) 1% injection [39034] 0.1-0.4 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.
Choice of medication should be based on patient’s
previous experience/preference, history of lidocaine
allergy and ease of access
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.
Choice of medication should be based on patient’s
previous experience/preference, history of lidocaine
allergy and ease of access
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
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
Page 14 of 20
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Surgical Prophylaxis
First line [149241]
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 160 kg and greater-
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) [149240]
Patients who are 40 - 80 kg - Cefazolin and
Vancomcyin [231958]
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 - Cefazolin and
Vancomycin [231961]
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 greater than 121 kg - Cefazolin
and Vancomycin [231964]
cefazolin (ANCEF) intraVENOUS [800000] 3 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 40 - 120 kg -
Ampicillin/Sulbactim and Vancomycin [231967]
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 -
Ampicillin/Sulbactim and Vancomycin [231970]
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
Immediate/Severe Reactions to Pencillin or Known Cephalosporin Allergies (Single Response) [148960]
URL:
Panel: Patients who are 40-160 kg -
Moxifloxacin-vancomycin [230590]
moxifloxacin (AVELOX) 400 mg in sodium
chloride 0.8% 250 mL bag [68662]
400 mg, Intravenous, EVERY 24 HOURS For 1
Doses, for 60 Minutes, Post-Op/Phase II
Page 15 of 20
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vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Panel: Patients who are greater than 160 kg -
Moxifloxacin-vancomycin [230593]
moxifloxacin (AVELOX) 400 mg in sodium
chloride 0.8% 250 mL bag [68662]
400 mg, Intravenous, EVERY 24 HOURS For 2
Doses, for 60 Minutes, Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
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 - Intravenous Opioids (Single Response) [193950]
HYDROmorphone PF (DILAUDID) injection
RANGE [750050]
0.2-0.4 mg, Intravenous, EVERY 2 HOURS PRN, For
severe pain if unable to take orally or by feeding tube,
for 3 Minutes, Post-Op/Phase II
MORPHine PF injection RANGE [750057] 1-4 mg, Intravenous, EVERY 2 HOURS PRN, pain,
For severe pain if unable to take orally or by feeding
tube, for 4 Minutes, Post-Op/Phase II
Analgesics - Oral Opioids [205070]
oxycodone 5 MG/5ML soln RANGE [750031] 5-10 mg, Dobhoff Tube, EVERY 4 HOURS PRN, pain,
severe pain
Do NOT administer until feeding tube is cleared for
use. For severe pain.
Post-Op/Phase II
Analgesics - Non-opioids [205071]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Dobhoff Tube, EVERY 4 HOURS PRN, pain,
Do NOT administer until feeding tube is cleared for
use. For mild to moderate pain or multimodal therapy.,
Post-Op/Phase II
Anti-emetics [205031]
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 12 HOURS PRN,
nausea/vomiting, For first line therapy if unable to take
orally., Post-Op/Phase II
ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
4 mg, Oral, EVERY 12 HOURS PRN,
nausea/vomiting, For first line therapy., Post-
Op/Phase II
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting, For second line therapy if
unresponsive to first line theraply after 30 minutes and
unable to take orally or by feeding tube., Post-
Op/Phase II
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Dobhoff Tube, EVERY 6 HOURS PRN,
nausea/vomiting
Do NOT administer until feeding tube is cleared for
use. For second line therapy if unresponsive to first
line selection after 30 minutes.
Post-Op/Phase II
prochlorperazine (COMPAZINE) rectal
suppository [46323]
25 mg, Rectal, EVERY 12 HOURS PRN,
nausea/vomiting, For second line therapy if
unresponsive to first line selection after 30 minutes
and unable to take orally., Post-Op/Phase II
Anti-hypertensives [149091]
Page 16 of 20
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hydrALAZINE (APRESOLINE) injection RANGE
[750049]
10-20 mg, Intravenous, EVERY 2 HOURS PRN
For systolic blood pressure greater than 160 mmHg
and heart rate LESS than 60 beats per minute.
Post-Op/Phase II
labetalol (NORMODYNE;TRANDATE) injection
RANGE [750053]
10-20 mg, Intravenous, EVERY 2 HOURS PRN
For systolic blood pressure greater than 160 mmHg
and heart rate GREATER than 60 beats per minute.
for 2 Minutes, 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]
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, Dobhoff Tube, 2 X DAILY PRN, constipation
Do NOT administer until feeding tube is cleared for
use. Hold for loose stool or suspected obstruction.
Use as first line rescue therapy if inadequate response
to scheduled bowel management.
Post-Op/Phase II
polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Dobhoff Tube, 1 X DAILY PRN, constipation
Do NOT administer until feeding tube is cleared for
use. Dissolve in 8 ounces of water. Hold for loose
stool or suspected obstruction. Use as second line
rescue therapy if inadequate response to previous
therapy.
Post-Op/Phase II
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal, 1 X DAILY PRN, constipation
Hold for loose stool or suspected obstruction. Use as
third line rescue therapy if inadequate response to
previous therapy or if immediate laxation is required.
Post-Op/Phase II
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
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
Page 17 of 20
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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
Laboratory
Postoperative Hour 4 [193951]
HEMATOCRIT [HCT] CONDITIONAL, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw postoperative
hour 4
Post-Op/Phase II
ELECTROLYTES [LYTE] CONDITIONAL, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw postoperative
hour 4
Post-Op/Phase II
BUN [BUN] CONDITIONAL, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw postoperative
hour 4
Post-Op/Phase II
CREATININE [CRET] CONDITIONAL, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw postoperative
hour 4
Post-Op/Phase II
GLUCOSE [GLU] CONDITIONAL, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw postoperative
hour 4
Post-Op/Phase II
CALCIUM [CA] CONDITIONAL, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw postoperative
hour 4
Post-Op/Phase II
Postoperative Day 1 [87666]
Page 18 of 20
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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
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
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
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
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [87668]
Page 19 of 20
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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
laryngectomy
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
laryngectomy
Is patient pregnant?
If being performed remotely, where? Bedside
Transport Method: Floor Determined/Entered
In PACU, Post-Op/Phase II
Consults
Consults [87670]
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 Swallow Therapy (Inpatient) [CON0079] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Evaluate and Treat Patient
May the Speech Pathologist and Registered Dietician
place diet orders on your behalf? No
Is this a potential new stroke patient? No
Indication: Electrolarynx. Postoperative Day 2. To be
performed in Swallow Service. Home Medical
Equipment Education/Training Postoperative Day 3.,
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 Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: DISCHARGE PLANNING
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 20 of 20
Printed by STRAKA, KEVIN F [KFS1] at 10/11/2017 7:39:52 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org