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/clinical/cckm-tools/content/order-sets/inpatient/ent/name-98357-en.cckm

201606170

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UWHC,UWMF,

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

IP – Thyroplasty/Phonosurgery/Endoscopic Partial Laryngectomy/Cricopharyngeal Myotomy – Adult – Postoperative [2824]

IP – Thyroplasty/Phonosurgery/Endoscopic Partial Laryngectomy/Cricopharyngeal Myotomy – Adult – Postoperative [2824] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, ENT


IP - Thyroplasty/Phonosurgery/Endoscopic Partial Laryngectomy/Cricopharyngeal Myotomy-
Adult-Postoperative [2824]
Intended for Adult Patients Only
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 [103401]
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:
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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/references/medication-
use-manual/anticoagulation-resources/resources/name-
26461-en.file
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered [COR0008] ONCE, Routine
Reason Not Ordered: Low Risk
Moderate VTE Risk with Low Bleed Risk (Single
Response) [129778]
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
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 HOURS
Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Post-Op/Phase II
High VTE Risk with Low Bleed Risk [130127]
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
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 HOURS
Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Page 2 of 12
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Post-Op/Phase II
High Bleed Risk (Single Response) [129757]
Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Post-Op/Phase II
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:
VTE Prophylaxis (Single Response) [150176]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/references/medication-
use-manual/anticoagulation-resources/resources/name-
26461-en.file
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered [COR0008] ONCE, Routine
Reason Not Ordered: Low Risk
Moderate VTE Risk with Low Bleed Risk (Single
Response) [129778]
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
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 HOURS
Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Post-Op/Phase II
High VTE Risk with Low Bleed Risk [130127]
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
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 HOURS
Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Post-Op/Phase II
High Bleed Risk (Single Response) [129757]
Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Post-Op/Phase II
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:
Patient Care Orders
Vital Signs [87801]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
Page 3 of 12
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BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 2 hours times 2, then every 4 hours., Post-Op/Phase II
Activity [87803]
Ad Lib [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB: ad lib
AMBULATE:
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Post-Op/Phase II
Elevate Head Of Bed [NURACT0002] Equal to (degrees): 45
Greater than (degrees):
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting today, Post-Op/Phase II
No Heavy Exertion [NURACT0008] CONTINUOUS, Starting today, 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
Ambulate with Assistance [NURACT0008] CONTINUOUS, Starting today, 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:
Post-Op/Phase II
Nutrition [87804]
NPO [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
STRICT NPO
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Page 4 of 12
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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
Strict NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: Strict NPO
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
NPO Except Medications by Feeding Tube [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25): NPO
EXCEPT MEDICATIONS
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:
Page 5 of 12
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
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Tube Feeding (Use Tube Feeding Order Set to indicate order
detail): TUBE FEEDING NPO EXCEPT MEDICATIONS
Room Service Class:
Begin when feeding tube cleared for use., Post-Op/Phase II
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
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 [87805]
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today, Routine, Alarm Parameters:
Page 6 of 12
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Oxygen greater than 90%; heart rate less than 60 or greater
than 120 beats/minute., 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: Face tent (humidified oxygen)
Attempt to Wean Off Oxygen?
Post-Op/Phase II
Wound Care [87806]
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
Wound Care [NURWND0015] CONTINUOUS, Starting today, Routine
Wound Type: Closed - Incision
Wound Site: Head/Neck
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
Maintain Drain [NURTAD0003] CONTINUOUS, Starting today, Routine
Type:
Site:
Location:
Drainage Options:
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For:
Dressing Change Frequency: (Reinforce gauze as needed)
Dressing Type:
Post-Op/Phase II
Intake and Output [87807]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today, Routine, Post-Op/Phase II
Non-Categorized Patient Care Orders [87808]
Initiate Bladder Management Protocol [NURELM0014] CONTINUOUS, Routine, Post-Op/Phase II
Assess Neck for Hematoma [NURWND0018] SEE COMMENTS, Starting today, Assess neck for
hematoma every 8 hours., Post-Op/Phase II
Voice Rest [NURCOM0022] CONTINUOUS, Starting today For Until specified, Voice rest
for *** hours., Post-Op/Phase II
Moderate Voice Use [NURCOM0022] CONTINUOUS, Starting tomorrow For 1 Weeks, Moderate
voice use (no yelling or screaming) for 1 week beginning after
voice rest., Post-Op/Phase II
Contingency Parameters [87809]
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
Page 7 of 12
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If diastolic blood pressure < (mmHg): 60
If temperature > (C): 38.5
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 milliliters for 8 hours
Other: Pain not controlled with ordered analgesics or ordered
interventions,Complains of Dyspnea,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 within 1 minute.
Choice of medication should be based on patient’s previous experience/preference, history of lidocaine allergy and ease
of access.
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 [84927]
Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
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
Discontinue IV fluids when patient tolerating oral intake ONCE, Starting today For 1 Occurrences, Post-Op/Phase II
Page 8 of 12
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[NURCOM0022]
Flushes [87823]
sodium chloride 0.9% flush 10 mL injection [785055] Flush, PRN, flush/line care
Flush per VAD guidelines
Post-Op/Phase II
Surgical Prophylaxis
First line [149665]
cefuroxime (ZINACEF) intraVENOUS - NOTE: Patients
who are 40 - 160 kg [800030]
1.5 g, Intravenous, ONCE For 1 Doses, Post-Op/Phase II
cefuroxime (ZINACEF) intraVENOUS - NOTE: Patients
who are 160 kg and greater [800030]
3 g, Intravenous, ONCE For 1 Doses, Post-Op/Phase II
ampicillin/sulbactam (UNASYN) intraVENOUS [800010] 1.5 g, Intravenous, EVERY 6 HOURS, Post-Op/Phase II
ampicillin/sulbactam (UNASYN) intraVENOUS [800010] 3 g, Intravenous, EVERY 6 HOURS, Post-Op/Phase II
MRSA/Documented MRSA History (Single Response) [145904]
Patients who are 40-120 kg [204451]
cefuroxime (ZINACEF) intraVENOUS [800030] 1.5 g, Intravenous, EVERY 8 HOURS For 2 Doses, Post-
Op/Phase II
vancomycin (VANCOCIN) intraVENOUS [800084] 20 mg/kg, Intravenous, EVERY 12 HOURS For 1 Doses,
Post-Op/Phase II
Patients who are 121 kg and greater [204454]
cefuroxime (ZINACEF) intraVENOUS [800030] 3 g, Intravenous, EVERY 8 HOURS For 2 Doses, Post-
Op/Phase II
vancomycin (VANCOCIN) intraVENOUS [800084] 20 mg/kg, Intravenous, EVERY 12 HOURS For 1 Doses,
Post-Op/Phase II
MRSA Positive and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies [149667]
vancomycin (VANCOCIN) intraVENOUS [800084] 15 mg/kg, Intravenous, ONCE For 1 Doses, Post-Op/Phase II
MRSA Negative and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies [149666]
clindamycin (CLEOCIN) intraVENOUS - NOTE: Patients
who are 40 - 80 kg [800033]
600 mg, Intravenous, ONCE For 1 Doses, Post-Op/Phase II
clindamycin (CLEOCIN) intraVENOUS - NOTE: Patients
who are 81 - 160 kg [800033]
900 mg, Intravenous, ONCE For 1 Doses, Post-Op/Phase II
clindamycin (CLEOCIN) inraVENOUS - NOTE: Patients
who are greater than 160 kg [800033]
1,200 mg, Intravenous, ONCE For 1 Doses, Post-Op/Phase II
Medications - General
Analgesics - Intravenous Opioids (Single Response) [84929]
HYDROmorphone PF (DILAUDID) injection RANGE
[750050]
0.2-0.5 mg, Intravenous, EVERY 2 HOURS PRN, For severe
pain if unable to tolerate oral medications, 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 tolerate oral medications, for 4
Minutes, Post-Op/Phase II
Analgesics - Oral Opioids (Single Response) [84930]
hydrocodone-acetaMINOPHEN (NORCO) 5-325 mg per
tab RANGE [750021]
1-2 tab, Oral, EVERY 4 HOURS PRN, pain, For severe pain,
Post-Op/Phase II
oxycodone-acetaminophen (PERCOCET) 5-325 mg per
tab RANGE [750033]
1-2 tab, Oral, EVERY 4 HOURS PRN, pain, For severe pain,
Post-Op/Phase II
oxycodone 5 MG/5ML soln RANGE [750031] 5-10 mg, Oral, EVERY 4 HOURS PRN, pain, For severe pain,
Post-Op/Phase II
oxycodone tab [45976] 5-10 mg, Oral, EVERY 4 HOURS PRN, pain, For severe pain,
Post-Op/Phase II
Analgesics - Non-opioids (Single Response) [87815]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain, For temperature
greater than 38.3 degrees Celsius, mild pain, or multimodal
therapy, Post-Op/Phase II
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Oral, EVERY 4 HOURS PRN, pain, For temperature
greater than 38.3 degrees Celsius, mild pain, or multimodal
Page 9 of 12
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
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therapy, Post-Op/Phase II
Anti-emetics [84932]
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, Post-Op/Phase II
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN, nausea/vomiting, For
second line therapy if unresponsive to first line therapy 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 therapy
after 30 minutes and unable to take orally., Post-Op/Phase II
Anti-hypertensives [149091]
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
Anti-inflammatories [103680]
dexamethasone (DECADRON) intraVENOUS - NOTE:
Order for patients with endoscopic partial laryngectomy
[800037]
6 mg, Intravenous, EVERY 6 HOURS For 3 Doses
Begin 6 hours after intra-operative dose.
NOTE: Order for patients with endoscopic partial
laryngectomy
Post-Op/Phase II
Bowel Management - Scheduled [149121]
senna-docusate (SENOKOT-S) 8.6-50 mg per tab
[60530]
2 tab, Oral, 2 X DAILY
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
docusate sodium (COLACE) soln [74449] 100 mg, Dobhoff Tube, 2 X DAILY
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
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 [149122]
magnesium hydroxide (MILK OF MAGNESIA) susp
[65443]
30 mL, Oral, 2 X DAILY PRN, constipation
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 powder [61353] 17 g, Oral, 1 X DAILY PRN, constipation
Dissolve in 8 ounces 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
Page 10 of 12
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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
Hypnotics [111640]
traZODONE (DESYREL) tab [720150] 25 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic interventions
(see IPOC supplemental Sleep/Rest Disturbance Adult)
Post-Op/Phase II
Non-categorized [87824]
Note: No NSAIDS [950012] 4 X DAILY (NOTE ACKNOWLEDGE), Post-Op/Phase II
Note: No Aspirin [950008] 4 X DAILY (NOTE ACKNOWLEDGE), Post-Op/Phase II
Note: No Heparin [950010] 4 X DAILY (NOTE ACKNOWLEDGE), Post-Op/Phase II
Note: No Ketorolac [950018] 4 X DAILY (NOTE ACKNOWLEDGE)
No Ketorolac
Post-Op/Phase II
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
Laryngopharyngeal Reflux (Single Response) [87825]
ranitidine (ZANTAC) injection [800075] 50 mg, Intravenous, EVERY 8 HOURS, Post-Op/Phase II
pantoprazole (PROTONIX) injection [800119] 40 mg, Intravenous, 1 X DAILY, Post-Op/Phase II
pantoprazole (PROTONIX) EC tab [62661] 40 mg, Oral, 1 X DAILY, Post-Op/Phase II
Diagnostic Tests and Imaging
Radiology [87827]
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? Postoperative
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 Dobhoff placement
Is patient pregnant?
If being performed remotely, where? Bedside
Transport Method: Floor Determined/Entered
Obtain in PACU., Post-Op/Phase II
For Patients Undergoing Cricopharyngeal Myotomy [113591]
GI ESOPHAGRAM [R74220] ONCE-RAD NEXT AVAILABLE, Starting tomorrow, Routine
Current signs and symptoms? Status post cricopharyngeal
myotomy
What specific question(s) would you like answered by this
exam? Evaluate for esophageal leak
Relevant recent/past history? Cricopharyngeal dysfunction
Is patient pregnant?
For scheduling purposes, does the patient require general
anesthesia, sedation or anxiolytics? Note: ordering provider is
responsible for prescribing oral anxiolytics or arranging peds
anesthesia / sedation services. See reference link above.
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
GI Esophagram to be done on post operative day 1., Post-
Page 11 of 12
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org

Op/Phase II
Consults
Consults [87829]
Consult Nutrition (Inpatient) [CON0043] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Delegate to Initiate and Manage Tube Feeding:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
Can this consult be done via video?
Post-Op/Phase II
Consult Swallow Therapy (Inpatient) [CON0079] ONCE, Routine
Reason for Consult: EVALUATE AND TREAT PATIENT
(Swallow evaluation)
May the Speech Pathologist and Registered Dietician place
diet orders on your behalf?
Swallow evaluation., 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 12 of 12
Printed by LIND, JANNA S [JSL237] at 5/26/2016 1:08:52 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org