/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/general-surgery/,

/clinical/cckm-tools/content/order-sets/inpatient/general-surgery/name-118173-en.cckm

201712341

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,General Surgery

IP - General Surgery - Adult - Preop/Admission [6429]

IP - General Surgery - Adult - Preop/Admission [6429] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, General Surgery


IP - General Surgery - Adult - Preop/Admission [6429]
for Adult Patients OnlyIntended
Admission Status
Level of Care (Single Response) [186484]
*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:
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status (Single Response) [82665]
Page 1 of 20
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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:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status (Single Response) [20869]
Admit To Inpatient Status [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:
Admit To Observation Status [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [211046]
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
Moderate VTE Risk with Low Bleed Risk (Single
Response) [209954]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
Page 2 of 20
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:55:37 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

High VTE with Low Bleed Risk [211018]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 8 HOURS
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
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
VTE Prophylaxis (Single Response) [211047]
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
Moderate VTE Risk with Low Bleed Risk (Single
Response) [209954]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
High VTE with Low Bleed Risk [211018]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
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
No VTE Prophylaxis [130084]
Page 3 of 20
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:55:37 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Patient Care Orders
Vital Signs [224973]
Vital Signs [NURMON0013] EVERY 8 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Vital Signs [NURMON0013] SEE COMMENTS, Starting today with First
Occurrence As Scheduled, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 4 hours for 12 hours, then every 8 hours.
Vital Signs [NURMON0013] EVERY 4 HOURS, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Patient Monitoring [146142]
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
ONCE, Routine
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Functional Cardiac Defibrillator Present:
Activity [224974]
Mobilize Patients EarlyREMINDER:
Ambulate Ad Lib [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE: ad lib
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Nutrition [224602]
#1406Tube Feeding Orders, Refer to Tube Feeding Order Set, For
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Page 4 of 20
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Strict NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: Strict NPO
Bedside Meal Instructions:
Room Service Class:
NPO for Procedure - Hold Diet 18 hours
[DIE0007]
CONTINUOUS NPO, Routine
NPO For Which Procedure?
Modifiers:
Perioperative Normoglycemia Management - For Colorectal Patients ONLY (Single Response) [224977]
Patient Not a Colorectal Patient [224980]
Patient not a Colorectal Patient [NURCOM0022] ONCE
Patients withOUT Diabetes [224981]
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?
Glucose, POC [IPGLUCOSE] EVERY 2 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?
Repeat POC glucose if previous reading greater
than or equal to 180 mg/dL. No recheck for reading
< 180 mg/dL
Notify Provider [NURCOM0001] Provider to Notify: Other (Comment)
Notify based on: Blood Glucose
If blood glucose > (mg/dL): 179
If blood glucose < (mg/dL):
Patients WITH Diabetes [224982]
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?
Glucose, POC [IPGLUCOSE] EVERY 2 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?
Repeat POC glucose if previous reading greater
than or equal to 180 mg/dL. No recheck for reading
< 180 mg/dL
Notify Provider [NURCOM0001] Provider to Notify: Other (Comment)
Notify based on: Blood Glucose
If blood glucose > (mg/dL): 179
If blood glucose < (mg/dL):
Respiratory [224975]
Page 5 of 20
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:55:37 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Oxygen Therapy [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 92
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Respiratory Therapy per Protocol [RT0035] Routine
Protocol Type:
CPAP Overnight and Nap [RT0063] OVERNIGHT AND NAP, Routine
Therapy Settings: Per RT
CPAP Level (cm H2O):
Oxygen (LPM or %):
Self Administered (Only RT may document in this box
after patient assessment): RT Approval Required
Incentive Spirometry [NURTRT0018] EVERY 2 HOURS, Starting today, Routine, While
awake.
Cough And Deep Breathe [NURTRT0019] EVERY 2 HOURS, Starting today, Routine, While
awake.
Intake and Output [224976]
Measure Intake And Output [NURMON0005] EVERY 4 HOURS, Starting today, Routine
Non-Categorized Patient Care Orders [225641]
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With? Portable Scale
Weigh when? AM
Standing preferred.
Insert and 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:
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Insert and Maintain Nasogastric Tube
[NURTAD0014]
CONTINUOUS, Routine
Options:
Flush with:
Flush Frequency:
Clamp NG Tube:
Check Residual:
Does this need to be inserted/placed?
Device Status:
Contingency Parameters [7488]
Page 6 of 20
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12/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 175
If systolic blood pressure < (mmHg): 95
If diastolic blood pressure > (mmHg): 110
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.3
If temperature < (C):
If heart rate > (bpm): 115
If heart rate < (bpm): 45
If respiratory rate >: 26
If respiratory rate <: 6
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 92% RA
If urine output < (mL):
Other:
Intravenous Therapy
Premedications for Needle Insertion [106310]
Use lidocaine topical dressing kit for stable patient, no lidocaine allergies, have at least 30
minutes time prior to needing to use IV
Sodium chloride (bacteriostatic) 0.9% intradermal: Useful for patients requiring urgent IV
access; onset is immediate.
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
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.
IV Fluids/Venous Access [224885]
lactated ringers infusion [38890] Intravenous, CONTINUOUS
sodium chloride 0.9 % infusion [64367] Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.9% infusion [51641] Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L
infusion [44910]
Intravenous, CONTINUOUS
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Surgical Prophylaxis - Appendectomy
First Line (Single Response) [224869]
cefoxitin (MEFOXIN) intraVENOUS - Patients
who are 40 - 120 kg [800022]
2 g, Intravenous, ON CALL For 1 Doses
cefoxitin (MEFOXIN) intraVENOUS - Patients
who are 121 kg or greater [800022]
3 g, Intravenous, ON CALL For 1 Doses
Patients who are 40 - 120 kg - Cefazolin +
Metronidazole [228300]
Page 7 of 20
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 120 kg - Cefazolin
+ Metronidazole [228301]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
MRSA/Documented MRSA History (Single Response) [224870]
Patients who are 40-120 kg - Cefoxitin +
Vancomycin [228397]
cefoxitin (MEFOXIN) intraVENOUS [800022] 2 g, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 120 kg - Cefoxtin
+ Vancomycin [228401]
cefoxitin (MEFOXIN) intraVENOUS [800022] 3 g, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are 40 - 120 kg - Cefazolin +
Metronidazole + Vancomycin [228399]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 120 kg - Cefazolin
+ Metronidazole + Vancomycin [228405]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
MRSA Negative and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single
Response) [224871]
Patients who are 40-120 kg [224089]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses
Patients who are 121 - 160 kg [224091]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 160 kg [224092]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
MRSA and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single
Response) [224873]
Patients who are 40-120 kg [228487]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses
Page 8 of 20
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

vancomycin (VANCOCIN) intraVENOUS -
Maximum 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are 121 - 160 kg [228490]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum of 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 160 kg [228488]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Surgical Prophylaxis - Biliary Tract
First Line (Single Response) [224906]
cefazolin (ANCEF) intraVENOUS - NOTE:
Patients who are 40 - 120 kg [800000]
2 g, Intravenous, ON CALL For 1 Doses
cefazolin (ANCEF) intraVENOUS - NOTE:
Patients who are 121 kg and greater [800000]
3 g, Intravenous, ON CALL For 1 Doses
ampicillin/sulbactam (UNASYN) intraVENOUS -
NOTE: Patients who are 40 kg and greater
[800010]
3 g, Intravenous, ON CALL For 1 Doses
MRSA/Documented MRSA History (Single Response) [224874]
Patients who are 40 - 120 kg - Cefazolin +
Vancomycin [228785]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 120 kg - Cefazolin
+ Vancomycin [228787]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are 40 kg and greater - Ampicillin /
Sulbactam + Vancomycin [228786]
ampicillin/sulbactam (UNASYN) intraVENOUS
[800010]
3 g, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
MRSA Negative and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single
Response) [224876]
Patients who are 40 - 120 kg - Ciprofloxacin +
metRONIDazole [226768]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses
Patients who are 121-160 kg - Ciprofloxacin +
metRONIDazole [226771]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 160 kg -
Ciprofloxacin + metRONIDazole [226769]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses
Page 9 of 20
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
Patients who 40 -120 kg - metRONIDazole and
Gentamicin [226770]
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses
gentamicin (GARAMYCIN) intraVENOUS
[800049]
5 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who 121 kg and greater -
metRONIDazole and Gentamicin [226773]
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
gentamicin (GARAMYCIN) intraVENOUS
[800049]
5 mg/kg, Intravenous, ON CALL For 1 Doses
MRSA and Immediate/Severe Reactions to Pencillin or Known Cephalosporin Allergies (Single
Response) [224877]
Patients who are 40-120 kg - Ciprofloxacin -
MetRONIDazole - Vancomycin [228587]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are 121 - 160 kg - Ciprofloxacin -
Metronidazole - Vancomycin [228589]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 160 kg -
Ciprofloxacin - MetRONIDazole - Vancomycin
[228588]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Surgical Prophylaxis - Colorectal
First Line (Single Response) [224878]
Patients who are 40 - 120 kg - Cefazolin +
metRONIDazole [228298]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 120 kg - Cefazolin
+ metRONIDazole [228299]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
MRSA/Documented MRSA History (Single Response) [224879]
Patients who are 40 - 120 kg - Cefazolin +
metRONIDazole + Vancomycin [228286]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses
Page 10 of 20
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:55:37 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 120 kg - Cefazolin
+ metRONIDazole + Vancomycin [228288]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
MRSA Negative and Immediate/Severe Reaction to Penicillin or Known Cephalosporin Allergies (Single
Response) [224880]
Patients who are 40 - 120 kg [224102]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses
Patients who are 121 - 160 kg [224103]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 160 kg [224104]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
MRSA and Immediate/Severe Reaction to Penicillin or Known Cephalosporin Allergies (Single
Response) [224883]
Patients who are 40 - 120 kg [228595]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose - 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are 121 - 160 kg [228597]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose - 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 160 kg [228596]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose - 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Surgical Prophylaxis - Gastroduodenal
First Line (Single Response) [224925]
cefazolin (ANCEF) intraVENOUS - Patients who
are 40 - 120 kg [800000]
2 g, Intravenous, ON CALL For 1 Doses, IntraOp
cefazolin (ANCEF) intraVENOUS - Patients who
are 121 kg or greater [800000]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
MRSA/Documented MRSA History (Single Response) [224881]
Patients who are 40 - 120 kg [228837]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses
Page 11 of 20
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:55:37 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are 121 kg or greater [228838]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
MRSA Negative and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies
[224928]
moxifloxacin (AVELOX) 400 mg in sodium
chloride 0.8% 250 mL bag - NOTE: Patients who
are 40 - 160 kg [168649]
400 mg, Intravenous, ON CALL For 1 Doses, for 60
Minutes
moxifloxacin (AVELOX) 400 mg in sodium
chloride 0.8% 250 mL - NOTE: Patients who are
greater than 160 kg [168649]
400 mg, Intravenous, EVERY 1 HOUR For 2 Doses,
for 60 Minutes
MRSA and Immediate Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single
Response) [224882]
URL:
Patients who are 40-160 kg [234206]
moxifloxacin (AVELOX) 400 mg in sodium
chloride 0.8% 250 mL bag [168649]
400 mg, Intravenous, ON CALL For 1 Doses, for 60
Minutes
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 160 kg [234209]
moxifloxacin (AVELOX) 400 mg in sodium
chloride 0.8% 250 mL bag [168649]
400 mg, Intravenous, EVERY 1 HOUR For 2 Doses,
for 60 Minutes
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Surgical Prophylaxis - Hernia Repair
First Line (Single Response) [224925]
cefazolin (ANCEF) intraVENOUS - Patients who
are 40 - 120 kg [800000]
2 g, Intravenous, ON CALL For 1 Doses, IntraOp
cefazolin (ANCEF) intraVENOUS - Patients who
are 121 kg or greater [800000]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
MRSA/Documented MRSA History (Single Response) [224881]
Patients who are 40 - 120 kg [228837]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are 121 kg or greater [228838]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Immediate/Severe Reactions to Pencillin or Known Cephalosporin Allergies (Single Response) [224931]
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Surgical Prophylaxis - Small Intestine (non-obstructed)
First Line (Single Response) [224925]
cefazolin (ANCEF) intraVENOUS - Patients who
are 40 - 120 kg [800000]
2 g, Intravenous, ON CALL For 1 Doses, IntraOp
cefazolin (ANCEF) intraVENOUS - Patients who
are 121 kg or greater [800000]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
MRSA/Documented History of MRSA (Single Response) [224884]
Patients who are 40 - 120 kg [228791]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses
Page 12 of 20
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:55:37 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 120 kg [228792]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
MRSA Negative and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single
Response) [224871]
Patients who are 40-120 kg [224089]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses
Patients who are 121 - 160 kg [224091]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 160 kg [224092]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
MRSA and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single
Response) [224873]
Patients who are 40-120 kg [228487]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are 121 - 160 kg [228490]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum of 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 160 kg [228488]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Surgical Prophylaxis – Small Intestine (obstructed)
First Line (Single Response) [224878]
Patients who are 40 - 120 kg - Cefazolin +
metRONIDazole [228298]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 120 kg - Cefazolin
+ metRONIDazole [228299]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
MRSA/Documented MRSA History (Single Response) [224879]
Page 13 of 20
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:55:37 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Patients who are 40 - 120 kg - Cefazolin +
metRONIDazole + Vancomycin [228286]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 120 kg - Cefazolin
+ metRONIDazole + Vancomycin [228288]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
MRSA Negative and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single
Response) [224871]
Patients who are 40-120 kg [224089]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses
Patients who are 121 - 160 kg [224091]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 160 kg [224092]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
MRSA and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single
Response) [224873]
Patients who are 40-120 kg [228487]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are 121 - 160 kg [228490]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum of 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are greater than 160 kg [228488]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Medications - General
Nursing Communication Orders [152794]
Page 14 of 20
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:55:37 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

On day of surgery, do not administer ACE
inhibitors (angiotensin-converting-enzyme
inhibitors which include benzepril, captopril,
enalapril, fosinopril, lisinopril, moexipril,
perindopril, quinapril, ramipril, trandolapril)
[NURCOM0022]
ONCE
On day of surgery, do not administer ARB
(antiotensin II receptor blockers which include
losartan, candesartan, valsartan, irbesartan,
telmisartan, eprosartan, olmesartan)
[NURCOM0022]
ONCE
On day of surgery, do not administer oral diabetic
medications or fast acting insulin [NURCOM0022]
ONCE
On day of surgery, do not administer aspirin
UNLESS stents are in place then continue
[NURCOM0022]
ONCE
If patient is on any of the following: ACE; ARB;
oral diabetic medications or fast acting insulin; or
aspirin - please contact house officer.
[NURCOM0022]
ONCE
Patient should have discontinued use of any
herbal medications and NSAIDs now
[NURCOM0022]
ONCE
Wash abdomen with Hibiclens the night before
surgery and the morning of surgery
[NURCOM0022]
ONCE
Analgesics - Acetaminophen - Scheduled (Single Response) [224886]
acetaMINOPHEN (TYLENOL) tab [34149] 975 mg, Oral, 4 X DAILY
Antiemetics [224887]
Adult - Standard - Anti-emetics [240445]
ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
4 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
Use first line
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Use first line if unable to take medications by mouth
or enteral tube OR if immediate effect is needed.
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
Use second line if there is inadequate response to
first line anti-emetic within 30 minutes. If there is no
response to second line therapy within 30 minutes,
notify provider
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Use second line. Use if there is inadequate
response to first line anti-emetic within 30 minutes
and if unable to take medications by mouth or
enteral tube OR if immediate effect is needed. If
there is no response to second line therapy within 30
minutes, notify provider
Bowel Management - Scheduled [147657]
senna-docusate (SENOKOT-S) 8.6-50 mg per tab
[60530]
2 tab, Oral, 2 X DAILY
Bowel Management - As Needed [226355]
Page 15 of 20
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:55:37 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Adult - Bowel Management - As Needed
[240448]
polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 1 X DAILY PRN, constipation
First Line Therapy
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, Oral, 1 X DAILY PRN, constipation
Second line therapy, if no response to first line
therapy within 12 hours
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal, 1 X DAILY PRN, constipation
If unable to take medications by mouth or enteral
tube OR if need immediate laxation OR if failure of
second line agent after 6 hours
Pruritus [224888]
diphenhydramine (BENADRYL) injection [800106] 25-50 mg, Intravenous, EVERY 6 HOURS PRN,
itching
Hypnotics (Single Response) [228331]
traZODONE (DESYREL) tab [720150] 50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
melatonin tab [119466] 3 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
Trazodone - Melatonin [227992] "And" Linked Panel
traZODONE (DESYREL) tab [720150] 50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Use first line.
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
melatonin tab [119466] 3 mg, Oral, 1 X DAILY (HS) PRN, sleep
Use second line if failure to respond to trazodone
within 60 minutes
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
Hypnotics (Single Response) [228334]
traZODONE (DESYREL) tab [720150] 25 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
If needed, give prior to midnight if possible. May
contribute to sedation the following day.
melatonin tab [119466] 1 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
Steriod Dosing (Single Response) [224889]
hydrocortisone sodium succinate injection
[800189]
25 mg, Intravenous, ON CALL For 1 Doses
Administer 1 hour prior to incision
hydrocortisone sodium succinate injection
[800189]
35 mg, Intravenous, ON CALL For 1 Doses
Administer 1 hour prior to incision
hydrocortisone sodium succinate injection
[800189]
50 mg, Intravenous, ON CALL For 1 Doses
Administer 1 hour prior to incision
Bowel Prep [225609]
Preferred Bowel Prep [226358]
Page 16 of 20
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:55:37 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

G.I. lavage (GOLYTELY) 236 G soln [103976] 4 L, Oral, ONCE For 1 Doses
Give 240mL every 10 minutes until 4 L are
consumed or the rectal effluent is clear.
Start pre-day of surgery
metRONIDazole (FLAGYL) tab [39639] 750 mg, Oral, SEE ADMIN INSTRUCTIONS
Give one hour after finishing GI lavage solution.
Pharmacy may adjust schedule based on bowel
prep start time.
metRONIDazole (FLAGYL) tab [39639] 750 mg, Oral, SEE ADMIN INSTRUCTIONS
Give two hours after finishing GI lavage solution.
Pharmacy may adjust schedule based on bowel
prep start time.
metRONIDazole (FLAGYL) tab [39639] 750 mg, Oral, SEE ADMIN INSTRUCTIONS
Give at 10pm the night before surgery. Pharmacy
may adjust schedule based on bowel prep start time.
neomycin tab [40142] 1,000 mg, Oral, SEE ADMIN INSTRUCTIONS
Give one hour after finishing GI lavage solution.
Pharmacy may adjust schedule based on bowel
prep start time.
neomycin tab [40142] 1,000 mg, Oral, SEE ADMIN INSTRUCTIONS
Give two hours after finishing GI lavage solution.
Pharmacy may adjust schedule based on bowel
prep start time.
neomycin tab [40142] 1,000 mg, Oral, ONCE For 1 Doses
Give at 10pm the night before surgery. Pharmacy
may adjust schedule based on bowel prep start time
phosphate (FLEET) enema [37517] 1 enema, Rectal, ONCE For 1 Doses
Pharmacist to schedule 1 hour prior to time of
surgery.
Caution in patients with renal dysfunction.
Anti-hypertensives (Single Response) [136615]
hydrALAZINE (APRESOLINE) injection RANGE
[750049]
10-20 mg, Intravenous, EVERY 2 HOURS PRN,
hypertension
Systolic Blood pressure > 175 mmHg
labetalol (NORMODYNE;TRANDATE) injection
RANGE [750053]
10-20 mg, Intravenous, EVERY 2 HOURS PRN,
Hypertension
Systolic Blood Pressure > 175 mmHg. Hold for heart
rate < 60 beats/minute
for 2 Minutes
cloNIDINE (CATAPRES) tab [720040] 0.1 mg, Oral, EVERY 2 HOURS PRN, hypertension
Systolic Blood Pressure > 175. Maximum of 4 doses in
24 hours.
Laboratory
Draw Now (If Not Completed in ED) [224978]
CBC WITHOUT DIFFERENTIAL [HEMO] NEXT DRAW, 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?
ELECTROLYTES [LYTE] NEXT DRAW, 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?
Page 17 of 20
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:55:37 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

BUN [BUN] NEXT DRAW, 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?
CREATININE [CRET] NEXT DRAW, 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?
GLUCOSE [GLU] NEXT DRAW, 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?
CALCIUM [CA] NEXT DRAW, 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?
BILIRUBIN, TOTAL [TBIL] NEXT DRAW, 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?
ALKALINE PHOSPHATASE [ALKP] NEXT DRAW, 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?
AST/SGOT [AST] NEXT DRAW, 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?
ALT/SGPT [ALT] NEXT DRAW, 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?
PROTHROMBIN TIME/INR [PT] NEXT DRAW, 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?
TYPE AND SCREEN [HCTS] NEXT DRAW, Starting today For 1 Occurrences,
Routine, As good clinical practice and for patient
safety, the Transfusion Service will automatically
crossmatch 2 packed RBCs on all patients with
antibodies to ensure blood would be available in the
event it is needed. If you would like to opt out of this
automatic order for this patient please contact the
UWHC Blood Bank at (608) 263-8367 or The
American Center Lab at (608) 234-6600 as
appropriate.
Page 18 of 20
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:55:37 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

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?
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?
Draw in AM [224979]
CBC WITH DIFFERENTIAL [CBC] 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?
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?
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?
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?
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?
PROTHROMBIN TIME/INR [PT] 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?
ALT/SGPT [ALT] 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?
AST/SGOT [AST] 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?
ALKALINE PHOSPHATASE [ALKP] 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?
BILIRUBIN, TOTAL [TBIL] 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?
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?
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?
Page 19 of 20
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:55:37 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Laboratory - Pregnancy Test [112034]
surgery is pelvic, renal, pregnancy test if female between menarche & menopause and any of: (1) Obtain
intercourse, (3) patient missed menses, (4) patient says abdominal, (2) patient had unprotected -or intra
pregnant. she "could" be
Urine, Pregnancy Test [UPREG] STAT, 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?
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [7497]
ECG - 12 Lead Without Rhythm [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
Disclaimer for University Hospital Only: A Stat status
for an ECG is in reference to the timing of the ECG.
The goal is to perform a STAT ECG within 10 minutes
of the order being placed. It is the responsibility of the
ordering provider to review the STAT ECGs. All ECGs
(stat or routine) will be formally reviewed within one
business day.
BestPractice
No Hospital Problems have yet been identified. [107035]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing.
Page 20 of 20
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:55:37 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org