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IP - Capsule Enteroscopy - Adult - Preprocedure [1026]

IP - Capsule Enteroscopy - Adult - Preprocedure [1026] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, GI/Renal


IP - Capsule Enteroscopy - Adult - Preprocedure [1026]
Intended for Adult Patients Only
Patient Care Orders
Procedure Order [20636]
Capsule Enteroscopy [GI0004] ONCE, Starting today For 1 Occurrences, Routine
Reason for Exam:
Nutrition [14194]
Clear Liquid Diet [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24): CLEAR LIQUID;
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):
Room Service Class:
Starting 20 hours prior to capsule enteroscopy. Avoid red
liquids. NPO except meds 10 hours prior to procedure. Strict
NPO 2 hours prior to procedure.
Clear Liquid Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Liquid
Liquid: Clear Liquid
No Red or Purple Dye:
Liquid Thickness:
Bedside Meal Instructions:
Room Service Class:
Starting 20 hours prior to capsule enteroscopy. Avoid red
liquids. NPO except meds 10 hours prior to procedure. Strict
NPO 2 hours prior to procedure.
Preprocedure Diet Instructions [NURDIE0013] CONTINUOUS, Starting today For Until specified, Start Clear
Liquid diet 20 hours prior to capsule enteroscopy. Avoid red
liquids. NPO except meds 10 hours prior to procedure. Strict
NPO 2 hours prior to procedure.
Contingency Parameters [14195]
Page 1 of 2
Printed by O'BRIEN, RYLEY P [RPO249] at 5/25/2016 2:54:29 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org

Notify Capsule Nurse [NURCOM0001] Provider to Notify: Other (Comment)
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Diabetes,Pacemaker/Defibrillator,Problems
swallowing,History of slow motility or slow gastric
emptying,Ingested an iron supplement or medication
containing iron within last 5 days,Prior bowel surgery/history
of bowel obstruction
Medications
Medications - Preprocedure [12978]
Note: Hold Iron or Vitamins with Iron 5 Days Before
Capsule Enteroscopy [950018]
EVERY 8 HOURS For 5 Days
Hold Iron or Vitamins with Iron 5 Days Before Capsule
Enteroscopy
G.I. lavage (GOLYTELY) 236 GM soln [103976] 2 L, Oral, ONCE For 1 Doses
Give 240 mL every 20 minutes until 2 liters have been
consumed. Complete 10 hours prior to capsule enteroscopy
Page 2 of 2
Printed by O'BRIEN, RYLEY P [RPO249] at 5/25/2016 2:54:29 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2016CCKM@uwhealth.org