/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/gynecology/,

/clinical/cckm-tools/content/order-sets/inpatient/gynecology/name-98287-en.cckm

201606170

page

100

UWHC,UWMF,

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

IP - Gynecology Oncology - Vulvectomy - Adult - Postoperative [2725]

IP - Gynecology Oncology - Vulvectomy - Adult - Postoperative [2725] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Gynecology


IP - Gynecology Oncology - Vulvectomy - Adult - Postoperative [2725]
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 [103155]
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:
Page 1 of 13
Printed by LIND, JANNA S [JSL237] at 1/29/2016 11:07:12 AM

Copyright © 201� University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

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
Post-Op/Phase II
Page 2 of 13
Printed by LIND, JANNA S [JSL237] at 1/29/2016 11:07:12 AM

Copyright © 201� University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

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 [85288]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
Page 3 of 13
Printed by LIND, JANNA S [JSL237] at 1/29/2016 11:07:12 AM

Copyright © 201� University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

BP Location:
BP Position:
BP Restrictions:
Every 1 hour times 2, every 2 hours times 2, every 4 hours
times one day, then every 8 hours., Post-Op/Phase II
Activity [85289]
Ambulate [NURACT0008] CONTINUOUS, Starting tomorrow, Routine
AD LIB:
AMBULATE: 4x 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
Elevate Head Of Bed [NURACT0002] Equal to (degrees):
Greater than (degrees):
Less than (degrees): 30
Other options:
Routine, CONTINUOUS, Post-Op/Phase II
No Sitting in Chair [NURCOM0022] CONTINUOUS, Starting today, Post-Op/Phase II
May Shower [NURCOM0022] CONTINUOUS, Starting today, May shower on postoperative
day ***., Post-Op/Phase II
Nutrition [85290]
Goal Post-Operative Intake [NURCOM0022] CONTINUOUS, The Goal Post-Operative intake for Post-
Operative Day 0 is 800-2000 mL. For Post-Operative Day 1
until Discharge, the goal Post-Operative intake is 1500-2500
mL., Post-Op/Phase II
NPO With Sips of Water and Ice Chips, May Take
Medications [NUT0001]
EFFECTIVE NOW, Starting today, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25): NPO
EXCEPT MEDICATIONS,NPO WITH SIPS OF WATER,NPO
WITH ICE CHIPS
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):
Page 4 of 13
Printed by LIND, JANNA S [JSL237] at 1/29/2016 11:07:12 AM

Copyright © 201� University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

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
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):
Tube Feeding Management:
Room Service Class:
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:
Page 5 of 13
Printed by LIND, JANNA S [JSL237] at 1/29/2016 11:07:12 AM

Copyright © 201� University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

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
Diabetes Meal Plan [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet:
Diabetic Diet: DIABETES MEAL PLAN;
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
Glucose POC and Hypoglycemia Managment [197949]
Select BOTH orders when ordering.
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
Hypoglycemia Management (Adult) [191576]
Adult Hypoglycemia Treatment Algorithm URL: https://uconnect.wisc.edu/clinical/cckm-
tools/cpg/guidelines/diabetes-and-
endocrinology/resources/name-77827-en.file
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
Page 6 of 13
Printed by LIND, JANNA S [JSL237] at 1/29/2016 11:07:12 AM

Copyright © 201� University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

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
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
Page 7 of 13
Printed by LIND, JANNA S [JSL237] at 1/29/2016 11:07:12 AM

Copyright © 201� University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

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 - RN COLLECT, 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 - RN COLLECT, Starting 2/6/16 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
Respiratory [85291]
Pulse Oximetry [NURMON0009] SEE COMMENTS, Starting today, Routine, Every 1 hour
times 2, every 2 hours times 2, every 4 hours times one day,
then every 8 hours., Post-Op/Phase II
Turn, Cough And Deep Breathe [NURTRT0022] EVERY 1 HOUR, Starting today, Routine, While awake.,
Post-Op/Phase II
Incentive Spirometry [NURTRT0018] EVERY 1 HOUR, Starting today, Routine, While awake.,
Post-Op/Phase II
Oxygen Therapy (Nasal Cannula) [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%):
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 92
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen?
Post-Op/Phase II
Wound/Procedure Site Care [85292]
Maintain Drain [NURTAD0003] CONTINUOUS, Starting today, Routine
Type: Closed Suction (Jackson-Pratt)
Site:
Location:
Drainage Options: Bulb
Irrigate Frequency: DAILY
Irrigate With:
Irrigant Volume (mL):
Strip: EVERY 2 HOURS
Strip For: 48 Hours (Then strip every 8 hours.)
Dressing Change Frequency:
Dressing Type:
Post-Op/Phase II
Clean Perineal Area with Warm Water Peri-Bottle
[NURCOM0022]
SEE COMMENTS, Starting today, Pat dry, then blow dry on
cool setting after every void and bowel movement and as
needed., Post-Op/Phase II
Apply Ice Pack to Perineum [NURTRT0008] PRN, Starting today, Routine
Site: Affected Area
Apply for 15 minutes every 4 hours as needed., Post-
Op/Phase II
Page 8 of 13
Printed by LIND, JANNA S [JSL237] at 1/29/2016 11:07:12 AM

Copyright © 201� University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

Intake and Output [85293]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today, Routine, Post-Op/Phase II
Non-Categorized Patient Care Orders [85294]
Sitz Bath (Treatment) [NURTRT0013] 2X DAILY, Starting today, Routine, Post-Op/Phase II
Insert and Maintain Urinary Catheter [NURELM0013] CONTINUOUS, Starting today For Until specified, 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:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Post-Op/Phase II
May switch to foot pumps if patint not tolerating SCDs
[NURCOM0022]
ONCE, Post-Op/Phase II
Contingency Parameters [85295]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 160
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg): 60
If temperature > (C): 38.3
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 60
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): 150
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 90
If urine output < (mL): 30 mL/hour over 4 hours
Other: If patient on heparin and platelets decrease by half
from baseline or are below normal range,If persistant back
pain, lower extremity numbness or weakness and on heparin
and epidural
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
Page 9 of 13
Printed by LIND, JANNA S [JSL237] at 1/29/2016 11:07:12 AM

Copyright © 201� University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

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 [85297]
Insert and 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] at 125 mL/hr, Intravenous, CONTINUOUS, Post-Op/Phase II
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L infusion
[44910]
at 125 mL/hr, Intravenous, CONTINUOUS, Post-Op/Phase II
dextrose 5%- NaCl 0.9% with KCl 20 mEq/L infusion
[44904]
at 125 mL/hr, Intravenous, CONTINUOUS, Post-Op/Phase II
sodium chloride 0.9% with KCl 20 mEq/L infusion
[46261]
at 125 mL/hr, Intravenous, CONTINUOUS, Post-Op/Phase II
sodium chloride 0.9% infusion [64367] at 125 mL/hr, Intravenous, CONTINUOUS, Post-Op/Phase II
Medications - General
Analgesics - Opioid (Intravenous) [198933]
HYDROmorphone PF (DILAUDID) injection [750050] Intravenous, EVERY 3 HOURS PRN For 4 Doses, pain, For
severe pain when unable to take orally, for 3 Minutes, Post-
Op/Phase II
Analgesics - Opioid (Oral) [198934]
oxycodone tab RANGE [750032] 5-10 mg, Oral, EVERY 3 HOURS PRN, pain, For severe pain,
Post-Op/Phase II
Analgesics - NSAIDs (Scheduled) - NOTE: Do NOT order ketorolac if patient 65 years of older, weight less than 50 kg,
CrCl less than 50 mL/hr, or active bleeding (Single Response) [154903]
ketOROLAC (TORADOL) injection - 30 mg - NOTE: Do
NOT order ketorolac if patient 65 years or older, 50 kg or
less, or serum creatinine 1.2 mg/dL or more [800050]
30 mg, Intravenous, EVERY 6 HOURS For 72 Hours, Post-
Op/Phase II
ketOROLAC (TORADOL) injection - 15 mg - NOTE: Do
NOT order ketorolac if patient 65 years or older, 50 kg or
less, or serum creatinine 1.2 mg/dL or more [800050]
15 mg, Intravenous, EVERY 6 HOURS For 72 Hours, Post-
Op/Phase II
Analgesics - NSAIDSs PRN (Single Response) [198935]
ibuprofen (MOTRIN) tab [38353] 600 mg, Oral, EVERY 6 HOURS PRN, pain, For mild pain or
multimodal therapy, Post-Op/Phase II
Analgesics - Acetaminophen - Scheduled [198936]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 6 HOURS, Post-Op/Phase II
Anti-emetics [85301]
ondansetron (ZOFRAN ODT) disintegrating tab [64224] 4 mg, Oral, EVERY 12 HOURS PRN, nausea/vomiting,
Administer as first line therapy, Post-Op/Phase II
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 12 HOURS PRN,
nausea/vomiting, Administer as first line therapy when unable
to take orally., Post-Op/Phase II
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN, nausea/vomiting,
Administer as second line therapy when unresponsive to first
line therapy within 30 mintues, Post-Op/Phase II
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
Page 10 of 13
Printed by LIND, JANNA S [JSL237] at 1/29/2016 11:07:12 AM

Copyright © 201� University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

nausea/vomiting, Administer as second line therapy when
unresponsive to first line therapy within 30 minutes and
unable to take orally., Post-Op/Phase II
scopolamine (TRANSDERM-SCOP) 1 MG/3DAYS 72hr
patch [166671]
1 patch, Transdermal, EVERY 72 HOURS PRN,
nausea/vomiting, Administer as third line when unresponsive
to previous therapies, Post-Op/Phase II
Hypnotics [198810]
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
Bowel Management [85270]
senna-docusate (SENOKOT S) 8.6-50 MG per tab
[60530]
2 tab, Oral, 2 X DAILY, Post-Op/Phase II
polyethylene glycol (MIRALAX) oral powder [61353] Oral, 1 X DAILY PRN, constipation, Post-Op/Phase II
Laboratory
Laboratory [85307]
HEMOGLOBIN [HGB] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
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?
Post-Op/Phase II
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?
CREATININE [CRET] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
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?
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?
Post-Op/Phase II
Laboratory - Next AM [144075]
HEMOGLOBIN [HGB] 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?
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?
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?
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?
Page 11 of 13
Printed by LIND, JANNA S [JSL237] at 1/29/2016 11:07:12 AM

Copyright © 201� University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

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?
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?
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?
Consults
Consults [85310]
Consult Occupational Therapy (Inpatient) Eval and Treat
[CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Post-Op/Phase II
Diabetes Consult Order Panel (Adult) [188497]
Diabetes Management Service: Will provide management or treatment recommendations for patients with hyperglycemia
and/or those who report outpatient use of insulin or other diabetes medications. Patients should be expected to remain
inpatient > 24 hrs from time of consult. Consult is required for patients with insulin pumps or who use U-500 insulin.
Consult Endocrine for any non-diabetes-related endocrine questions.
Learning Center - Diabetes Education (Adult): Diabetes education (meter/insulin skills/other diabetes survival skills) for
patients/families with knowledge deficits and/or need for diabetes knowledge assessment.
Diabetes Education – Nutrition: Diabetes nutrition therapy including nutrition assessment, carbohydrate education
(consistent carbohydrate meals, use of insulin-to-carbohydrate ratio), and/or individualized, nutritious meal planning for
carbohydrates, portions, or considering other comorbidities.
Consult Diabetes Management Service (DMS)
(Inpatient) [CON0022]
ONCE
Can this consult be done via video?
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Phone number:
Consult Learning Center - Diabetes Education (Adult)
[CON0021]
ONCE, Routine, · If patient is newly diagnosed or is new
to insulin, provide 24 hours notice to allow adequate time
for education.
· Indicate diabetes medication/treatment plan if known.
· Consults requested after 1600 on Fridays may not be
seen until following Monday. Learning Center available
Mon-Sat 0800-1630 (only 1 RN available on Saturday for
CSC and AFCH).
· Learning Center staff are not available on holidays.
Type of Education: Diabetes Self-Management Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Post-Op/Phase II
Consult Diabetes Education - Nutrition (Inpatient)
[CON0126]
ONCE, Routine, · If your patient is newly diagnosed and/or
is new to insulin therapy, provide 24 hours notice to allow
adequate time for nutrition education.
· Indicate diabetes medication/treatment plan if known.
· Consults requested after 1300 on Friday may not be
completed until the following Monday.
· If you are placing a consult on a weekend day for a
patient who will be discharging that weekend, please have
the Paging Center contact the on-call dietitian to help you
facilitate the diabetes nutrition education session prior to
the patient's discharge.
Page 12 of 13
Printed by LIND, JANNA S [JSL237] at 1/29/2016 11:07:12 AM

Copyright © 201� University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

Type of Education: Diabetes Self-Management Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Post-Op/Phase II
Consult Health Psychology (Inpatient) [CON0033] ONCE For 1 Occurrences, Routine, Please notify consulting
provider if patient needs to be seen same day (Monday-
Friday) or if special assessment needs.
Intent for Consult:
Concern or Specific Question or Task to be Addressed:
Consult Physical Therapy (Inpatient) Eval and Treat
[CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
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 13 of 13
Printed by LIND, JANNA S [JSL237] at 1/29/2016 11:07:12 AM

Copyright © 201� University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org