/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/hospital-wide/,

/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98222-en.cckm

201710300

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Hospital-wide

IP – Opioid Withdrawal – Adult – Supplemental [3497]

IP – Opioid Withdrawal – Adult – Supplemental [3497] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Opioid Withdrawal - Adult - Supplemental [3497]
Intended for Adult Patients Only
Patient Care Orders
Vital Signs [103191]
Vital Signs - Days 1-4 [NURMON0013] EVERY 6 HOURS, Starting today For 4 Days, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Measure vital signs prior to each dose of Clonidine.
Vital Signs - Day 5 [NURMON0013] EVERY 8 HOURS, Starting 10/31/17 For 1 Days,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Measure vital signs prior to each dose of Clonidine.
Vital Signs - Day 6 [NURMON0013] SEE COMMENTS, Starting 11/1/17 For 1 Days,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Measure vital signs every 12 hours, prior to each dose
of Clonidine.
Vital Signs - Day 7 [NURMON0013] ONCE, Starting 11/2/17 For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Measure vital signs once in the morning, prior to dose
of Clonidine.
Contingency Parameters [103192]
Page 1 of 7
Printed by STRAKA, KEVIN F [KFS1] at 10/26/2017 11:46:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Notify Provider If: [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg): 80
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg): 50
If temperature > (C):
If temperature < (C):
If heart rate > (bpm): 120
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:
Non-categorized Patient Care Orders [186045]
T-Pump (Heating) [EQP0028] CONTINUOUS, Starting today, Routine
Medications - Clonidine Taper
Select from one of the following tapers based on patient weight, heart rate and blood pressure:
NOTE: Baseline ECG should be ordered. Hold ANY clonidine if AV block present.
NOTE: For Reduced and Lowest Regimens - Initial dose OK for HR 55-60 if AV block not present
and patient not symptomatic (HOLD if <55). For subsequent doses, hold clonidine for (1) HR < 50,
where symptomatic or not, (2) HR <60 and symptomatic.
Standard Regimen (0.2 mg Doses)
- 70 kg or more, blood pressure GREATER than 100/60 mmHg, and heart rate GREATER than 60
beats per minute
Reduced Regimen (0.1 mg Doses)
- 70 kg or more, and heart rate LESS than 60 beats per minute, or systolic blood pressure LESS
than 100 mmHg, or diastolic blood pressure LESS than 60 mmHg
- LESS than 70 kg, and blood pressure GREATER than 100/60 mmHg, and heart rate GREATER
than 60 beats per minute
Reduced Regimen (0.05 mg Doses)
- LESS than 70 kg, and heart rate LESS than 60 beats per minute, or systolic blood pressure -
LESS than 100 mmHg, or diastolic blood pressure LESS than 60 mmHg
Clonidine (Single Response) [103042]
Clonidine - Standard Regimen (0.2 mg Doses)
[184757]
cloNIDINE (CATAPRES) tab [720040] 0.2 mg, Oral, EVERY 6 HOURS For 4 Days
Hold if SBP less than *** mmHg. Hold for HR < 60.
cloNIDINE (CATAPRES) tab [720040] 0.2 mg, Oral, EVERY 8 HOURS Starting 10/31/17
For 1 Days
Hold if SBP less than *** mmHg. Hold for HR < 60.
cloNIDINE (CATAPRES) tab [720040] 0.2 mg, Oral, EVERY 12 HOURS Starting 11/1/17
For 1 Days
Hold if SBP less than *** mmHg. Hold for HR < 60.
cloNIDINE (CATAPRES) tab [720040] 0.2 mg, Oral, 1 X DAILY Starting 11/2/17 For 1 Days
Hold if SBP less than *** mmHg. Hold for HR < 60.
Clonidine - Reduced Regimen (0.1 mg Doses)
[184758]
cloNIDINE (CATAPRES) tab [720040] 0.1 mg, Oral, EVERY 6 HOURS For 4 Days
Hold if SBP less than *** mmHg. Hold for HR < 55.
Page 2 of 7
Printed by STRAKA, KEVIN F [KFS1] at 10/26/2017 11:46:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

cloNIDINE (CATAPRES) tab [720040] 0.1 mg, Oral, EVERY 8 HOURS Starting 10/31/17
For 1 Days
Hold if SBP less than *** mmHg. Hold for HR < 55.
cloNIDINE (CATAPRES) tab [720040] 0.1 mg, Oral, EVERY 12 HOURS Starting 11/1/17
For 1 Days
Hold if SBP less than *** mmHg. Hold for HR < 55.
cloNIDINE (CATAPRES) tab [720040] 0.1 mg, Oral, 1 X DAILY Starting 11/2/17
Hold if SBP less than *** mmHg. Hold for HR < 55.
Clonidine - Lowest Regimen (0.05 mg Doses)
[184759]
cloNIDINE (CATAPRES) tab [720040] 0.05 mg, Oral, EVERY 6 HOURS For 4 Days
Hold if SBP less than *** mmHg. Hold for HR < 55.
cloNIDINE (CATAPRES) tab [720040] 0.05 mg, Oral, EVERY 8 HOURS Starting 10/31/17
For 1 Days
Hold if SBP less than *** mmHg. Hold for HR < 55.
cloNIDINE (CATAPRES) tab [720040] 0.05 mg, Oral, EVERY 12 HOURS Starting 11/1/17
For 1 Days
Hold if SBP less than *** mmHg. Hold for HR < 55.
cloNIDINE (CATAPRES) tab [720040] 0.05 mg, Oral, 1 X DAILY Starting 11/2/17 For 1
Days
Hold if SBP less than *** mmHg. Hold for HR < 55.
Medications
Analgesics (Single Response) [185834]
acetaMINOPHEN (TYLENOL) tab RANGE
[750002]
500-1,000 mg, Oral, EVERY 6 HOURS PRN,
pain/fever, Mild to moderate pain
Analgesics - NSAIDS - Oral - PRN (Single Response) [234757]
ibuprofen (MOTRIN) tab [38353] 600 mg, Oral, EVERY 6 HOURS PRN, pain, Mild to
moderate pain
naproxen (NAPROSYN) tab [720103] 250-500 mg, Oral, EVERY 8 HOURS PRN, Mild to
Moderate Pain
Abdominal Cramping (Single Response) [103038]
dicyclomine (BENTYL) cap [36696] 10-20 mg, Oral, EVERY 6 HOURS PRN For 48 Hours,
nausea/vomiting, abdominal cramps
Agitation/Anxiety/Restlessness [103041]
lorazepam (ATIVAN) tab RANGE [750026] 1 mg, Oral, EVERY 6 HOURS PRN For 72 Hours,
Withdrawal related anxiety symptoms
1st Line Therapy
Second Line (Single Response) [234758]
gabapentin (NEURONTIN) cap [54258] 300 mg, Oral, 4 X DAILY PRN, pain, Withdrawal
related anxiety symptoms, restlessness, sleep
2nd Line Therapy for opioid related anxiety
symptoms and insomnia
quetiapine (SEROQUEL) tab [720129] 25 mg, Oral, EVERY 6 HOURS PRN, delirium,
agitation, withdrawal related anxiety symptoms,
restlessness, sleep
2nd Line Therapy for opioid related anxiety
symptoms and insomnia
Anti-emetics [104612]
ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
4 mg, Oral, EVERY 12 HOURS PRN, nausea/vomiting
1st Line Therapy
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 12 HOURS PRN,
nausea/vomiting
1st Line Therapy. Administer if unable to tolerate PO
promethazine (PHENERGAN) tab [41416] 25 mg, Oral, EVERY 6 HOURS PRN, nausea/vomiting
2nd Line Agent
Page 3 of 7
Printed by STRAKA, KEVIN F [KFS1] at 10/26/2017 11:46:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

prochlorperazine (COMPAZINE) injection [41369] 2.5 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
2nd line therapy. Administer if failed response to 1st
line therapy after 30 minutes and unable to tolerate
orally.
Diarrhea [104611]
loperamide (IMODIUM) tab [39152] 2-4 mg, Oral, PRN, diarrhea
Give 4 mg at onset of diarrhea, then 2 mg after each
loose stool to a maximum of 16 mg/day
Muscle/Leg Cramps (Single Response) [103040]
cyclobenzaprine (FLEXERIL) tab [36263] 10 mg, Oral, EVERY 6 HOURS PRN For 48 Hours,
muscle/leg cramps
TB Skin Test - NOTE: Select BOTH if ordering from this group [104645]
TB SKIN TEST [117075]
tuberculin (APLISOL) injection [43217] 5 units, Intradermal, ONCE PRN For 1 Doses, TB
Competent RN to Administer
TB INTRADERMAL TEST [IMM0001] ONCE, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
Staff with competency in TB Testing to complete
Non-categorized [105660]
diphenhydramine (BENADRYL) cap RANGE
[750014]
25-50 mg, Oral, EVERY 6 HOURS PRN,
lacrimation/rhinorrhea
Laboratory
Laboratory [103193]
HCG, QUALITATIVE, URINE [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?
ELECTROLYTES [LYTE] 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?
POTASSIUM [K] 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?
SODIUM [NA] 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?
CHLORIDE [CL] 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?
CARBON DIOXIDE [CO2] 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?
GLUCOSE [GLU] 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?
Page 4 of 7
Printed by STRAKA, KEVIN F [KFS1] at 10/26/2017 11:46:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

BUN [BUN] 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?
CREATININE [CRET] 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?
CALCIUM [CA] 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?
ALBUMIN [ALB] 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?
PROTEIN, TOTAL [TP] 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?
ALKALINE PHOSPHATASE [ALKP] 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?
AST/SGOT [AST] 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?
ALT/SGPT [ALT] 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?
BILIRUBIN, TOTAL [TBIL] 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?
DRUG SCREEN, URINE [HCUPNL] STAT, Starting today For 1 Occurrences, Routine,
Test includes: Amphetamines/Methamphetamines,
Barbiturates, Benzodiazepine, Cocaine, and Opiates
(primarily targets morphine, codeine, and heroin).
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALCOHOL [GM2440] 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?
For Past IV Drug Use [103196]
Page 5 of 7
Printed by STRAKA, KEVIN F [KFS1] at 10/26/2017 11:46:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

HIV AB/AG COMBO [HIVABAG] COLLECT UPON ADMISSION, Starting today For 1
Occurrences, Routine, I, the ordering provider, have
verified that the patient/patient's authorized
representative was:
1. Notified that the patient will be subjected to an HIV
test unless the patient/rep declines the test;
2. Given educational materials on HIV and HIV testing;
3. Notified that they may decline the test and health
care providers may not use the fact that the
patient/rep declined an HIV test as a basis for denying
other services; and
4. Provided an opportunity to ask questions and to
decline the HIV test.
The ordering provider verifies:
5. The patient/patient's authorized representative
understands that an HIV test will be performed; and
6. The decision of the patient/rep regarding whether to
have an HIV test performed was not coerced or
involuntary.
Pt/Pt's Rep did not opt out. Steps listed in instructions
taken. If test is declined, type ".HIVTESTDECLINE" in
progress note.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEPATITIS B SURFACE AB (IMMUNE STATUS)
[HBSABI]
COLLECT UPON ADMISSION, 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?
HEPATITIS B SURFACE AG [HBSAG] COLLECT UPON ADMISSION, 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?
HEPATITIS B CORE AB, TOTAL [HBCAB] COLLECT UPON ADMISSION, 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?
HEPATITIS C AB [HCV] COLLECT UPON ADMISSION, 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?
Consults
Consults [103197]
Behavioral Health Consults (select below)
[132899]
Page 6 of 7
Printed by STRAKA, KEVIN F [KFS1] at 10/26/2017 11:46:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

amp, transplant), - adjustment, protocol (eg. burn, trauma, rehab, pre-Psychology Health
noncompliance, grief, pain
Addictive Disorders - alcohol or drug related problems (eg. treatment recommendations,
withdrawal mgmt)
Psychiatry - safety, agitation, capacity, med mgmt, psychotropic SE
ACE - 60 and older - delirium, dementia, depression, decisional capacity, sleep (also for non-
behavioral geriatric syndromes; overall geriatric evaluation, mobility/falls, functional decline,
social/caregiver issues, disposition, medication management)
Consult Health Psychology (Inpatient)
[CON0033]
ONCE, 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 (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Consult Addictive Disorders (Inpatient)
[CON0003]
ONCE, Routine, This order is for ADULT patients.
Please use the Consult Adolescent/Pediatric AODA
Counselor order for adolescent/pediatric patients
instead.
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Consult Psychiatry (Inpatient) [CON0064] ONCE
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Call back number:
Consult Ace/Geriatric (Inpatient) [CON0001] ONCE, Routine
Reason for Consult:
Can this consult be done via video?
Page 7 of 7
Printed by STRAKA, KEVIN F [KFS1] at 10/26/2017 11:46:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org