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/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98224-en.cckm

201712342

page

100

UWHC,UWMF,

Tools,

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

IP - Comfort Care for Advanced Disease - Adult – Admission [1377]

IP - Comfort Care for Advanced Disease - Adult – Admission [1377] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Comfort Care for Advanced Disease - Adult – Admission [1377]
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) [7417]
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:
Page 1 of 7
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:27:48 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Admit To Observation Status [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status (Single Response) [82665]
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:
Patient Care Orders
Non-Categorized [111815]
Initiate Palliative Care [COR0025] ONCE For 1 Occurrences, Routine
Code Status [147854]
Code Status (Single Response) [232957]
No CPR: The patient does not want CPR in the
setting of cardiac arrest (Single Response)
[232802]
May intubate for medical management of non-
arrest situations (e.g. pneumonia). (Single
Response) [232811]
No CPR/May Intubate [CDSTS0001] Patient Location:
Does not want intubation under any
circumstance, even for a treatable problem (e.g.,
pneumonia). (Single Response) [232824]
No CPR/No Intubation [CDSTS0005] Patient Location:
Full Code [CDSTS0003] Details
Vital Signs [18628]
Vital Signs [NURMON0013] DAILY, Starting today with First Occurrence As
Scheduled For Until specified, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Page 2 of 7
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:27:48 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Vital Signs [NURMON0013] EVERY 8 HOURS, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Activity [18629]
Bedrest [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: other (comment)
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Ad Lib [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB: ad lib
AMBULATE:
CHAIR:
DANGLE:
BEDREST: other (comment)
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Nutrition [18630]
Patient Approved for Additional Menu Items
[NURDIE0013]
CONTINUOUS
Patient may order food items from UWHC café or
Mendota Market?
Patient may order regular soda or other sugar-
sweetened beverages?
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
NPO Except Medications [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
Respiratory [18631]
Pulse Oximetry [NURMON0009] EVERY 8 HOURS, Starting today For Until specified,
Routine
Page 3 of 7
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:27:48 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 For Until specified,
Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen?
Contingency Parameters [18632]
Notify Provider [NURCOM0001] Provider to Notify: Provider
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 >: 20
If respiratory rate <: 8
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
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 [18922]
sodium chloride 0.9 % infusion [64367] Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS
Analgesics - Option # 2 - Continuous Opioid Infusion (Select one agent)
MORPHine [19018]
MORPHhine Infusion and Injection [218539]
MORPHine 60 mg in sodium chloride 0.9% 60
mL infusion syringe [755102]
Intravenous, CONTINUOUS
Page 4 of 7
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:27:48 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

MORPHine PF injection [800122] Intravenous, EVERY 15 MINUTES PRN, pain,
Breakthrough pain
HYDROmorphone (DILAUDID) [19019]
HYDROmorphone Infusion and Injection
[218541]
HYDROmorphone (DILAUDID) 12 mg in sodium
chloride 0.9% 60 mL infusion syringe [755106]
Intravenous, CONTINUOUS
HYDROmorphone PF (DILAUDID) injection
[800120]
Intravenous, EVERY 15 MINUTES PRN,
breakthrough pain
FENTanyl [19020]
FENTanyl Infusion and Injection [219530]
FENTanyl (50 mcg/ml) infusion [800264] Intravenous, CONTINUOUS
FENTanyl PF injection [800187] Intravenous, EVERY 15 MINUTES PRN,
Breakthrough Pain
Analgesics - Option # 3 - Long Acting Analgesia and Breakthrough Medications
(Select one agent from each section)
Long Acting Agents (Single Response) [18944]
MORPHine (MS CONTIN, ORAMORPH) ER tab
[156572]
Oral
methadone (DOLOPHINE) tab [39575] Oral
FENTanyl (DURAGESIC) patch [800256] Transdermal, EVERY 72 HOURS
Remove old patch
Breakthrough Pain Medications [19001]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain, Pain and
Shortness of Breath
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
acetaMINOPHEN (TYLENOL) suppository
[34153]
650 mg, Rectal, EVERY 4 HOURS PRN, pain/fever,
Pain and Shortness of Breath
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
MORPHine tab RANGE [750028] Oral, EVERY 1 HOUR PRN, pain, Pain and Shortness
of Breath
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
MORPHine PF injection [800122] Intravenous, EVERY 15 MINUTES PRN, pain, Pain
and Shortness of Breath
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
MORPHine soln RANGE [750029] Oral, EVERY 1 HOUR PRN, pain, Pain and Shortness
of Breath
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
HYDROmorphone (DILAUDID) tab RANGE
[750022]
Oral, EVERY 1 HOUR PRN, pain, Pain and Shortness
of Breath
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
HYDROmorphone PF (DILAUDID) injection
[800120]
Intravenous, EVERY 1 HOUR PRN, Pain and
Shortness of Breath
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
Page 5 of 7
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:27:48 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

oxycodone tab RANGE [750032] Oral, EVERY 1 HOUR PRN, pain, Pain and Shortness
of Breath
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
oxycodone soln RANGE [750031] Oral, EVERY 1 HOUR PRN, pain, Pain and Shortness
of Breath
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
Medications - General
Anti-emetics [18931]
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
Anti-anxiety [152475]
lorazepam (ATIVAN) tab [720081] Oral, EVERY 4 HOURS PRN, anxiety
lorazepam (ATIVAN) tab [720081] Sublingual, EVERY 4 HOURS PRN, anxiety
Administer if unable to swallow tablets.
lorazepam (ATIVAN) injection [800053] Intravenous, EVERY 4 HOURS PRN, anxiety
If ordered IV: push rate 2 mg/minute.
Administer when unable to take orally.
Bowel Management [18933]
Adult - Bowel Management - Scheduled
[240446]
senna-docusate (SENOKOT S) 8.6-50 MG per
tab [60530]
2 tab, Oral, 2 X DAILY
Adult - Bowel Management - As Needed
[241590]
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
Hypnotics [205867]
Page 6 of 7
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:27:48 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

traZODONE (DESYREL) tab [720150] 25-50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see IPOC supplemental Sleep/Rest
Disturbance Adult)
Dyspnea (Single Response) [219521]
albuterol neb soln (3 mL) [800248] 2.5 mg, Nebulization, EVERY 4 HOURS PRN,
dyspnea
ipratropium (ATROVENT) 0.02 % neb soln
[47883]
500 mcg, Nebulization, EVERY 4 HOURS PRN,
dyspnea
ipratropium-albuterol (DUO-NEB) 0.5-2.5 mg/3
mL neb soln [67220]
3 mL, Nebulization, EVERY 4 HOURS PRN, dyspnea
Non-Categorized [18935]
hyoscyamine disintegrating tab [66503] Sublingual, EVERY 4 HOURS PRN, oral secretion
management
Administer as first line therapy for secretion
management.
atropine 1 % ophthalmic soln [34849] Oral, EVERY 2 HOURS PRN, secretions, secretion
management
Administer as second line therapy for secretion
management if hyoscyamine is too drying.
haloperidol (HALDOL) tab [38061] Oral, EVERY 4 HOURS PRN, For extreme
restlessness, delirium, or nausea
haloperidol lactate (HALDOL) injection [800108] Intravenous, EVERY 4 HOURS PRN, agitation, For
extreme restlessness, delirium, or nausea
Administer if unable to tolerate oral.
polyvinyl alcohol (ARTIFICIAL TEARS) 1.4 %
ophthalmic soln [64529]
1 drop, Eyes (Each), EVERY 1 HOUR PRN, dry eyes
saliva substitute (BIOTENE ORAL BALANCE)
oral gel [135759]
Mouth/Throat, EVERY 4 HOURS PRN, Dry Mouth
nystatin topical powder 100000 unit/g [103228] Topical, 2 X DAILY PRN, Skin Irritation / Rash
Consults
Consults [18633]
Consult Spiritual Care (Inpatient) [CON0056] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Consult Palliative Care (Inpatient) [CON0055] ONCE, Starting today For 1 Occurrences, Routine
Reason For Consult:
Page at 0500 for consult.
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 7 of 7
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:27:48 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org