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/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98249-en.cckm

201712342

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UWHC,UWMF,

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

IP – Urgent Intubation – Adult – Supplemental [4369]

IP – Urgent Intubation – Adult – Supplemental [4369] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Urgent Intubation - Adult - Supplemental [4369]
Patient Care Orders
Communication Orders [116215]
Respiratory Therapy Communication [RT0065] ONCE, Routine, Prepare for intubation
Medications - Intubation Induction
Sedatives/Amnestics [116207]
midazolam (VERSED) injection RANGE [750056] 2-5 mg, Intravenous, ONCE PRN For 2 Hours,
sedation, sedation and/or amnesia for intubation
Dose to be directed by physician
Induction Agents (Single Response) [117856]
etomidate (AMIDATE) vial [56527] 0.15-0.3 mg/kg, Intravenous, ONCE PRN For 2 Hours,
sedation for intubation induction
Dose to be directed by physician
for 1 Minutes
ketAMINE injection [800191] 1-2 mg/kg, Intravenous, ONCE PRN For 2 Hours,
Sedation for intubation induction
Dose to be directed by physician
propofol (DIPRIVAN) IV BOLUS [730017] 25-100 mg, Intravenous, ONCE PRN For 2 Hours,
sedation for intubation induction
Dose to be directed by physician
Analgesics [116210]
FENTanyl PF injection RANGE [750047] 50-200 mcg, Intravenous, ONCE PRN For 2 Hours,
pain, analgesia for intubation
Dose to be directed by physician
for 1 Minutes
Paralytics (Single Response) [116211]
succinylcholine (ANECTINE) 20 mg/mL 10 mL
injection [42431]
1-2 mg/kg, Intravenous, ONCE PRN For 2 Hours,
muscle relaxation for intubation
Dose to be directed by physician
rocuronium (ZEMURON) injection [800213] 0.6-1.2 mg/kg, Intravenous, ONCE PRN For 2 Hours,
muscle relaxation for intubation
Dose to be directed by physician
Vasopressors [116217]
phenylEPHRINE in sodium chloride 0.9% 0.1
MG/ML injection - NOTE: for systolic blood
pressure < 90 and heart rate > or equal to 50
[755110]
100-200 mcg, Intravenous, EVERY 5 MINUTES PRN
For 2 Hours, hypotension during intubation - see
Admin Instructions
NOTE: for systolic blood pressure < 90 and heart rate
> or equal to 50
for 2 Hours
NOTE: for systolic blood pressure < 90 and heart rate
> or equal to 50
epHEDRINE in sodium chloride 0.9% 5MG/ML
injection - NOTE: for systolic blood pressure <90
and heart rate < or equal to 49 [755112]
5-10 mg, Intravenous, EVERY 5 MINUTES PRN For 2
Hours, hypotension during intubation- see Admin
Instructions
for systolic blood pressure <90 and heart rate < or
equal to 49
for 2 Hours
NOTE: or systolic blood pressure <90 and heart rate <
or equal to 49
Intravenous Bolus Therapy
IV Fluids (Single Response) [116221]
sodium chloride 0.9% BOLUS [730003] Intravenous, ONCE For 1 Doses
lactated ringers BOLUS [730001] Intravenous, ONCE For 1 Doses
Pain/Agitation/Delirium in Intubated Patients
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Spontaneous Awakening Trial (Single Response) [128869]
Initiate spontaneous awakening trial
[NURCOM0081]
CONTINUOUS
Do NOT initiate spontaneous awakening
trial/physician directed weaning [NURCOM0022]
CONTINUOUS
Delirium [127671]
Haloperidol [242331]
ECG - 12 Lead [EKG0008] ONCE, 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.
haloperidol lactate (HALDOL) injection RANGE
[750048]
2.5-5 mg, Intravenous, EVERY 1 HOUR PRN,
agitation, acute hyperactive delirium
If ordered IV: push rate 5 mg/minute.
Pain Single Response Low Dose Analgesics (Single Response) [135451]
adverse reactions, i.e. patients Dose Analgesics: Consider for use in patients who may be at risk for Low
with renal or liver dysfunction greater than age 65 years or patients
FENTanyl PRN with Option for Continuous
Infusion - LOW Dose [210606]
FENTanyl PF injection RANGE [750047] 12.5-50 mcg, Intravenous, EVERY 15 MINUTES
PRN, pain/agitation
If patient fails to respond after 3 doses in an hour
consider starting continuous infusion.
for 1 Minutes
Contact Pharmacist or Physician to enter order
for FENTanyl continuous infusion. Order rate 25-
200 mcg/hr [950018]
CONTINUOUS
Initiate/Titrate/Bolus per Pain, Agitation and Delirium
Continuous Infusion Titration - Adult - Inpatient
Practice Protocol
Do NOT start analgesic continuous infusion
unless 3 or more intermittent doses have been
used within one hour [NURCOM0022]
CONTINUOUS
FENTanyl PRN with Option for Continuous
Infusion - STANDARD Dose [210607]
FENTanyl PF injection RANGE [750047] 25-100 mcg, Intravenous, EVERY 15 MINUTES
PRN, pain/agitation
If patient fails to respond after 3 doses in an hour
consider starting continuous infusion.
for 1 Minutes
Contact Pharmacist or Physician to enter order
for FENTanyl continuous infusion. Order rate 25-
200 mcg/hr [950018]
CONTINUOUS
Initiate/Titrate/Bolus per Pain, Agitation and Delirium
Continuous Infusion Titration - Adult - Inpatient
Practice Protocol
Do NOT start analgesic continuous infusion
unless 3 or more intermittent doses have been
used within one hour [NURCOM0022]
CONTINUOUS
FENTanyl infusion [800264] 25-200 mcg/hr, Intravenous, CONTINUOUS
Initiate/Titrate/Bolus per Assessment and Treatment of
Pain, Agitation, and Delirium in Mechanically
Ventilated Adult Intensive Care Unit Patient.
HYDROmorphone PRN with Option for
Continuous Infusion - LOW Dose [210610]
Page 2 of 10
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:14:56 AM
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12/2017CCKM@uwhealth.org

HYDROmorphone PF (DILAUDID) injection
RANGE [750050]
0.1-0.4 mg, Intravenous, EVERY 15 MINUTES PRN,
pain/agitation
If patient fails to respond after 3 doses in an hour
consider starting continuous infusion.
for 3 Minutes
Contact Pharmacist or Physician to enter order
for HYDROmorphone continuous infusiton. Order
at rate of 0.2-2 mg/hr [950018]
CONTINUOUS
Initiate/Titrate/Bolus per Pain, Agitation and Delirium
Continuous Infusion Titration - Adult - Inpatient
Practice Protocol
Do NOT start analgesic continuous infusion
unless 3 or more intermittent doses have been
used within one hour [NURCOM0022]
CONTINUOUS
HYDROmorphone PRN with Option for
Continuous Infusion - STANDARD Dose
[210611]
HYDROmorphone PF (DILAUDID) injection
RANGE [750050]
0.4-1 mg, Intravenous, EVERY 15 MINUTES PRN,
pain/agitation
If patient fails to respond after 3 doses in an hour
consider starting continuous infusion.
for 3 Minutes
Contact Pharmacist or Physician to enter order
for HYDROmorphone continuous infusiton. Order
at rate of 0.2-2 mg/hr [950018]
CONTINUOUS
Initiate/Titrate/Bolus per Pain, Agitation and Delirium
Continuous Infusion Titration - Adult - Inpatient
Practice Protocol
Do NOT start analgesic continuous infusion
unless 3 or more intermittent doses have been
used within one hour [NURCOM0022]
CONTINUOUS
HYDROmorphone (DILAUDID) 12 mg in sodium
chloride 0.9% 60 mL infusion syringe [755106]
0.2-2 mg/hr, Intravenous, CONTINUOUS
Initiate/Titrate/Bolus per Assessment and Treatment of
Pain, Agitation, and Delirium in Mechanically
Ventilated Adult Intensive Care Unit Patient.
MORPHine PRN with Option for Continuous
Infusion - LOW Dose [210602]
MORPHine PF injection RANGE [750057] 0.5-2 mg, Intravenous, EVERY 15 MINUTES PRN,
pain, pain/agitation
If patient fails to respond after 3 doses in an hour
consider starting continuous infusion.
for 4 Minutes
Contact Pharmacist or Physician to enter order
for MORPHine continuous infusion. Order at a
rate of 1-10 mg/hr [950018]
CONTINUOUS
Initiate/Titrate/Bolus per Pain, Agitation and Delirium
Continuous Infusion Titration - Adult - Inpatient
Practice Protocol
Do NOT start analgesic continuous infusion
unless 3 or more intermittent doses have been
used within one hour [NURCOM0022]
CONTINUOUS
MORPHine PRN with Option for Continuous
Infusion - STANDARD Dose [210603]
MORPHine PF injection RANGE [750057] 1-4 mg, Intravenous, EVERY 15 MINUTES PRN,
pain, pain/agitation
If patient fails to respond after 3 doses in an hour
consider starting continuous infusion.
for 4 Minutes
Contact Pharmacist or Physician to enter order
for MORPHine continuous infusion. Order at a
rate of 1-10 mg/hr [950018]
CONTINUOUS
Initiate/Titrate/Bolus per Pain, Agitation and Delirium
Continuous Infusion Titration - Adult - Inpatient
Practice Protocol
Page 3 of 10
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:14:56 AM
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12/2017CCKM@uwhealth.org

Do NOT start analgesic continuous infusion
unless 3 or more intermittent doses have been
used within one hour [NURCOM0022]
CONTINUOUS
MORPHine 60 mg in sodium chloride 0.9% 60 mL
infusion syringe [755102]
1-10 mg/hr, Intravenous, CONTINUOUS
Initiate/Titrate/Bolus per Assessment and Treatment of
Pain, Agitation, and Delirium in Mechanically
Ventilated Adult Intensive Care Unit Patient.
Agitation (Single Response) [135458]
Options:Infusion
Propofol-1st Line
Dexmedetomidine - 2nd Line
Midazolam-3rd Line
adverse reactions, i.e. patients Dose Sedatives: Consider for use in patients who may be at risk for Low
with renal or liver dysfunctiongreater than age 65 years or patients
Midazolam PRN with Option for Propofol Infusion
- LOW Dose [220026]
midazolam (VERSED) injection RANGE [750056] 0.5-2 mg, Intravenous, EVERY 15 MINUTES PRN,
sedation, agitation
If patient fails to respond after 3 doses in an hour
consider starting continuous infusion.
Contact Pharmacist or Physician to enter order
for propofol continuous infusion. Order at rate of
10-70 mcg/kg/min. [950018]
CONTINUOUS
Initiate/Titrate/Bolus per Assessment and Treatment
of Pain, Agitation, and Delirium in Mechanically
Ventilated Adult Intensive Care Unit Patient to
achieve RASS score.
Goal Richmond Agitation-Sedation Scale (RASS)
Score [NURCOM0015]
CONTINUOUS
Goal RASS Score:
Initiate/Titrate/Bolus per Assessment and Treatment
of Pain, Agitation, and Delirium in Mechanically
Ventilated Adult Intensive Care Patient to achieve
ordered goal RASS score.
Do NOT start sedative continuous infusion unless
3 or more intermittent midazolam doses have
been used within one hour [NURCOM0022]
CONTINUOUS
TRIGLYCERIDE [TRIG] CONDITIONAL For 7 Days, Routine, Fasting
specimen is preferred.
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Obtain every 72
hours while patient receiving propofol infusion
CK, TOTAL [CPK] CONDITIONAL For 7 Days, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Obtain every 72
hours while patient receiving propofol infusion
LACTATE [GM2255] CONDITIONAL For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Obtain every 72
hours while patient receiving propofol infusion
Midazolam PRN with Option for Propofol Infusion
-STANDARD Dose [220029]
Page 4 of 10
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:14:56 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

midazolam (VERSED) injection RANGE [750056] 1-4 mg, Intravenous, EVERY 15 MINUTES PRN,
sedation, agitation
If patient fails to respond after 3 doses in an hour
consider starting continuous infusion.
Contact Pharmacist or Physician to enter order
for propofol continuous infusion. Order at rate of
10-70 mcg/kg/min. [950018]
CONTINUOUS
Initiate/Titrate/Bolus per Assessment and Treatment
of Pain, Agitation, and Delirium in Mechanically
Ventilated Adult Intensive Care Unit Patient to
achieve RASS score.
Goal Richmond Agitation-Sedation Scale (RASS)
Score [NURCOM0015]
CONTINUOUS
Goal RASS Score:
Initiate/Titrate/Bolus per Assessment and Treatment
of Pain, Agitation, and Delirium in Mechanically
Ventilated Adult Intensive Care Patient to achieve
ordered goal RASS score.
Do NOT start sedative continuous infusion unless
3 or more intermittent midazolam doses have
been used within one hour [NURCOM0022]
CONTINUOUS
TRIGLYCERIDE [TRIG] CONDITIONAL For 7 Days, Routine, Fasting
specimen is preferred.
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Obtain every 72
hours while patient receiving propofol infusion
CK, TOTAL [CPK] CONDITIONAL For 7 Days, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Obtain every 72
hours while patient receiving propofol infusion
LACTATE [GM2255] CONDITIONAL For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Obtain every 72
hours while patient receiving propofol infusion
Propofol Infusion [220039]
propofol (DIPRIVAN) 10 mg/mL infusion [800260] 10-70 mcg/kg/min, Intravenous, CONTINUOUS
Initiate/Titrate/Bolus per Assessment and Treatment
of Pain, Agitation, and Delrium in Mechanically
Ventilated Adult Intensive Care Unit Patient
Goal Richmond Agitation-Sedation Scale (RASS)
Score [NURCOM0015]
CONTINUOUS
Goal RASS Score:
Initiate/Titrate/Bolus per Assessment and Treatment
of Pain, Agitation, and Delirium in Mechanically
Ventilated Adult Intensive Care Patient to achieve
ordered goal RASS score.
TRIGLYCERIDE [TRIG] CONDITIONAL For 7 Days, Routine, Fasting
specimen is preferred.
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Obtain every 72
hours while patient receiving propofol infusion
CK, TOTAL [CPK] CONDITIONAL For 7 Days, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Obtain every 72
hours while patient receiving propofol infusion
Page 5 of 10
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:14:56 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

LACTATE [GM2255] CONDITIONAL For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Obtain every 72
hours while patient receiving propofol infusion
Midazolam PRN with Option for
Dexmedetomidine Infusion - LOW Dose
[220032]
midazolam (VERSED) injection RANGE [750056] 0.5-2 mg, Intravenous, EVERY 15 MINUTES PRN,
sedation, agitation
If patient fails to respond after 3 doses in an hour
consider starting continuous infusion.
Contact Pharmacist or Physician to enter order
for dexmedetomidine continuous infusion. Order
at a rate of 0.2-1.5 mcg/kg/hr [950018]
CONTINUOUS
Initiate/Titrate/Bolus per Assessment and Treatment
of Pain, Agitation, and Delirium in Mechanically
Ventilated Adult Intensive Care Patient to achieve
RASS score. May bolus ONLY if heart rate is greater
than 70 bpm, MAP is greater than 70 mmHg and
RASS score is greater than 2. May increase infusion
by 0.1 mcg/kg/hr every 5 minutes to keep RASS
score at goal. If heart rate is less than 50 bpm or
MAP is less than 55 mmHg, hold dexmedetomidine
for 10 minutes, then restart with dose reduced by 0.3
mcg/kg/hr.
Goal Richmond Agitation-Sedation Scale (RASS)
Score [NURCOM0015]
CONTINUOUS
Goal RASS Score:
Initiate/Titrate/Bolus per Assessment and Treatment
of Pain, Agitation, and Delirium in Mechanically
Ventilated Adult Intensive Care Patient to achieve
ordered goal RASS score.
Do NOT start sedative continuous infusion unless
3 or more intermittent midazolam doses have
been used within one hour [NURCOM0022]
CONTINUOUS
Midazolam PRN with Option for
Dexmedetomidine Infusion - STANDARD Dose
[220035]
midazolam (VERSED) injection RANGE [750056] 1-4 mg, Intravenous, EVERY 15 MINUTES PRN,
sedation, agitation
If patient fails to respond after 3 doses in an hour
consider starting continuous infusion.
Contact Pharmacist or Physician to enter order
for dexmedetomidine continuous infusion. Order
at a rate of 0.2-1.5 mcg/kg/hr [950018]
CONTINUOUS
Initiate/Titrate/Bolus per Assessment and Treatment
of Pain, Agitation, and Delirium in Mechanically
Ventilated Adult Intensive Care Patient to achieve
RASS score. May bolus ONLY if heart rate is greater
than 70 bpm, MAP is greater than 70 mmHg and
RASS score is greater than 2. May increase infusion
by 0.1 mcg/kg/hr every 5 minutes to keep RASS
score at goal. If heart rate is less than 50 bpm or
MAP is less than 55 mmHg, hold dexmedetomidine
for 10 minutes, then restart with dose reduced by 0.3
mcg/kg/hr.
Page 6 of 10
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:14:56 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Goal Richmond Agitation-Sedation Scale (RASS)
Score [NURCOM0015]
CONTINUOUS
Goal RASS Score:
Initiate/Titrate/Bolus per Assessment and Treatment
of Pain, Agitation, and Delirium in Mechanically
Ventilated Adult Intensive Care Patient to achieve
ordered goal RASS score.
Do NOT start sedative continuous infusion unless
3 or more intermittent midazolam doses have
been used within one hour [NURCOM0022]
CONTINUOUS
Dexmedetomidine Infusion [220045]
dexmedetomidine (PRECEDEX) 200 mcg in
sodium chloride 0.9 % 50 mL infusion [700431]
0.2-1.5 mcg/kg/hr, Intravenous, CONTINUOUS
Initiate/Titrate/Bolus per Assessment and Treatment
of Pain, Agitation, and Delirium in Mechanically
Ventilated Adult Intensive Care Unit Patient May
bolus ONLY if heart rate is greater than 70 bpm,
MAP is greater than 70 mmHg and RASS score is
greater than 2. May increase infusion by 0.1
mcg/kg/hr every 5 minutes to keep RASS score at
goal. If heart rate is less than 50 bpm or MAP less
than 55 mmHg, hold dexmedetomidine for 10
minutes, then restart with dose reduced by 0.3
mcg/kg/hr
Goal Richmond Agitation-Sedation Scale (RASS)
Score [NURCOM0015]
CONTINUOUS
Goal RASS Score:
Initiate/Titrate/Bolus per Assessment and Treatment
of Pain, Agitation, and Delirium in Mechanically
Ventilated Adult Intensive Care Patient to achieve
ordered goal RASS score.
Midazolam PRN with Option for Midazolam
Infusion - LOW Dose [220002]
midazolam (VERSED) injection RANGE [750056] 0.5-2 mg, Intravenous, EVERY 15 MINUTES PRN,
sedation, agitation
If patient fails to respond after 3 doses in an hour
consider starting continuous infusion.
Contact Pharmacist or Physician to enter order
for midazolam infusion. Order at rate of 1-10
mg/hr [950018]
CONTINUOUS
Initiate/Titrate/Bolus per Assessment and Treatment
of Pain, Agitation, and Delirium in Mechanically
Ventilated Adult Intensive Care Patient to achieve
RASS score
Goal Richmond Agitation-Sedation Scale (RASS)
Score [NURCOM0015]
CONTINUOUS
Goal RASS Score:
Initiate/Titrate/Bolus per Assessment and Treatment
of Pain, Agitation, and Delirium in Mechanically
Ventilated Adult Intensive Care Patient to achieve
ordered goal RASS score.
Do NOT start sedative continuous infusion unless
3 or more intermittent midazolam doses have
been used within one hour [NURCOM0022]
CONTINUOUS
Midazolam PRN with Option for Midazolam
Infusion - STANDARD Dose [220005]
midazolam (VERSED) injection RANGE [750056] 1-4 mg, Intravenous, EVERY 15 MINUTES PRN,
sedation, agitation
If patient fails to respond after 3 doses in an hour
consider starting continuous infusion.
Page 7 of 10
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:14:56 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Contact Pharmacist or Physician to enter order
for midazolam infusion. Order at rate of 1-10
mg/hr [950018]
CONTINUOUS
Initiate/Titrate/Bolus per Assessment and Treatment
of Pain, Agitation, and Delirium in Mechanically
Ventilated Adult Intensive Care Patient to achieve
RASS score
Goal Richmond Agitation-Sedation Scale (RASS)
Score [NURCOM0015]
CONTINUOUS
Goal RASS Score:
Initiate/Titrate/Bolus per Assessment and Treatment
of Pain, Agitation, and Delirium in Mechanically
Ventilated Adult Intensive Care Patient to achieve
ordered goal RASS score.
Do NOT start sedative continuous infusion unless
3 or more intermittent midazolam doses have
been used within one hour [NURCOM0022]
CONTINUOUS
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [116286]
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
STAT
Current signs and symptoms? Intubated
What specific question(s) would you like answered by
this exam? Evaluate ET Tube
Relevant recent/past history? Status Post Intubation
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Perform 30 minutes after order is signed
Laboratory
Laboratory [116287]
BLOOD GASES AND O2 SATURATION
[HCBGASOS]
STAT For 1 Occurrences, STAT
Indicate FIO2: FiO2 Per RN
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Collect 30 minutes post-intubation.
Patient Care Orders
Non-Categorized Patient Care Orders [116444]
Mechanical Ventilation - Adult [117146]
Provide Manual Resuscitator at Bedside
[RT0039]
CONTINUOUS, Routine
Page 8 of 10
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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Mechanical Ventilation [RT0028] Routine, For ADULT patients order chlorihexidene
gluconate (PERIDEX) 0.12% soln 15 mL to swab
oral cavity 2x daily while on ventilation.
Is this a modification to a current vent order?
Ventilator Management:
Wean:
Set Rate/Min:
PEEP (cmH2O):
Mode:
Tidal Volume Multiplier: 6
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Pressure Support:
Pressure Control:
P High (cmH20):
P Low (PEEP) (cmH20):
T High (sec):
T Low (T PEEP) (sec):
PS above P High (cmH2O):
PS above PEEP (cmH2O):
NAVA Level (µV):
chlorhexidine (PERIDEX) 0.12 % soln
MULTIDOSE [792004]
15 mL, Mouth/Throat, 2 X DAILY Starting today
Use to swab oral cavity. Discontinue when patient no
longer on ventilation.
OG Tube Placement - Adult [120995]
Insert and Maintain Orogastric Tube
[NURTAD0015]
CONTINUOUS, Routine
Options:
Flush with:
Flush Frequency: EVERY 8 HOURS
Check Residual:
Does this need to be inserted/placed?
Device Status:
Refer to Policy 2.20AP Care & Maintenance of
Enteral Tubes (Adult & Pediatric)
Recommendations for flush quantity:
For adult patients, 30 mLs of fluid should be
sufficient.
X-RAY ABDOMEN AP VIEW (KUB) [R74000] CONDITIONAL For 3 Days, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? Orogastric tube
placement
What specific question(s) would you like answered
by this exam? Evaluate orogastric tube placement
Relevant recent/past history? Cardiac Surgery
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date
in comment):
Transport Method: Floor Determined/Entered
If Conditional, What Condition? Evaluate orogastric
tube placement. The location of orogastric tube
should be confirmed prior to the instillation of fluids,
medications, or feedings. Refer to Policy 2.20
Enteral Tubes Used for Instillation of Fluids,
Medications, or Feeding
NG Tube Placement - Adult [120994]
Page 9 of 10
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12/2017CCKM@uwhealth.org

Insert and Maintain Nasogastric Tube
[NURTAD0014]
CONTINUOUS, Routine
Options:
Flush with:
Flush Frequency: EVERY 8 HOURS
Clamp NG Tube:
Check Residual:
Does this need to be inserted/placed?
Device Status:
Refer to Policy 2.20 Enteral Tubes Used for
Instillation of Fluids, Medications, or Feeding
Recommendations for flush quantity:
For adult patients, 30 mLs of fluid should be
sufficient.
lidocaine-oxymetazoline 4%-0.05% (ADULT)
nasal spray [785081]
2 spray, Nasal, ONCE For 1 Doses
For numbing prior to feeding tube insertion.
Slowly spray the chosen nostril once, if required may
repeat x1 in opposite nostril. Angle toward back of
throat spraying the anterior nostril and wait 30-60
seconds before introducing more local
anesthetic into the nostril. Caution: Entire bottle
should not be used for insertion of tube. Discard
excess solution when procedure completed.
X-RAY ABDOMEN AP VIEW (KUB) [R74000] CONDITIONAL For 3 Days, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered
by this exam? Evaluate nasogastric tube placement
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date
in comment):
Transport Method: Floor Determined/Entered
If Conditional, What Condition? Evaluate nasogastric
tube placement. The location of nasogastric tube
should be confirmed prior to the instillation of fluids,
medications, or feedings. Refer to Policy 2.20
Enteral Tubes Used for Instillation of Fluids,
Medications, or Feeding
Page 10 of 10
Printed by BENNETT, SARA J [SJB008] at 12/8/2017 9:14:56 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org