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UWHC,UWMF,

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

IP - Suspected Ebola Virus Disease - Adult - Admission [5457]

IP - Suspected Ebola Virus Disease - Adult - Admission [5457] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Suspected Ebola Virus Disease - Adult - Admission [5457]
Admission Status
Admit to Inpatient Status [182189]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor: F6/5
Service: SPECIAL PATHOGEN
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: Suspected Ebola Virus Disease
E - EVALUATIONS PLANNED: Multiple Lab Tests and
Studies
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED: Aggressive Fluids and
Symptoms Management
Admission Status [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:
Resuscitation Status [184056]
Limited Resuscitation - Ebola [CDSTS0099] Select from the following: No Chest Compressions
Blue wristband option to communicate Limited Resuscitation
status? No
Refer to Policy 8.02 Ebola Virus Disease Inpatient Code and
Treatment Policy
Isolation Status
Isolation Status [182304]
Isolation - Special - Ebola Viral Hemorrhagic Fever -
Panel [116360]
Isolation - Special - Ebola Viral Hemorrhagic Fever
[ISO0017]
CONTINUOUS
Isolation Cart [EQP0016] CONTINUOUS, Routine
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [182275]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/servlet/Satellite?
cid=1126673704572&pagename=B_EXTRANET_UWH_HOME%
2FFlexMemberFile%2FLoad_File&c=FlexMemberFile
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Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered [COR0008] ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single Response)
[129777]
enoxaparin (LOVENOX) injection [800040] 40 mg, Subcutaneous, EVERY 24 HOURS
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
High Bleed Risk with High VTE Risk (Single Response)
[129757]
Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered [COR0008] ONCE, Routine
Reason Not Ordered:
Pharmacologic - high hemorrhage risk; Mechanical - high
soilage risk
VTE Prophylaxis (Single Response) [182278]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/servlet/Satellite?
cid=1126673704572&pagename=B_EXTRANET_UWH_HOME%
2FFlexMemberFile%2FLoad_File&c=FlexMemberFile
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered [COR0008] ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single Response)
[129777]
enoxaparin (LOVENOX) injection [800040] 40 mg, Subcutaneous, EVERY 24 HOURS
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
High Bleed Risk with High VTE Risk (Single Response)
[129757]
Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis [184771]
VTE Prophylaxis - Reason Not Ordered [COR0008] ONCE, Routine
Reason Not Ordered:
Patient Care Orders
Vital Signs [182411]
Vital Signs [NURMON0013] EVERY 8 HOURS, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Patient Monitoring [182412]
Cardiac Rhythm Monitoring - Adult [NURMON0010] INTERMITTENT (MAY REMOVE WHEN BATHING ONLY),
Routine
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Notify Provider:
Functional Cardiac Defibrillator Present:
Activity [182422]
Activity [NURACT0008] CONTINUOUS, Routine
AD LIB: ad lib
AMBULATE:
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Patient may not leave the room.
Nutrition [182433]
Diet - Custom [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:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail):
Room Service Class:
Nourishments & Supplements [NUT0005] EFFECTIVE NOW, Starting today, Routine
Medical Food / Oral Supplement(s): Ceralyte 90
Nourishment / Snack Item(s):
Schedule:
Respiratory [182440]
Respiratory Therapy per Protocol [RT0035] CONTINUOUS, Starting today, Routine
Protocol Type:
Intake and Output [182453]
Measure Intake And Output [NURMON0005] EVERY 4 HOURS, Routine
Measure Weight [NURMON0015] 1X DAILY, Routine
Weigh With? Bed Scale
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Weigh when?
Non-Categorized Patient Care Orders [182462]
UW Tele-ICU in use [NURCOM0022] ONCE, UW Tele-ICU in use.
Emerging Pathogens Lab Protocol is activated
[NURCOM0022]
ONCE
Contingency Parameters [182467]
Notify [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 170
If systolic blood pressure < (mmHg): 95
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm): 110
If heart rate < (bpm): 40 for one minute
If respiratory rate >: 24
If respiratory rate <: 6
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 92% RA
If urine output < (mL): 0.5 mL/kg/hr
Other:
Intravenous Therapy
IV Fluids [182102]
lactated ringers IV BOLUS [730001] Intravenous, ONCE For 1 Doses
sodium chloride 0.9% IV BOLUS [730003] Intravenous, ONCE For 1 Doses
lactated ringers infusion [38890] at 125 mL/hr, Intravenous, CONTINUOUS
sodium chloride 0.9 % infusion [64367] at 125 mL/hr, Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L infusion
[44910]
at 125 mL/hr, Intravenous, CONTINUOUS
lactated ringers infusion [38890] at 20 mL/hr, Intravenous, CONTINUOUS
Run in PICC ports to maintain patency.
Medications - General
General Medications [182210]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain/fever, blood
products, mild to moderate pain or temperature greater than
38 C
For mild to moderate pain. No more than 4 grams
acetaminophen per 24 hours for adults or 15 mg/kg per dose
for peds < 40 kg.
loperamide (IMODIUM) tab [39152] 2 mg, Oral, EVERY 4 HOURS PRN, diarrhea
diphenoxylate-atropine (LOMOTIL) 2.5-0.025 MG per
tab RANGE [750016]
1-2 tab, Oral, EVERY 6 HOURS PRN, diarrhea
Anti-emetics [182214]
ondansetron (ZOFRAN ODT) disintegrating tab [64224] 4 mg, Oral, EVERY 24 HOURS PRN, nausea/vomiting
For first line therapy.
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 24 HOURS PRN,
nausea/vomiting
For first line therapy when unable to take orally.
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN, nausea/vomiting
For second line therapy when unresponsive to first line
therapy within 30 minutes.
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
IV push slowly, max rate 5 mg minute. For second line
therapy when unresponsive to first line therapy within 30
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minutes and unable to take orally.
Hypnotics [111639]
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)
Hypnotics (Single Response) [148301]
zolpidem (AMBIEN) tab [46913] 5 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic interventions
(see IPOC supplemental Sleep/Rest Disturbance Adult)
temazepam (RESTORIL) cap [46696] 15 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic interventions
(see IPOC supplemental Sleep/Rest Disturbance Adult)
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)
Anti-anxiety [182244]
lorazepam (ATIVAN) injection RANGE [750075] 0.5-2 mg, Intravenous, EVERY 2 HOURS PRN, anxiety
lorazepam (ATIVAN) tab RANGE [750026] 0.5-2 mg, Oral, EVERY 2 HOURS PRN, anxiety
Anti-infectives [182222]
Consider additional anti-infectives if the patient meets 2 or more of the following criteria: (1) Temperature greater than 38
C or less than 36 C, (2) Heart rate greater than 90 beats per minute, (3) Respiratory rate greater than 20 breaths per
minute, (4) White cell count (WBC) greater than 12 K/mcL or less than 4 K/mcL.
ceftriaxone (ROCEPHIN) intraVENOUS [800027] 2 g, Intravenous, EVERY 24 HOURS
ciprofloxacin (CIPRO) tab [720037] 500 mg, Oral, 2 X DAILY
oseltamivir (TAMIFLU) cap [62994] 75 mg, Oral, 2 X DAILY
Anti-malaria (Single Response) [182236]
Patients who are 25 kg to less than 35 kg [182251]
artemether-lumefantrine (COARTEM) 20-120 MG tab
[135431]
3 tab, Oral, ONCE For 1 Doses
artemether-lumefantrine (COARTEM) 20-120 MG tab
[135431]
3 tab, Oral, EVERY 8 HOURS For 1 Doses
Administer 8 hours after initial dose
artemether-lumefantrine (COARTEM) 20-120 MG tab
[135431]
3 tab, Oral, 2 X DAILY Starting tomorrow For 2 Days
Patients who are 35 kg or greater [182252]
artemether-lumefantrine (COARTEM) 20-120 MG tab
[135431]
4 tab, Oral, ONCE For 1 Doses
artemether-lumefantrine (COARTEM) 20-120 MG tab
[135431]
4 tab, Oral, EVERY 8 HOURS For 1 Doses
Administer 8 hours after initial dose
artemether-lumefantrine (COARTEM) 20-120 MG tab
[135431]
4 tab, Oral, 2 X DAILY Starting tomorrow For 2 Days
Laboratory
Laboratory [183944]
HIV-1,2 AB AND HIV-1 P24 AG, RAPID (ED AND EHS
ONLY) [HCHIVRAPD]
NEXT AM For 1 Occurrences, Routine, This test is intended
for the use by UWHC Emergency Department and UWHC
Employee Health Services. HIV-1,2 Ab [HIV] is available to
order for all other locations. Reactive specimens will be sent
to a reference lab for confirmation by Western Blot.
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
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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?
Consults
Consults [182471]
Consult Infectious Disease (Inpatient) [CON0037] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Fever/Suspected Ebola Virus
Disease
Consult Renal-Acute (Inpatient) [CON0069] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Acute Kidney injury in
suspected Ebola patient
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Copyright © 2015 University of Wisconsin Hospital and Clinics Authority