/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-98267-en.cckm

201712341

page

100

UWHC,UWMF,

Tools,

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

IP - Intensive Care - Adult - Admission [1538]

IP - Intensive Care - Adult - Admission [1538] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Intensive Care - Adult - Admission [1538]
for Adult Patients OnlyIntended
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) [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:
Page 1 of 18
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Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status [7248]
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:
Transfer
Transfer [191753]
Transfer Patient [ADT0005] Details
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [130123]
Padua VTE Risk Assessment Tool URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
High VTE Risk with Low Bleed Risk (Single
Response) [129777]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE Risk [129757]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/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]
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VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
VTE Prophylaxis (Single Response) [147942]
Padua VTE Risk Assessment Tool URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
High VTE Risk with Low Bleed Risk (Single
Response) [129777]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE Risk [129757]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/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:
Patient Care Orders
Vitals [20936]
Vital Signs [NURMON0013] EVERY 1 HOUR, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Patient Monitoring [20937]
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
ONCE, Routine
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Functional Cardiac Defibrillator Present:
Measure Intracranial Pressure [NURMON0040] EVERY 1 HOUR, Starting today, Routine
Page 3 of 18
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Measure Hemodynamic Parameters
[NURMON0023]
CONTINUOUS, Starting today, Routine
Pulmonary Artery Systolic Pressure (mmHg):
Pulmonary Artery Diastolic Pressure (mmHg):
Pulmonary Artery Mean Pressure (mmHg): Every 4
hours
Pulmonary Artery Wedge Pressure (mmHg): Every 4
hours
Central Venous Pressure (mmHg): Every 4 hours
Central Venous Pressure (mmH2O):
Cardiac Output: Every 4 hours
Cardiac Output Method:
Cardiac Index:
Systemic Vascular Resistance:
Pulmonary Vascular Resistance:
Pulmonary Vascular Resistance Index:
Stroke Volume (mL/beat):
Stroke Volume Index:
Systemic Vascular Resistance Index:
Left Cardiac Work Index:
Right Cardiac Work Index:
Left Ventricular Stroke Work Index:
Right Ventricular Stroke Work Index:
Pulmonary Capillary Wedge Pressure (mmHg):
Measure with FloTrac? No
Measure Height [NURMON0052] ONCE, Starting today For 1 Occurrences, Routine,
Measure height once upon admission.
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With?
Weigh when?
Measure weight upon admission, and daily thereafter.
Activity [184974]
-(CSS) and NonTLC Mobility Delegation Protocol for patients on the Critical Care Service Initiate
benefit from mobility advancement.Traumatic Surgery Center (TLC) unit for patients who would
TLC Progressive Mobility Algorithm URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/delegationpractice-
protocols/inpatient-delegation-
protocols/related/name-97311-en.cckm
Initiate TLC Mobility Delegation Protocol
[NURMON0090]
CONTINUOUS, Routine
Do Not Initiate TLC Mobility Protocol
[NURMON0190]
CONTINUOUS, Routine
Activity [NURACT0008] CONTINUOUS, Routine
Location:
Nutrition [21352]
NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: Strict NPO
Bedside Meal Instructions:
Room Service Class:
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
POC Glucose and Hypoglycemia Management [184925]
Page 4 of 18
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Select BOTH orders when ordering.
Glucose, POC [IPGLUCOSE] ONCE, 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?
Hypoglycemia Management (Adult) [191576]
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
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?
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)
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
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.
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.
Page 5 of 18
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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.
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.
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
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 access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
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
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, 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.
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting 12/15/17 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.
Respiratory [21353]
Respiratory Therapy per Protocol [RT0035] Routine
Protocol Type:
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today For Until specified,
Routine
Oxygen Therapy [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device:
Attempt to Wean Off Oxygen?
Page 6 of 18
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CPAP Continuous [RT0009] Routine
PEEP (cmH2O):
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Titrate oxygen to maintain O2 sat at (%):
Self Administered (Only RT may document in this box
after patient assessment): RT Approval Required
Biphasic Positive Airway Pressure (BIPAP)
[RT0004]
Routine
Mode:
IPAP (cm H2O):
EPAP (cm H2O):
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Set Rate/Min:
Titrate oxygen to maintain O2 sat at (%):
Self Administered (Only RT may document in this box
after patient assessment): RT Approval Required
Mechanical Ventilation - Adult [117146]
Provide Manual Resuscitator at Bedside
[RT0039]
CONTINUOUS, Routine
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, Other, 2 X DAILY Starting today
Use to swab oral cavity. D/C when patient no longer
on ventilation.
Intake and Output (Single Response) [21356]
Place order for Measure Intake and Output Every 1 Hour for postoperative patients, new trauma
patients, and patients with hemodynamic instability; for all other patients order Every 2 Hours.
Measure Intake And Output [NURMON0005] EVERY 1 HOUR, Starting today For Until specified,
Routine
Measure Intake And Output [NURMON0005] EVERY 2 HOURS, Starting today For Until specified,
Routine
Non-Categorized Patient Care Orders [184793]
Elevate Head Of Bed [NURACT0002] Equal to (degrees): 30
Greater than (degrees):
Less than (degrees):
Other options:
Routine, CONTINUOUS
Page 7 of 18
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Weigh Disposable Pads for Output Measuring
[NURELM0040]
CONTINUOUS, Starting today For Until specified,
Routine
Weigh pads for:
NG Tube Placement - Adult [120994]
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
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.
Page 8 of 18
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12/2017CCKM@uwhealth.org

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
Contingency Parameters [21360]
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): 38.5
If temperature < (C):
If heart rate > (bpm): ***
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 < (%): Less than ***%
If urine output < (mL): 0.5 milliliter/kilogram/hour
Other: MAP less than *** or greater than *** mmHg
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
Page 9 of 18
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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 [21152]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
sodium chloride 0.9% infusion [64367] Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L
infusion [44910]
Intravenous, CONTINUOUS
Flushes [111871]
sodium chloride 0.9% flush 10 mL injection
[785055]
Flush, PRN, flush/line care
Flush per VAD guidelines
heparin lock flush 10 UNIT/ML injection [75031] 1-150 units, Flush, PRN, flush/line care
Flush per VAD guideline
heparin lock flush 100 units/mL 5 mL injection
[64978]
500 units, Flush, PRN, flush/line care
Implanted port use ONLY to be used when de-
accessing port. Flush per VAD guidelines
Medications
Supplemental [4738} for -ICU -Adult -Pain/Agitation/Delirium in Intubated Patients -Refer to IP
orders specific for pain, agitation, and delirium in intubated patients.
Anti-ulcer [21332]
famotidine (PEPCID) intraVENOUS [800279] 20 mg, Intravenous, EVERY 12 HOURS
famotidine (PEPCID) tab [45134] 20 mg, Oral, EVERY 12 HOURS
pantoprazole (PROTONIX) injection [800119] 40 mg, Intravenous, 1 X DAILY
pantoprazole (PROTONIX) delayed release tab
[62661]
40 mg, Oral, 1 X DAILY
pantoprazole (PROTONIX) susp [780113] 40 mg, Nasogastric Tube, 1 X DAILY
Bowel Management - Scheduled [184415]
senna-docusate (SENOKOT-S) 8.6-50 mg per tab
[60530]
2 tab, Oral, 2 X DAILY
Hold for loose stools
Bowel Management - As Needed [21335]
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
Page 10 of 18
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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
Vasoactive Agents [21338]
DOPamine (INTROPIN) 800 mg in dextrose 5%
250 mL infusion [50506]
2-20 mcg/kg/min, Intravenous, CONTINUOUS
Titrate per Intensive Care Vasoactive Continuous
Infusion Titration - Adult delegation protocol. Initiate at
2 mcg/kg/min or current rate and titrate to maintain
{parameters:2000164}
DOBUTamine (DOBUTREX) 1000mg in dextrose
5% 250 mL infusion [51747]
2.5-20 mcg/kg/min, Intravenous, CONTINUOUS
Titrate per Intensive Care Vasoactive Continuous
Infusion Titration - Adult delegation protocol. Initiate at
2 mcg/kg/min or current rate and titrate to maintain
{parameters:2000165}
epINEPHrine infusion [700197] 0.01-0.4 mcg/kg/min, Intravenous, CONTINUOUS
Titrate per Intensive Care Vasoactive Continuous
Infusion Titration - Adult delegation protocol. Initiate at
0.01 mcg/kg/min or current rate and titrate to maintain
{parameters:2000164}
norepinephrine (LEVOPHED) infusion [700247] 0.01-2 mcg/kg/min, Intravenous, CONTINUOUS
Titrate per Intensive Care Vasoactive Continuous
Infusion Titration - Adult delegation protocol. Initiate at
0.01 mcg/kg/min or current rate and titrate to maintain
{parameters:2000164}
phenylEPHRINE(NEO-SYNEPHRINE) infusion
[700258]
0.1-5 mcg/kg/min, Intravenous, CONTINUOUS
Titrate per Intensive Care Vasoactive Continuous
Infusion Titration - Adult delegation protocol. Initiate at
0.25 mcg/kg/min or current rate and titrate to maintain
{parameters:2000164}
Pain/Agitation/Delirium in Non-Intubated Patients
Analgesics - Non-opioid [21175]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain/fever
See Pain Management Algorithm for the Selection of
As-needed Analgesics
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Nasogastric Tube, EVERY 4 HOURS PRN,
pain/fever
See Pain Management Algorithm for the Selection of
As-needed Analgesics
acetaMINOPHEN (TYLENOL) suppository
[43994]
650 mg, Rectal, EVERY 4 HOURS PRN, pain/fever
See Pain Management Algorithm for the Selection of
As-needed Analgesics
Opioids - As Needed (Single Response) [21331]
FENTanyl PF injection RANGE [750047] Intravenous
See Pain Management Algorithm for the Selection of
As-needed Analgesics
for 1 Minutes
HYDROmorphone PF (DILAUDID) injection
RANGE [750050]
Intravenous
See Pain Management Algorithm for the Selection of
As-needed Analgesics
for 3 Minutes
Page 11 of 18
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MORPHine PF injection RANGE [750057] Intravenous
See Pain Management Algorithm for the Selection of
As-needed Analgesics
for 4 Minutes
Sedatives - As Needed (Single Response) [21334]
midazolam (VERSED) injection RANGE [750056] Intravenous
lorazepam (ATIVAN) injection RANGE [750075] Intravenous, EVERY 6 HOURS PRN, sedation
Electrolyte Supplementation
Potassium Chloride (Single Response) [146649]
potassium chloride 10 mEq/100 mL bag [46253] 10 mEq, Intravenous, PRN - NOTIFY PHARMACY
WHEN NEEDED, potassium supplementation - See
Admin Instruction
For serum K between 3.6 - 3.9 mmol/L give 10 mEq
every 1 hour for 2 doses
For serum K between 3.1 - 3.5 mmol/L give 10 mEq
every 1 hour for 4 doses
For serum K less than or equal to 3.0 mmol/L give 10
mEq every 1 hour for 6 doses
Use only if patient is unable to tolerate enteral
administration
Do NOT give IV and oral formulation at the same time.
for 60 Minutes
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
potassium chloride 20 mEq/ 100 mL bag
CENTRAL LINE ONLY [46255]
20 mEq, Intravenous, PRN, Reminder: Pharmacist to
adjust per UWHC Renal Dosing Protocol if applicable
For central line use ONLY For serum K between 3.6 -
3.9 mmol/L give 20 mEq ONCE For serum K between
3.1 - 3.5 mmol/L give 20 mEq every 1 hour for 2 doses
For serum K less than or equal to 3.0 mmol/L give 20
mEq every 1 hour for 3 doses for 60 Minutes Use only
if patient is unable to tolerate enteral administration Do
NOT give IV and oral formulation at the same time.,
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
for 60 Minutes
potassium chloride 20 mEq oral packet [41217] 20 mEq, Oral, PRN, potassium supplementation - See
Admin Instructions
For serum K between 3.6 - 3.9 mmol/L give 1 packet
(20 mEq) ONCE;
For serum K between 3.1 - 3.5 mmol/L give 2 packets
(40 mEq) ONCE;
For serum K less than or equal to 3.0 mmol/L give 2
packets (40 mEq) ONCE followed by 1 packet
(20mEq) ONCE 1 hour later
Do NOT give IV and oral formulation at the same time.
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
Page 12 of 18
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12/2017CCKM@uwhealth.org

potassium chloride ER tab [73470] 20 mEq, Oral, PRN, potassium supplementation - See
Admin Instructions
For serum K between 3.6 - 3.9 mmol/L give 1 tab (20
mEq) ONCE
For serum K between 3.1 - 3.5 mmol/L give 2 tabs (40
mEq) ONCE
For serum K less than or equal to 3.0 mmol/L give 2
tabs (40 mEq) ONCE followed by 1 tab (20mEq)
ONCE 1 hour later
Do NOT give IV and oral formulation at the same time.
Swallow whole; do not break, chew, or crush tablet
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
potassium chloride ER cap [49087] 10 mEq, Oral, PRN, potassium supplementation - See
Admin Instruction
For serum K between 3.6 - 3.9 mmol/L give 2 caps (20
mEq) ONCE;
For serum K between 3.1 - 3.5 mmol/L give 4 caps (40
mEq) ONCE;
For serum K less than or equal to 3.0 mmol/L give 4
caps (40 mEq) ONCE followed by 2 caps (20mEq)
ONCE 1 hour later
Do NOT give IV and oral formulation at the same time.
Swallow whole; do not break, chew, or crush tablet
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
Magnesium Sulfate [142608]
Magnesium Supplemental Scale [950039] PRN - NOTIFY PHARMACY WHEN NEEDED,
magnesium supplementation - see Admin Instructions
Non-cardiac patients: For serum magnesium 1.6-1.8
mg/dL - do not replace
Cardiac patients: For serum magnesium 1.6-1.8
mg/dL give 0.05 g/kg IV x1
For serum magnesium 1.0-1.5 mg/dL give 0.1 g/kg IV
x1
For serum magnesium less than 1 mg/dL give 0.15
g/kg IV x1
Administer each 2 gram bag over 3 hours at a
frequency of one bag every 4 hours.
Maximum 6 grams per replacement dose
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
Phosphate Sodium (Single Response) [146650]
phosphate-potassium & sodium (PHOS-NAK) oral
packet - For normal renal function [112317]
2 packet, Oral, PRN, phosphate supplementation -
See Admin Instructions
For serum phosphate 1.6 - 2.4 mg/dL, give 2 packets
every 4 hours while awake x 3 doses;
For serum phosphate 1.0 - 1.5 mg/dL, give 2 packets
every 4 hours while awake x 4 doses
For serum phosphate less than 1.0 mg/dL, call
provider for IV dosing.
Page 13 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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phosphorus (K-PHOS NEUTRAL) tab - For renal
dysfunction [45503]
1 tab, Oral, PRN, phosphate supplementation - See
Admin Instructions
For serum phosphate 1.6 - 2.3 mg/dL give 1 tablet
every 4 h while awake x 3 doses
For serum phosphate 1.0 - 1.5 mg/dL give 1 tablet
every 4 h while awake x 4 doses
For serum phosphate less than 1.0 mg/dL, call
provider
Post Supplementation [211496]
POTASSIUM [K] 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? Draw 1 hour after IV
replacement or 4 hours after oral
replacement.,Arrhythmias
MAGNESIUM [MAG] 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? Draw AM following
completion of infusion,Arrhythmias
PHOSPHATE [PHOS] 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? Draw 4 hours after
enteral replacement.
Laboratory
Labs [21362]
BLOOD GASES AND O2 SATURATION
[HCBGASOS]
NEXT DRAW, Starting today For 1 Occurrences,
Routine
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CBC WITH DIFFERENTIAL [CBC] NEXT DRAW, 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] NEXT DRAW, 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] NEXT DRAW, 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?
BUN [BUN] NEXT DRAW, 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 14 of 18
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12/2017CCKM@uwhealth.org

CREATININE [CRET] NEXT DRAW, 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] NEXT DRAW, 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] NEXT DRAW, 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] NEXT DRAW, 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] NEXT DRAW, 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] NEXT DRAW, 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] NEXT DRAW, 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] NEXT DRAW, 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?
MAGNESIUM [MAG] NEXT DRAW, 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?
PHOSPHATE [PHOS] NEXT DRAW, 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?
PROTHROMBIN TIME/INR [PT] NEXT DRAW, 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 15 of 18
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12/2017CCKM@uwhealth.org

URINALYSIS WITH MICROSCOPY [UA] ONCE, 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?
LACTATE [GM2255] EVERY 3 HOURS, Starting today For 2 Occurrences,
STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Repeat draw in 3 hours if previous lactate > 2.0
mmol/L.
CULTURE, BLOOD, BACTERIA/YEAST (2
SITES) [116728]
.Practices for Blood Culturing Best This order equals 2 sites (4 bottles). See link below for
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
NEXT DRAW, Routine, For optimum diagnosis of
sepsis, sample 3-4 sites only on the first day of a
septic episode. Cultures on subsequent days are of
minimal diagnostic value. Culture detects bacteria,
Candida and Cryptococcus. If filamentous fungi are
suspected see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition?
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
NEXT DRAW, Routine, For optimum diagnosis of
sepsis, sample 3-4 sites only on the first day of a
septic episode. Cultures on subsequent days are of
minimal diagnostic value. Culture detects bacteria,
Candida and Cryptococcus. If filamentous fungi are
suspected see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition?
Diagnostic Tests and Imaging
Studies [21480]
ECG - 12 Lead [EKG0008] PRN, Routine
Reason for exam: Other (enter comments)
Comment: ST Segmant Changes
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.
ECG - 12 Lead Without Rhythm [EKG0008] ONCE, Starting today For 1 Occurrences, 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.
Page 16 of 18
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12/2017CCKM@uwhealth.org

X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
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 not done in the ED.
Consults
Consults [21481]
Complex Pancreatitis Consults - Adult [206103]
If there is a need for complex pancreatitis management recommendations, please consult and
call all 3 services. Patients will then be followed by the UW Multi Disciplinary PANC
(Pancreatitis: Acute, Necrotizing, Complex) Workgroup. Qualifying patients are any with acute
fluid collections, pseudocysts, loculated necrosis, acute necrotizing collections, walled off
necrosis and as determined by submitting practitioner.
Consult General Surgery (Inpatient) [CON0029] ONCE
Intent: Consult and Recommend (No Orders)
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis): Complex
Pancreatitis Management Recommendations
Can this consult be done via video?
Call back number:
CONSULT INTERVENTIONAL RADIOLOGY -
BODY (INPATIENT) [CON0187]
ONCE
Intent: Consult and Recommend (No Orders)
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis): Complex
Pancreatitis Management Recommendations
Can this consult be done via video?
Call back number:
Consult Gastroenterology (Inpatient) [CON0027] ONCE
Intent: Consult and Recommend (No Orders)
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis): Complex
Pancreatitis Management Recommendations
Can this consult be done via video?
Call back number:
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult:
Consult Nutrition (Inpatient) [CON0043] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Delegate to Initiate and Manage Tube Feeding:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
Can this consult be done via video?
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Occupational Therapy Consult:
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
BestPractice
Page 17 of 18
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:10:19 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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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 18 of 18
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:10:19 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org