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/clinical/cckm-tools/content/order-sets/inpatient/neurosciences/name-111188-en.cckm

201712349

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100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Neurosciences

IP - Neurosurgery - PostOperative Transition to ICU - Supplemental [5881]

IP - Neurosurgery - PostOperative Transition to ICU - Supplemental [5881] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Neurosciences


IP - Neurosurgery - PostOperative Transition to ICU - Supplemental [5881]
for Adult Patients OnlyIntended
Admission Status
Level of Care (Single Response) [216211]
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.
Patient Care Orders
Vital Signs [85909]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every hour times 12, then every 2 hours., Post-
Op/Phase II
Assess Neurologic Status [NURMON0006] SEE COMMENTS, Starting today For Until specified,
Routine, Every hour times 12, then every 2 hours.,
Post-Op/Phase II
Activity [216212]
Activity [NURACT0008] CONTINUOUS, Starting tomorrow, Routine
AD LIB:
AMBULATE:
CHAIR: 4x daily,for all meals
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Post-Op/Phase II
Respiratory [216199]
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today For Until specified,
Routine, Post-Op/Phase II
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 (%): 92
O2 Delivery Device:
Attempt to Wean Off Oxygen? Yes
Post-Op/Phase II
Mechanical Ventilation - Adult [117146]
Provide Manual Resuscitator at Bedside
[RT0039]
CONTINUOUS, Routine, Post-Op/Phase II
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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):
Post-Op/Phase II
chlorhexidine (PERIDEX) 0.12 % soln
MULTIDOSE [792004]
15 mL, Other, 2 X DAILY Starting today
Use to swab oral cavity. Discontinue when patient no
longer on ventilation.
Post-Op/Phase II
Respiratory Therapy per Protocol [RT0035] Routine
Protocol Type:
Post-Op/Phase II
Wound Care [85913]
Monitor Wound Dressing For Expanding
Hemorrhage [NURWND0018]
CONTINUOUS, Starting today For Until specified,
Monitor wound dressing for expanding hemorrhage.,
Post-Op/Phase II
Maintain Drain - HEMOVAC [NURTAD0003] CONTINUOUS, Starting today For Until specified,
Routine
Type: Closed Suction (Jackson-Pratt) (HEMOVAC)
Site:
Location:
Drainage Options: Dependent Drainage
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For:
Dressing Change Frequency:
Dressing Type:
Post-Op/Phase II
Page 2 of 15
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Maintain Drain - JACKSON-PRATT
[NURTAD0003]
CONTINUOUS, Starting today For Until specified,
Routine
Type: Closed Suction (Jackson-Pratt)
Site:
Location:
Drainage Options: Bulb
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For:
Dressing Change Frequency:
Dressing Type:
Post-Op/Phase II
Maintain Drain - Subdural Catheter
[NURTAD0003]
CONTINUOUS, Starting today For Until specified,
Routine
Type: Other (Comment) (Subdural Catheter)
Site: Head/Neck
Location:
Drainage Options: Dependent Drainage
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For:
Dressing Change Frequency:
Dressing Type:
Drain subdural catheter for a maximum of ***
milliliters/hour., Post-Op/Phase II
Measure Drain Output [NURTAD0005] SEE COMMENTS, Starting today For Until specified,
Routine, Every hour times 12, then every 2 hours.,
Post-Op/Phase II
Intracranial Pressure Monitoring [85914]
Transduce Intracranial Pressure [NURMON0060] CONTINUOUS, Starting today For Until specified,
Transduce intracranial pressure - Continuous, Post-
Op/Phase II
Measure Cerebral Perfusion Pressure Every Hour
[NURMON0060]
SEE COMMENTS, Starting today For Until specified,
Measure cerebral perfusion pressure every hour.,
Post-Op/Phase II
Maintain Ventriculostomy Catheter
[NURTAD0039]
CONTINUOUS, Routine
Ventriculostomy Details:
Height Change:
Continuously open ventriculostomy at *** mmHg.,
Post-Op/Phase II
Lumbar Drains [85915]
Maintain Lumbar Drain [NURTAD0051] CONTINUOUS, Routine
Location: Posterior
Drainage Amount/Drainage Level:
Drainage Unit of Measurement:
Dressing Type: Transparent
Post-Op/Phase II
Intake and Output [216213]
Measure Intake And Output [NURMON0005] EVERY 2 HOURS, Starting today For Until specified,
Routine, Post-Op/Phase II
Non-Categorized Patient Care Orders [216214]
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(aka Diabetes)" Supplemental -Adult -Diabetes Management, Refer to "Insulin Infusion For
Order Set
-ICU/IMC -Adult -Electrolyte Supplementation, Refer to "Electrolyte Supplementation For
Supplemental" Order Set
Supplemental" -Feeding Tube Placement, Refer to "Feeding Tube Placement Request For
Order Set
-Request Adult PICC Placement -PICC Placement, Refer to "Venous Access Team For
Supplemental" Order Set
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
ONCE, Routine
Indication:
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Functional Cardiac Defibrillator Present:
Post-Op/Phase II
Maintain Urinary Catheter [NURELM0013] CONTINUOUS, Starting today, Routine, To
discontinue this order, enter a new order for
"Discontinue Urinary Catheter".
To modify this order, enter a new order for "Maintain
Urinary Catheter" and make the necessary changes in
the new order.
Type:
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Post-Op/Phase II
Maintain Arterial Line [NURVAD0001] CONTINUOUS, Starting today For Until specified,
Routine
Flush Solution:
Post-Op/Phase II
Contingency Parameters [85918]
Page 4 of 15
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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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): 37.2
If temperature < (C):
If heart rate > (bpm): ***
If heart rate < (bpm): ***
If respiratory rate >: ***
If respiratory rate <: ***
If blood glucose > (mg/dL): 180
If blood glucose < (mg/dL): 80
If pain score >:
Pulse Oximetry < (%): 90
If urine output < (mL): 30 mL/hour for 2 hours or
greater than 250 mL/hour for 2 hours
Other: Mean arterial pressure less than *** or greater
than *** mmHg,Intracranial pressure greater than 20
mmHg for greater than 5 minutes,Intracranial pressure
remains greater than *** mmHg after draining 10 mL
from ventriculostomy,Cerebral perfusion pressure less
than 60 mmHg ,Any change in neurological exam,Pain
not controlled with ordered analgesics or ordered
interventions,Stat laboratory results
received,Expanding hemorrhage at dressing site,Drain
output greater than *** milliliters over 8 hours,More
than 3 doses of labetalol given within an hour.
Post-Op/Phase II
Intravenous Therapy
IV Fluids [85920]
sodium chloride 0.9 % infusion [64367] Intravenous, CONTINUOUS, Post-Op/Phase II
sodium chloride 0.9% with KCl 20 mEq/L infusion
[46261]
Intravenous, CONTINUOUS, Post-Op/Phase II
Surgical Prophylaxis
First Line (Single Response) [145905]
cefuroxime (ZINACEF) intraVENOUS - NOTE:
Patients who are 40-120 kg [800030]
1.5 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
cefuroxime (ZINACEF) intraVENOUS - NOTE:
Patients who are 121 kg and greater [800030]
3 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
MRSA/Documented MRSA History (Single Response) [145904]
Patients who are 40-120 kg [228690]
cefuroxime (ZINACEF) intraVENOUS [800030] 1.5 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses
Maximum Concentration: Peripheral 5 mg/mL;
Central line 10 mg/mL
Max dose = 2000 mg
Post-Op/Phase II
Patients who are 121 kg and greater [228693]
cefuroxime (ZINACEF) intraVENOUS [800030] 3 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
Page 5 of 15
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses
Maximum Concentration: Peripheral 5 mg/mL;
Central line 10 mg/mL
Max dose = 2000 mg
Post-Op/Phase II
Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies [145906]
vancomycin (VANCOCIN) intraVENOUS [800084] 20 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Medications - General
Analgesics - Acetaminophen - PRN (Single Response) [216215]
acetaMINOPHEN (TYLENOL) tab [750000] 325-650 mg, Oral, EVERY 4 HOURS PRN, pain
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
Post-Op/Phase II
acetaMINOPHEN (TYLENOL) suppository
[34153]
650 mg, Rectal, EVERY 4 HOURS PRN, pain
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
Post-Op/Phase II
Analgesics - Opioids - Oral - PRN [216216]
oxycodone tab RANGE [750032] 5-10 mg, Oral, EVERY 4 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-needed Analgesics
Post-Op/Phase II
Analgesics - Opioids - Intravenous - PRN (Single Response) [216217]
MORPHine PF injection [750057] 1-2 mg, Intravenous, EVERY 1 HOUR PRN For 48
Hours, pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
Do NOT give while on continuous opioid infusion
unless pain is uncontrolled and provider is notified
for 4 Minutes, Post-Op/Phase II
HYDROmorphone PF (DILAUDID) injection
[750050]
0.2-0.5 mg, Intravenous, EVERY 1 HOUR PRN For 48
Hours, pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
Do NOT give while on continuous opioid infusion
unless pain is uncontrolled and provider is notified.
for 3 Minutes, Post-Op/Phase II
Analgesics - NSAIDS - PRN (For Chiari Decompression Patients ONLY) [217190]
ibuprofen (MOTRIN) tab [38353] 200 mg, Oral, EVERY 4 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-needed Analgesics
Alternate with acetaminophen every 2 hours
Post-Op/Phase II
Anticonvulsants [216197]
Levetiracetam [216198] "Followed by" Linked Panel
levetiracetam (KEPPRA) intraVENOUS [800051] 500 mg, Intravenous, EVERY 12 HOURS For 2
Doses, Post-Op/Phase II
levetiracetam (KEPPRA) tab [720172] 500 mg, Oral, 2 X DAILY, Post-Op/Phase II
Anti-emetics [216218]
Adult - Standard - Anti-emetics [242385]
Page 6 of 15
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ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
4 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
Use first line
Post-Op/Phase II
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.
Post-Op/Phase II
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
Post-Op/Phase II
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
If ordered IV: push slowly, max rate 5 mg/minute.
Post-Op/Phase II
Antihypertensives - As Needed [216221]
hydrALAZINE (APRESOLINE) injection [750049] 10-20 mg, Intravenous, EVERY 1 HOUR PRN,
hypertension
Administer to keep blood pressure below the upper
limits identified in notify provider section of orders.
Give first line for blood pressure control if heart rate is
< 60 beats per minute or give second line if heart rate
is greater than or equal to 60 beats per minute and
labetalol is ordered. Wait at least 15 minutes after any
administration of bolus as needed antihypertensives,
including labetalol, before giving hydralazine. Do NOT
give while on a continuous infusion of an
antihypertensive unless the continuous infusion is at
maximum dose and provider is notified.
Post-Op/Phase II
labetalol (NORMODYNE;TRANDATE) injection
RANGE [750053]
10-20 mg, Intravenous, EVERY 1 HOUR PRN,
hypertension
Administer to keep blood pressure below the upper
limits identified in notify provider section of orders.
Give first line for blood pressure control if heart rate is
greater than or equal to 60 beats per minute. Do not
give if heart rate is < 60 beats per minute. Wait at
least 15 minutes after any administration of bolus as
needed antihypertensives, including hydralazine,
before giving labetalol. Do NOT give while on a
continuous infusion of an antihypertensive, unless the
continuous infusion is at maximum dose and provider
is notified.
for 2 Minutes, Post-Op/Phase II
Antihypertensives – Continuous Infusion [242492]
Page 7 of 15
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nicardipine (CARDENE) 50 mg in sodium chloride
0.9 % 250 mL infusion [700960]
5-15 mg/hr, Intravenous, CONTINUOUS
Titrate per Intensive Care Vasoactive Continuous
Infusion Titration - Adult Protocol.
Initiate at 5mg/hr or current rate and titrate to maintain
systolic blood pressure less than goal referred to in
the notify provider section of the orders.
Post-Op/Phase II
Antacid (Single Response) [212925]
mag-al-simeth (MYLANTA ES) 400-400-40
MG/5ML susp [44073]
15 mL, Oral, EVERY 4 HOURS PRN, dyspepsia,
Post-Op/Phase II
Acid Suppressants (Single Response) [217171]
clopidogrel should not be used in conjunction with PPI
Ranitidine [212923] "Followed by" Linked Panel
famotidine (PEPCID) intraVENOUS [800279] 20 mg, Intravenous, EVERY 12 HOURS
famotidine (PEPCID) tab [45134] 20 mg, Oral, 2 X DAILY
Pantoprazole [212924] "Followed by" Linked Panel
pantoprazole (PROTONIX) intraVENOUS
[800119]
40 mg, Intravenous, 1 X DAILY For 1 Doses, Post-
Op/Phase II
pantoprazole (PROTONIX) delayed release tab
[62661]
40 mg, Oral, 1 X DAILY, Post-Op/Phase II
Corticosteroids [216195]
Dexamethasone [216196] "Followed by" Linked Panel
dexamethasone (DECADRON) intraVENOUS
[800037]
4 mg, Intravenous, EVERY 6 HOURS For 24 Hours,
Post-Op/Phase II
dexamethasone (DECADRON) tab [36586] 4 mg, Oral, EVERY 6 HOURS, Post-Op/Phase II
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 [240448]
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
Flushes [85930]
sodium chloride 0.9% flush 10 mL injection
[785055]
Flush, PRN, flush/line care
Flush per VAD guidelines
Post-Op/Phase II
heparin lock flush 10 UNIT/ML injection [75031] 1-150 units, Flush, PRN, flush/line care
Flush per VAD Guidelines
Post-Op/Phase II
Vasopressors [85933]
phenylEPHRINE(NEO-SYNEPHRINE) infusion
[700258]
0.25-5 mcg/kg/min, Intravenous, CONTINUOUS
Titrate per Intensive Care Vasoactive Continuous
Infusion Titration - Adult Protocol.
Initiate at 0.25 mcg/kg/min or current rate and titrate to
maintain SBP greater than goal referred to in notify
provider section of the orders.
Post-Op/Phase II
Infusion Sedatives and Pain Control [216224]
Page 8 of 15
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propofol (DIPRIVAN) 10 mg/mL infusion [800260] 5-50 mcg/kg/min, Intravenous, CONTINUOUS
Initiate at 10 mcg/kg/min (or current rate) and titrate by
10 mcg/kg/min every 10 minutes to maximum of 50
mcg/kg/min to maintain a RASS sedation score of -3
Post-Op/Phase II
FENTanyl (50 mcg/mL) infusion [800264] 25-50 mcg/hr, Intravenous, CONTINUOUS
Initiate at 25 mcg/hr (or current rate) and titrate by 25
mcg/hr every 15 minutes to maximum of 50 mcg/hr as
needed for severe pain control.
Post-Op/Phase II
Non-Categorized [216225]
naloxone (NARCAN) injection [800199] 0.1 mg, Intravenous, PRN, opioid overdose
Administer every 3 minutes times 4 doses as needed
for respiratory rate less than 8 breaths/minute. Notify
MD if naloxone administered
Post-Op/Phase II
Laboratory
Draw in PACU [85936]
ELECTROLYTES, WHOLE BLOOD
[HCWBLYTS]
STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Collect in PACU., Post-Op/Phase II
GLUCOSE, WHOLE BLOOD [HCWBGLU] STAT For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Collect in PACU., Post-Op/Phase II
CREATININE, WHOLE BLOOD [HCWBCRET] STAT For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Collect in PACU., Post-Op/Phase II
HEMOGLOBIN, WHOLE BLOOD [HCWBHGB] STAT For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Collect in PACU., Post-Op/Phase II
CALCIUM, IONIZED, WHOLE BLOOD
[HCWBICA]
STAT For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Collect in PACU., Post-Op/Phase II
MAGNESIUM [MAG] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Collect in PACU., Post-Op/Phase II
PHOSPHATE [PHOS] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Collect in PACU., Post-Op/Phase II
Page 9 of 15
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CBC WITHOUT DIFFERENTIAL [HEMO] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Collect in PACU., Post-Op/Phase II
PROTHROMBIN TIME/INR [PT] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Collect in PACU., Post-Op/Phase II
PTT [PTT] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Collect in PACU., Post-Op/Phase II
BLOOD GASES [HCBGAS] STAT, 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?
Collect in PACU., Post-Op/Phase II
Postoperative Day 1 in AM [216986]
MAGNESIUM [MAG] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
PHOSPHATE [PHOS] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
CBC WITHOUT DIFFERENTIAL [HEMO] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
ELECTROLYTES [LYTE] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
GLUCOSE [GLU] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
BUN [BUN] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
CREATININE [CRET] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
Page 10 of 15
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CALCIUM [CA] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
PROTHROMBIN TIME/INR [PT] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
Conditional Labs [85938]
GLUCOSE [GLU] CONDITIONAL For 4 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw STAT as needed
for blood glucose (bedside) less than 40 or greater
than 400 mg/dL
Post-Op/Phase II
SODIUM [NA] CONDITIONAL For 4 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? For urine output
greater than 250 milliliters/hour for 2 hours
Post-Op/Phase II
SPECIFIC GRAVITY, URINE [HCSG] CONDITIONAL For 4 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? For urine output
greater than 250 milliliters/hour for 2 hours
Post-Op/Phase II
Diagnostic Tests and Imaging
Studies [85940]
X-RAY SKULL < 4 VIEWS [R70250] 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? Baseline study for future shunt evaluations
Relevant recent/past history? Status post placement
of ventriculoperitoneal shunt
Is patient pregnant?
If being performed remotely, where? Bedside
Transport Method: Floor Determined/Entered
Obtain in PACU., Post-Op/Phase II
CT HEAD W/ O IV CONTRAST [R70450] ONCE-RAD NEXT AVAILABLE, Starting tomorrow at
5:00 AM For 1 Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam? Please include relevant recent/past
history.
Last creatinine value? (will auto pull in date and value
in comment):
Last patient weight? (will auto pull in value and date in
comment):
Transport Method:
While patient is in PACU., Post-Op/Phase II
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12/2017CCKM@uwhealth.org

MRI HEAD W & W/ O CONTRAST [R70553] ONCE-RAD NEXT AVAILABLE, Starting tomorrow at
5:00 AM For 1 Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam? Evaluate for postoperative changes
Relevant recent/past history? Status post craniotomy
Is patient pregnant?
Does patient have a pacemaker or defibrillator?
Allergy to Gadolinium (MRI) contrast?
For Scheduling purposes, is the patient claustrophobic
or require any form of sedation? Note: ordering
provider is responsible for prescribing oral anxiolytic or
ordering sedation services.
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
Relevant Surgical History (Select all applicable or
None):
Implanted Devices? (Select all applicable or None):
History of Metal in Body? (Select all applicable or
None):
Has patient had a colonoscopy/endoscopy in the last 8
weeks?
Study Needed Within:
Last creatinine value? (will auto pull in date and value
in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date in
comment):
Last patient height? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Post-Op/Phase II
X-RAY CHEST AP VIEW - Bedside in PACU
[R71010]
ONCE-RAD NEXT AVAILABLE, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam? Baseline study for future shunt evaluations
Relevant recent/past history? Status post placement
of ventriculoperitoneal shunt
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Obtain in PACU.
Consults
Consults [214752]
Diabetes Consult Order Panel (Adult) [188497]
Page 12 of 15
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12/2017CCKM@uwhealth.org

Diabetes Management Service : Will provide management or treatment recommendations for
patients with hyperglycemia and/or those who report outpatient use of insulin or other diabetes
medications. Patients should be expected to remain inpatient > 24 hrs from time of consult.
Consult is required for patients with insulin pumps or who use U-500 insulin. Consult Endocrine
for any non-diabetes-related endocrine questions.
Learning Center - Diabetes Education (Adult): Diabetes Education (Adult): Diabetes education
(meter/insulin skills/other diabetes survival skills) for patients/families with knowledge deficits
and/or need for diabetes knowledge assessment. Recommended for all new diagnoses or
patients with A1C > 9.
Diabetes Education – Nutrition : Diabetes nutrition therapy including nutrition assessment,
carbohydrate education (consistent carbohydrate meals, use of insulin-to-carbohydrate ratio),
and/or individualized, nutritious meal planning for carbohydrates, portions, or considering other
comorbidities. Recommended for all new diagnoses or patients with A1C > 9
Consult Diabetes Management Service (DMS)
(Inpatient) [CON0022]
ONCE
Can this consult be done via video?
Call back number:
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Post-Op/Phase II
Consult Learning Center - Diabetes Education
(Adult) [CON0021]
ONCE, Routine, - If patient is newly diagnosed or is
new to insulin, provide 24 hours notice to allow
adequate time for education,
- Indicate diabetes medication/treatment plan if
known.
- Consults requested after 1600 on Fridays may not
be seen until following Monday. Learning Center
available Mon-Sat 0800-1630 (only 1 RN available
on Saturday for CSC and AFCH).
- Staff may be contacted by Pager 7927 on
weekdays and Pager 3276 on weekends.
- Learning Center staff are not available on holidays.
Type of Education: Diabetes Self-Management
Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Post-Op/Phase II
Page 13 of 15
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12/2017CCKM@uwhealth.org

Consult Diabetes Education - Nutrition (Inpatient)
[CON0126]
ONCE, Routine, · If your patient is newly diagnosed
and/or is new to insulin therapy, provide 24 hours
notice to allow adequate time for nutrition education.
· Indicate diabetes medication/treatment plan if
known.
· Consults requested after 1300 on Friday may not
be completed until the following Monday.
· If you are placing a consult on a weekend day for a
patient who will be discharging that weekend, please
have the Paging Center contact the on-call dietitian
to help you facilitate the diabetes nutrition education
session prior to the patient's discharge.
Type of Education: Diabetes Self-Management
Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Post-Op/Phase II
Behavioral Health Consults (select below)
[132899]
amp, transplant), - adjustment, protocol (eg. burn, trauma, rehab, pre-Psychology Health
noncompliance, grief, pain
Addictive Disorders - alcohol or drug related problems (eg. treatment recommendations,
withdrawal mgmt)
Psychiatry - safety, agitation, capacity, med mgmt, psychotropic SE
ACE - 60 and older - delirium, dementia, depression, decisional capacity, sleep (also for non-
behavioral geriatric syndromes; overall geriatric evaluation, mobility/falls, functional decline,
social/caregiver issues, disposition, medication management)
Consult Health Psychology (Inpatient)
[CON0033]
ONCE, Routine, Please notify consulting provider if
patient needs to be seen same day (Monday-Friday)
or if special assessment needs.
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Post-Op/Phase II
Consult Addictive Disorders (Inpatient)
[CON0003]
ONCE, Routine, This order is for ADULT patients.
Please use the Consult Adolescent/Pediatric AODA
Counselor order for adolescent/pediatric patients
instead.
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Post-Op/Phase II
Consult Psychiatry (Inpatient) [CON0064] ONCE
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Call back number:
Post-Op/Phase II
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12/2017CCKM@uwhealth.org

Consult Ace/Geriatric (Inpatient) [CON0001] ONCE, Routine
Reason for Consult:
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: ADL
Training
Post-Op/Phase II
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult: Mobility
Training
Post-Op/Phase II
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Can this consult be done via video?
Post-Op/Phase II
Consult Speech Therapy (Inpatient) Eval and
Treat [CON0077]
ONCE, Starting today For 1 Occurrences, Routine
Patient Type:
Post-Op/Phase II
Consult Swallow Therapy (Inpatient) [CON0079] ONCE, Routine
Reason for Consult: Evaluate and Treat Patient
May the Speech Pathologist and Registered Dietician
place diet orders on your behalf?
Is this a potential new stroke patient?
Post-Op/Phase II
Consult NeuroCritical Care (Inpatient) [CON0136] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Call back number:
Post-Op/Phase II
Consult Nutrition (Inpatient) [CON0043] ONCE, 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?
Post-Op/Phase II
BestPractice
No Hospital Problems have yet been identified [107363]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing., Post-Op/Phase II
Page 15 of 15
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:17:28 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org