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/clinical/cckm-tools/content/order-sets/inpatient/neurosciences/name-98142-en.cckm

201606170

page

100

UWHC,UWMF,

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

IP - Multiple Sclerosis Exacerbation - Adult - Admission [1654]

IP - Multiple Sclerosis Exacerbation - Adult - Admission [1654] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Neurosciences


IP - Multiple Sclerosis Exacerbation - Adult - Admission [1654]
Intended for Adult Patients Only
Admission Status
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:
Isolation Status
If patient requires isolation, please search for isolation in the additional orders section below.
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [130119]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/references/medication-
use-manual/anticoagulation-resources/resources/name-
26463-en.file
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) subcutanoeus injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 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:
Patient Care Orders
Vital Signs [23597]
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Vital Signs [NURMON0013] EVERY 8 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Patient Monitoring [23598]
Assess Neurologic Status [NURMON0006] EVERY 8 HOURS, Starting today, Routine
Activity [23602]
Ambulate [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE: other (comment)
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Chair [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR: other (comment)
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Dangle [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE: other (comment)
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Bedrest [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: other (comment)
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
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Ad Lib [NURACT0008] CONTINUOUS, Starting today, 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:
Nutrition [23639]
General Diet [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):
Tube Feeding Management:
Room Service Class:
Respiratory [23640]
Oxygen Therapy [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%):
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 93
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Respiratory Therapy per Protocol [RT0035] CONTINUOUS, Starting today, Routine
Protocol Type:
Pulse Oximetry [NURMON0009] EVERY 8 HOURS, Starting today, Routine
Non-Categorized Patient Care Orders [23641]
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Glucose, POC [IPGLUCOSE] BEFORE MEALS AND BEDTIME, Starting today For 4 Days,
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?
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With?
Weigh when?
Insert and 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: Indwelling Single Lumen
Indication for Placement:
Details: To Dependent Drainage
Irrigate With:
Irrigation Frequency:
Does this need to be inserted/placed?
Urinary Catheterization-Intermittent [NURELM0018] EVERY 6 HOURS PRN, Starting today, Routine, Every 6
hours as needed if unable to void.
Contingency Parameters [23642]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): 250
If blood glucose < (mg/dL): 60
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other:
Intravenous Therapy
Premedications for Needle Insertion [106310]
Use lidocaine topical dressing kit for stable patient, no lidocaine allergies, have at least 30 minutes time prior to needing
to use IV
Sodium chloride (bacteriostatic) 0.9% intradermal: Useful for patients requiring urgent IV access; onset is within 1 minute.
Choice of medication should be based on patient’s previous experience/preference, history of lidocaine allergy and ease
of access.
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
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lidocaine (XYLOCAINE) 1% injection [39034] 0.1-0.4 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. Choice of medication should be
based on patient’s previous experience/preference, history of
lidocaine allergy and ease of access
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. Choice of medication should be
based on patient’s previous experience/preference, history of
lidocaine allergy and ease of access
IV Fluids [23233]
sodium chloride 0.9% with KCl 20 mEq/L infusion
[46261]
Intravenous, CONTINUOUS
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size:
Peripheral IV Location:
Peripheral IV Device:
Peripheral IV Status: Capped
Does this need to be inserted/placed?
Medcations
Steroids (Single Response) [23237]
methylprednisolone sodium succ. (SOLU-MEDROL)
intraVENOUS [800058]
500 mg, Intravenous, 1 X DAILY For 5 Days
methylprednisolone sodium succ. (SOLU-MEDROL)
intraVENOUS [800058]
1,000 mg, Intravenous, 1 X DAILY For 5 Days
Analgesics [23238]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain
Benzodiazepines [23239]
lorazepam (ATIVAN) tab RANGE [750026] 0.5-1 mg, Oral, EVERY 6 HOURS PRN, anxiety
Gastric [23241]
mag-al-simeth (MYLANTA ES) susp MULTIDOSE
[44073]
30 mL, Oral, EVERY 6 HOURS PRN, dyspepsia
pantoprazole (PROTONIX) EC tab [62661] 40 mg, Oral, 1 X DAILY For 10 Days
ranitidine (ZANTAC) tab [52786] 150 mg, Oral, 2 X DAILY For 10 Days
Laboratory
Labs (If not obtained in previous 24 hours) [23643]
CBC WITHOUT DIFFERENTIAL [HEMO] 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?
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?
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?
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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?
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?
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?
ELECTROLYTES [LYTE] NEXT AM, 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?
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?
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?
Conditional [23644]
GLUCOSE [GLU] CONDITIONAL - RN COLLECT For 4 Days, STAT
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? Every time blood glucose
monitoring (bedside) less than 40 or greater than 400 mg/dL
Diagnostic Tests and Imaging
Studies [23645]
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MRI HEAD W & W/ O CONTRAST [R70553] 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? assess diesase activity and progression
Relevant recent/past history? Multiple sclerosis exacerbation
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):
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
MRI CERVICAL SPINE W & W/ O CONTRAST
[R72156]
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? Assess disease activity and progression
Relevant recent/past history? Multiple sclerosis exacerbation
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):
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
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MRI THORACIC SPINE W & W/ O CONTRAST
[R72157]
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? assess disease activity and progression
Relevant recent/past history? Multiple sclerosis exacerbation
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):
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
X-RAY CHEST PA & LAT VIEWS [R71020] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered by this
exam? Rule out infiltrates
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Consults
Consults [23647]
Consult Physical Therapy (Inpatient) Eval and Treat
[CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Consult Occupational Therapy (Inpatient) Eval and Treat
[CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Consult Speech Therapy (Inpatient) Eval and Treat
[CON0077]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
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?
BestPractice
No Hospital Problems have yet been identified. [107035]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing.
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