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/clinical/cckm-tools/content/order-sets/inpatient/neurosciences/name-98143-en.cckm

20180129

page

100

UWHC,UWMF,

Tools,

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

IP - Neuroendovascular - Angiogram - Adult - Postprocedure [1631]

IP - Neuroendovascular - Angiogram - Adult - Postprocedure [1631] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Neurosciences


IP - Neuroendovascular - Angiogram - Adult - Postprocedure [1631]
for Adult Patients OnlyIntended
For Carotid Stent or Carotid Endarterectomy Postoperative orders use order set:
[5433]Postprocedure -Adult -Carotid Endarterectomy/Stent -IP
Anticoagulation Regimens
Heparin Anticoagulation for Anti-Xa goal 0.4-0.8 IU/mL [221567]
Heparin Anticoagulation for Anti-Xa goal 0.4-0.8
IU/mL [224763]
HEPARIN LEVEL BY ANTI-XA [XLMWH] CONDITIONAL For 8 Hours, Routine
Is the patient receiving any anticoagulant?
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw STAT on
arrival then every 1 hour until heparin infusion is
started.
Start heparin infusion when Anti-Xa is between
0.4-0.8 IU/mL [NURCOM0022]
ONCE
HEPARIN LEVEL BY ANTI-XA [XLMWH] CONDITIONAL For 7 Days, Routine
Is the patient receiving any anticoagulant? Yes
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw STAT 6 hours
after initiation of heparin infusion and 6 hours after
every heparin dose adjustment
NOTE: No initial heparin bolus [NURCOM0022] ONCE For 1 Occurrences, NOTE: No initial heparin
bolus
heparin 25,000 units in dextrose 5% 500 mL
infusion [51597]
5-20 Units/kg/hr, Intravenous, CONTINUOUS
Initiate at 10 units/kg/hr
Titrate to anti-Xa goal 0.4-0.8 IU/mL
<0.2: inform MD, confirm bolus, and increase
infusion rate by 2 units/kg/hr
0.2-0.39: increase infusion rate by 1 unit/kg/hr
0.4-0.8: no change
0.81-1.0: decrease infusion rate by 1 unit/kg/hr
1.1-1.7: hold infusion for 1 hour and decrease
infusion rate by 2 units/kg/hr
>1.7: inform MD, hold infusion 1.5 hours, and
decrease infusion rate by 3 units/kg/hr
heparin 1000 units/mL vial - Maximum 5000
units/dose [45303]
20 Units/kg, Intravenous, PRN, anti-Xa < 0.2 IU/mL
Maximum 5000 units/dose
Notify Provider [NURCOM0022] CONTINUOUS, Anti-Xa less than 0.2 IU/mL or
greater than 1.7 IU/mL
Heparin Anticoagulation for Anti-Xa goal 0.7-1.0 IU/mL [221880]
Heparin Anticoagulation for Anti-Xa goal 0.7-1.0
IU/mL [224764]
Page 1 of 14
Printed by O'BRIEN, RYLEY P [RPO249] at 1/29/2018 9:14:11 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

HEPARIN LEVEL BY ANTI-XA [XLMWH] CONDITIONAL For 8 Hours, Routine
Is the patient receiving any anticoagulant?
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw STAT on
arrival then every 1 hour until heparin infusion is
started.
Start heparin infusion when Anti-Xa is between
0.7-1.0 IU/mL [NURCOM0022]
ONCE
HEPARIN LEVEL BY ANTI-XA [XLMWH] CONDITIONAL For 7 Days, Routine
Is the patient receiving any anticoagulant? Yes
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw STAT 6 hours
after initiation and 6 hours after every heparin dose
adjustment
NOTE: No initial heparin bolus [NURCOM0022] ONCE For 1 Occurrences, NOTE: No initial heparin
bolus
heparin 25,000 units in dextrose 5% 500 mL
infusion [51597]
5-20 Units/kg/hr, Intravenous, CONTINUOUS
Initiate at 10 units/kg/hr
Titrate to anti-Xa goal 0.7-1.0 IU/mL
<0.1: inform MD, confirm bolus, increase infusion
rate by 3 units/kg/hr
0.1-0.29: confirm bolus, increase infusion rate by 2
unit/kg/hr
0.3-0.69: increase infusion rate by 1 unit/kg/hr
0.7-1.0: no change
1.1-1.4: decrease infusion rate by 1 unit/kg/hr
1.5-1.7: hold infusion for 1 hour and decrease
infusion rate by 2 units/kg/hr
>1.7: inform MD, hold infusion 1.5 hours and
decrease infusion rate by 3 units/kg/hr
heparin 1000 units/mL vial - Maximum 10,000
units/dose [45303]
40 Units/kg, Intravenous, PRN, anti-Xa < 0.1 IU/mL
Maximum 10,000 units/dose
heparin 1000 units/mL vial - Maximum 5,000
units/dose [45303]
20 Units/kg, Intravenous, PRN, anti-Xa 0.1-0.29
IU/mL
Maximum 5,000 units/dose
Notify Provider [NURCOM0022] CONTINUOUS, Anti-Xa less than 0.1 IU/mL or
greater than 1.7 IU/mL
Heparin Anticoagulation for Anti-Xa goal 0.1-0.3 IU/mL [224681]
Heparin Anticoagulation for Anti-Xa goal 0.1-0.3
IU/mL [224687]
HEPARIN LEVEL BY ANTI-XA [XLMWH] CONDITIONAL For 8 Hours, Routine
Is the patient receiving any anticoagulant?
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw STAT on
arrival then every 1 hour until heparin infusion is
started.
Start heparin infusion when Anti-Xa is between
0.1-0.3 IU-mL [NURCOM0022]
ONCE
Page 2 of 14
Printed by O'BRIEN, RYLEY P [RPO249] at 1/29/2018 9:14:11 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

HEPARIN LEVEL BY ANTI-XA [XLMWH] CONDITIONAL For 7 Days, Routine
Is the patient receiving any anticoagulant?
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw STAT 6 hours
after initiation of heparin infusion and 6 hours after
every heparin dose adjustment.
Note: NO initial heparin bolus [950018] ONCE For 1 Doses
Note: NO initial heparin bolus
heparin 25,000 units in dextrose 5% 500 mL
infusion [51597]
5-20 Units/kg/hr, Intravenous, CONTINUOUS
Initiate at 10 units/kg/hr. Titrate to anti-Xa goal: 0.1 -
0.3
< 0.1: inform MD, bolus 20 units/kg and increase
infusion rate by 3 units/kg/hr
0.1-0.3: no change
0.31-0.5: decrease infusion rate by 1 unit/kg/hr
0.51-0.8: decrease infusion rate by 2 units/kg/hr
>0.8: Inform MD, hold infusion by 1 hour and
decrease infusion rate by 3 units/kg/hr
heparin 1000 Units/mL injection [45303] 20 Units/kg, Intravenous, PRN, PRN, anti-Xa <0.1
Maximum 5,000 units/dose
Notify Provider [NURCOM0001] Provider to Notify: Provider
Notify based on: Other
Other: anti-Xa less than 0.1 or greater than
0.8,Hemoglobin decreases by more than 2 g/dL from
baseline,Baseline INR greater than 1.2,Platelet
count less than 100 K/uL,Platelet count decreases
by more than 1/3 of baseline value,Any sign of
bleeding,Any deterioration in neurological status
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [132009]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
Moderate VTE Risk with Low Bleed Risk (Single
Response) [129778]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 8 HOURS
Sequential Compression Device (SCD) / Foot
Pump [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
High VTE Risk with Low Bleed Risk [130127]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 8 HOURS
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Page 3 of 14
Printed by O'BRIEN, RYLEY P [RPO249] at 1/29/2018 9:14:11 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
High Bleed 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:
VTE Prophylaxis (Single Response) [150178]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
Moderate VTE Risk with Low Bleed Risk (Single
Response) [129778]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 8 HOURS
Sequential Compression Device (SCD) / Foot
Pump [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
High VTE Risk with Low Bleed Risk [130127]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 8 HOURS
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
High Bleed 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:
Page 4 of 14
Printed by O'BRIEN, RYLEY P [RPO249] at 1/29/2018 9:14:11 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Patient Care Orders
Vital Signs [22790]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Postprocedure: Every 15 minutes times 4, then every
30 minutes times 4, then every hour times 4.
Patient Monitoring [22793]
Assess Neurologic Status [NURMON0006] SEE COMMENTS, Starting today, Routine,
Postprocedure: Every 15 minutes times 4, then every
30 minutes times 4, then every hour times 4.
Check Pulse [NURMON0008] SEE COMMENTS, Starting today, Routine
Method:
Pulse Side: Bilateral
Pulse Location: Pedal
Postprocedure: Every 15 minutes times 4, then every
30 minutes times 4, then every hour times 4, then
every 12 hours times 4.
Monitor Lower Extremity [NURMON0060] SEE COMMENTS, Starting today, Every 15 minutes
times 4, then every 30 minutes times 4, then every
hour times 4.
Wound Care - Closed Incision (Adult)
[NURWND0055]
CONTINUOUS, Routine
Wound Site:
Wound Location:
Assess Frequency: EVERY 8 HOURS
Incision Closed With: Other (Comment)
Maintain OR Dressing: Minimum of 48 hours
Remove OR Dressing after 48 hours: Yes
Removal of OR Dressing performed by: RN
Cleansing with Removal of OR Dressing: CHG
Primary Dressing (after 48 hours): Dry Gauze
Incision Care (after 48 hours): Cleanse daily with CHG
If dressing becomes saturated in 48 hours, sterile
dressing change? Yes - Notify provider
Postprocedure: Check groin for hematoma every 15
minutes times 4, then every 30 minutes times 4, then
every hour times 3, then every 4 hours.
Discharge From 10-bed [NURCOM0022] ONCE, Ok to discharge from 10-bed in *** hours if
ambulating well, pain under control, groin site okay,
and without headache/nausea/vomiting or neurologic
changes.
Activity [22796]
Page 5 of 14
Printed by O'BRIEN, RYLEY P [RPO249] at 1/29/2018 9:14:11 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

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:
Elevate Head Of Bed - Flat [NURACT0002] Equal to (degrees): 0
Greater than (degrees):
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting today
Elevate Head Of Bed [NURACT0002] Equal to (degrees):
Greater than (degrees):
Less than (degrees): 30
Other options:
Routine, CONTINUOUS, Starting today
Keep Leg Straight [NURACT0011] SEE COMMENTS, Starting today, Keep
{R/L/B:4001510} leg(s) straight for *** hours.
No Strenuous Activity for 5 Days [NURACT0008] CONTINUOUS, Starting today For 5 Days, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS: No Lifting,No Straining
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Nutrition [22797]
Diet - General [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
NPO Except Medications [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
Wound/Procedure Site Care [22828]
Femoral Compression System [NURTAD0048] CONTINUOUS, Starting today, Routine, Keep femoral
compression device (FEMOSTOP) at *** mmHg for ***
hours.
Femoral Compression System [NURTAD0048] CONTINUOUS, Starting today, Routine, Remove
Femoral compression device (FEMOSTOP) slowly
over 5 minutes, starting at ***.
Femoral Sheath Removal [NURCOM0022] SEE COMMENTS, Starting today, Femoral sheath to
be pulled by neuroendovascular or neurosurgical staff
only.
Neuroendovascular Femoral Sheath Maintenance [95842]
Page 6 of 14
Printed by O'BRIEN, RYLEY P [RPO249] at 1/29/2018 9:14:11 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Maintain Femoral Arterial Sheath [NURVAD0060] CONTINUOUS, Starting today, Routine
Location:
Infuse With (Separate Medication Order Must Also be
Completed):
Site Assessment Frequency: Other (Comment
Required) (Every hour performed by neurosurgery)
Care Frequency: Every 24 Hours
Wash With: Chlorhexidine Sponge
Primary Dressing: Biopatch
Secondary Dressing: Transparent Dressing
(TEGADERM)
Non-Categorized Patient Care Orders [22798]
Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, Starting today For Until specified,
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
Does this need to be inserted/placed?
Contingency Parameters [22799]
Notify Neuroradiology Fellow [NURCOM0001] Provider to Notify: Other (Comment)
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 < (%): ***
If urine output < (mL):
Other: Mean arterial pressure less than *** or greater
than *** mmHg,Any deterioration in neurological
status,Access site hematoma or new bleeding,Loss of
pedal pulses,Pain not controlled with ordered
analgesics or ordered interventions
Intravenous Therapy
IV Fluids [22968]
dextrose 5%-NaCl 0.45% infusion [51613] at 125 mL/hr, Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.9% infusion [51641] at 125 mL/hr, Intravenous, CONTINUOUS
sodium chloride 0.9 % infusion [64367] at 125 mL/hr, Intravenous, CONTINUOUS
Medications - Postprocedure
Postprocedure [23036]
Note: Discontinue metformin-containing products
postprocedure [950018]
ONCE For 1 Doses
Discontinue metformin-containing products
postprocedure
Femoral Sheath Infusion [95633]
Page 7 of 14
Printed by O'BRIEN, RYLEY P [RPO249] at 1/29/2018 9:14:11 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

heparin 1000 units/500 mL (2 units/mL) infusion: For
mL/hr = 60 units/hr30
40 mL/hr = 80 units/hr
50 mL/hr = 100 units/hr
heparin 1,000 units in sodium chloride 0.9% 500
mL bag - NOTE: Suggested dose 60, 80 or 100
units/hr [51599]
Intraarterial, CONTINUOUS
Administer via FEMORAL arterial line For intra-arterial
infusion via femoral sheath, using pump labeled
"Arterial Use Only"
NOTE: Suggested dose 60, 80 or 100 units/hr
sodium chloride 0.9% infusion - NOTE: Order for
patients with heparin sensitivities or
contraindications. Suggested rate 30, 40 or 50
mL/hr [64367]
Other, CONTINUOUS
For intra-arterial infusion via femoral sheath, using
pump labeled "Arterial Use Only"
NOTE: Order for patients with heparin sensitivities or
contraindications. Suggested rate 30, 40 or 50 mL/hr
Analgesics - Acetaminophen - PRN [129846]
acetaMINOPHEN (TYLENOL) tab RANGE
[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.
Analgesics - Opioid - Oral - PRN (Single Response) [22971]
oxycodone-acetaminophen (PERCOCET) 5-325
mg per tab RANGE [750033]
1-2 tab, 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.
oxycodone 5 MG/5ML soln RANGE [750031] 5-10 mg, Nasogastric Tube, EVERY 4 HOURS PRN,
pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
oxycodone tab RANGE [750032] 5-10 mg, Oral, EVERY 4 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
Analgesics - Opioid - Injection - PRN [221403]
MORPHine PF injection RANGE [750057] 1-4 mg, Intravenous, EVERY 2 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
for 4 Minutes
Anti-platelets [23034]
aspirin chew tab [720014] 81 mg, Oral, 1 X DAILY
aspirin EC delayed release tab [49098] 325 mg, Oral, 1 X DAILY
clopidogrel (PLAVIX) tab [58345] 75 mg, Oral, 1 X DAILY
Anti-emetics [129847]
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.
Page 8 of 14
Printed by O'BRIEN, RYLEY P [RPO249] at 1/29/2018 9:14:11 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

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
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
Antihypertensives [23035]
labetalol (NORMODYNE;TRANDATE) injection
RANGE [750053]
10-20 mg, Intravenous, EVERY 10 MINUTES PRN,
Systolic blood pressure control
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
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
hydrALAZINE (APRESOLINE) injection RANGE
[750049]
10-20 mg, Intravenous, EVERY 10 MINUTES PRN,
hypertension, Systolic blood pressure control
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.
Laboratory
Labs [22800]
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?
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?
Page 9 of 14
Printed by O'BRIEN, RYLEY P [RPO249] at 1/29/2018 9:14:11 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

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?
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?
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?
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?
PTT [PTT] 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?
Platelet Reactivity (PRU) Test and ADP
Aggregation (w/ Platelet and Hematocrit)
[183724]
Test measures the ability of platelets to aggregate in whole blood in response to ADP. This test
can be used to assess the affect of clopidogrel, prasugrel or any drug specific for the inhibition of
the ADP receptor.
valid.count must be greater that 75 K/uL for test results to be Platelet
Page 10 of 14
Printed by O'BRIEN, RYLEY P [RPO249] at 1/29/2018 9:14:11 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

PLATELET REACTIVITY (PRU) TEST
[HCVNPRU]
NEXT AM For 1 Occurrences, Routine, Patients who
have been treated with Glycoprotein IIb/IIIa inhibitors
should not be tested until platelet function has
recovered. This time period is approximately 14 days
after discontinuation of abciximab (ReoPro) and up
to 48 hours after discontinuation of eptifibatide
(Intergrilin) and tirofiban (Aggrastat).
Dose and name of antiplatelet medication:
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
HEMATOCRIT [HCT] 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?
PLATELET COUNT [PLT] 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?
PLATELET AGGREGATION, ADP [HCADPAGG] NEXT AM For 1 Occurrences, Routine, Test
measures the ability of platelets to aggregate in
whole blood in response to ADP. This test can be
used to assess the affect of clopidogrel, prasugrel or
any drug specific for the inhibition of the ADP
receptor. Platelet count must be greater that 75 K/uL
for test results to be valid.
Dose of Clopidogrel?
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
IP - LAB - ARACHIDONIC ACID
AGGREGATION (W/ PLATELET AND
HEMATOCRIT) [181407]
to arachidonic measures the ability of platelets to aggregate in whole blood in response Test
like drug. -or any aspirinacid. This test can be used to assess the affect of aspirin
valid.count must be greater that 75 K/uL for test results to be Platelet
HEMATOCRIT [HCT] 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?
PLATELET COUNT [PLT] 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?
PLATELET AGGREGATION, ARACHIDONIC
ACID [HCAAAGG]
NEXT AM For 1 Occurrences, Routine, Test
measures the ability of platelets to aggregate in
whole blood in response to arachidonic acid. This
test can be used to assess the affect of aspirin or
any aspirin-like drug. Platelet count must be greater
that 75 K/uL for test results to be valid.
Dose of Aspirin:
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
Page 11 of 14
Printed by O'BRIEN, RYLEY P [RPO249] at 1/29/2018 9:14:11 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Diagnostic Tests and Imaging
Studies [22801]
MRA HEAD W/ O & MRA NECK W & W/ O & MRI
HEAD W & W/ O CONTRAST [R07007]
ONCE-RAD NEXT AVAILABLE, Starting tomorrow For
1 Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Study Needed Within:
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?
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:
CT ANGIO HEAD, NECK W PERFUSION
[R07001]
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? 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:
Page 12 of 14
Printed by O'BRIEN, RYLEY P [RPO249] at 1/29/2018 9:14:11 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

CT HEAD W/ O IV CONTRAST [R70450] 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? 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:
Consults
Consults [22802]
Consult Ace/Geriatric (Inpatient) [CON0001] ONCE, Starting today For 1 Occurrences, Routine
Purpose of Consult: EVALUATE AND TREAT
PATIENT
Reason for Consult:
Consult Cardiology (Inpatient) [CON0012] 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:
Diabetes Consult Order Panel (Adult) [188497]
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):
Page 13 of 14
Printed by O'BRIEN, RYLEY P [RPO249] at 1/29/2018 9:14:11 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

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?
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?
Consult Hematology (Inpatient) [CON0034] 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:
Consult Stroke - Non-Acute (Inpatient)
[CON0133]
ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Stroke - Non-acute
Consult Renal-Acute (Inpatient) [CON0069] 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:
Page 14 of 14
Printed by O'BRIEN, RYLEY P [RPO249] at 1/29/2018 9:14:11 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org