/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/neurosciences/,

/clinical/cckm-tools/content/order-sets/inpatient/neurosciences/name-98161-en.cckm

201712341

page

100

UWHC,UWMF,

Tools,

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

IP - Stroke - Adult - Admission [4572]

IP - Stroke - Adult - Admission [4572] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Neurosciences


IP - Stroke - Adult - Admission [4572]
for Adult Patients OnlyIntended
Stroke Admission Diagnosis
Diagnosis Specific Orders (Single Response) [123057]
Intracranial Hemorrhage [122962]
Vital Signs [NURMON0013] EVERY 1 HOUR, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Assess Neurologic Status using UWHC
Abbreviated NIHSS Flowsheet [NURMON0006]
EVERY 1 HOUR, Routine, Assess neurologic status
using "UWHC Abbreviated NIHSS Flowsheet" -
Every 1 Hour
Notify Provider [NURCOM0001] Provider to Notify: Provider
Notify based on: Blood Pressure,Temperature,Blood
Glucose,Other
Other: Patient requiring more than 2 labetalol doses
(20mg) in a 4 hour period,Any decrease in
neurologic status
If blood glucose > (mg/dL): 200
If blood glucose < (mg/dL): 70
If temperature > (C): 38.0
If temperature < (C):
If systolic blood pressure > (mmHg): 160
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg): 100
If diastolic blood pressure < (mmHg):
labetalol injection [800192] 10 mg, Intravenous, EVERY 10 MINUTES PRN, See
Admin Instructions
Administer for systolic blood pressure greater than
160 mmHg. Hold if heart rate less than 52 beats per
minute.
Activity [NURACT0008] CONTINUOUS, Routine
AD LIB:
AMBULATE: with assistance
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Apply IPOC Template -- Stroke,
Hemorrhagic/ICH IPOC [NURCOM0074]
Name of IPOC template to apply? Stroke,
Hemorrhagic/ICH IPOC
Ischemic Stroke - Post Thrombolysis [122964]
Page 1 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:20:21 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Vital Signs [NURMON0013] SEE COMMENTS, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Starting with alteplase (tPA) bolus: every 15 minutes
time 12, then every 30 minutes times 12 then every
hour
@FLOWDATETIME[310023@
@FLOWDATETIME[310030@
@FLOWDATETIME[310031@
Assess Neurologic Status using UWHC
Abbreviated NIHSS Flowsheet [NURMON0006]
SEE COMMENTS, Routine, Assess neurologic
status using "UWHC Abbreviated NIHSS Flowsheet"
- Starting with alteplase (tPA) bolus: every 15
minutes times 12, then every 30 minutes times 12,
then every hour.
@FLOWDATETIME(310023)@
@FLOWDATETIME(310030)@
@FLOWDATETIME(310031)@
Notify Provider [NURCOM0001] Provider to Notify: Provider
Notify based on: Blood Pressure,Temperature,Blood
Glucose,Other
Other: Patient requiring more than 2 labetalol doses
(20mg) in a 4 hour period,Any decrease in
neurologic status
If blood glucose > (mg/dL): 200
If blood glucose < (mg/dL): 70
If temperature > (C): 38
If temperature < (C):
If systolic blood pressure > (mmHg): 180
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg): 105
If diastolic blood pressure < (mmHg):
labetalol (NORMODYNE;TRANDATE) injection
RANGE [750053]
10 mg, Intravenous, EVERY 10 MINUTES PRN, See
Admin Instructions
Administer for systolic blood pressure greater than
180 mmHg. Hold if heart rate less than 52 beats per
minute.
for 2 Minutes
Note: Hold all antithrombotics (antiplatelet agents
and anticoagulants) until 24 hours after
completion of thrombolysis [950018]
EVERY 6 HOURS Starting today For 4 Doses
@FLOWDATETIME(310023)@
@FLOWDATETIME(310030)@
@FLOWDATETIME(310031)@
AST/SGOT [AST] 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?
NOTE: Draw 12 hours after initiation of NPO diet
order
Page 2 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:20:21 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

LIPID PANEL [LIPID] NEXT AM, Starting today For 1 Occurrences,
Routine, Test includes Cholesterol, Total; HDL
Cholesterol; Triglyceride; LDL cholesterol,
calculated; and non-HDL cholesterol.
Patient must fast for a minimum of 10 hours and be
heparin free for 48 hours prior to specimen
collection. The patient can only have water during
the fasting period.
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
NOTE: Draw 12 hours after initiation of NPO diet
order
Patient should be fasting 12-14 hours
Bed Rest [NURACT0011] SEE COMMENTS For 12 Hours, Bed rest for 12
hours post alteplase (tPA) completion
@FLOWDATETIME[310023@
@FLOWDATETIME[310030@
@FLOWDATETIME[310031@
Activity [NURACT0008] SEE COMMENTS, Routine
AD LIB:
AMBULATE: with assistance
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Start 12 hours after completion of alteplase (tPA)
@FLOWDATETIME[310023@
@FLOWDATETIME[310030@
@FLOWDATETIME[310031@
Apply IPOC Template [NURCOM0074] Name of IPOC template to apply? Stroke, Ischemic
IPOC
Ischemic Stroke - ICU (Non-Thrombolysis)
[122967]
Vital Signs [NURMON0013] EVERY 1 HOUR, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Assess Neurologic Status using UWHC
Abbreviated NIHSS Flowsheet [NURMON0006]
EVERY 1 HOUR, Routine, Assess neurologic status
using "UWHC Abbreviated NIHSS Flowsheet" -
Every 1 Hr
Page 3 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:20:21 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
Notify based on: Blood Pressure,Temperature,Blood
Glucose,Other
Other: Patient requiring more than 2 labetalol doses
(20 milligrams) in a 4 hour period,Any decrease in
neurologic status
If blood glucose > (mg/dL): 200
If blood glucose < (mg/dL): 70
If temperature > (C): 38.0
If temperature < (C):
If systolic blood pressure > (mmHg): 220
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg): 120
If diastolic blood pressure < (mmHg):
labetalol injection [800192] 10 mg, Intravenous, EVERY 10 MINUTES PRN, See
Admin Instructions
Administer for systolic blood pressure greater than
220 mmHg. Hold if heart rate less than 52 beats per
minute
AST/SGOT [AST] 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?
NOTE: Draw 12 hours after initiation of NPO diet
order
LIPID PANEL [LIPID] NEXT AM, Starting today For 1 Occurrences,
Routine, Test includes Cholesterol, Total; HDL
Cholesterol; Triglyceride; LDL cholesterol,
calculated; and non-HDL cholesterol.
Patient must fast for a minimum of 10 hours and be
heparin free for 48 hours prior to specimen
collection. The patient can only have water during
the fasting period.
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
NOTE: Draw 12 hours after initiation of NPO diet
order
Patient should be fasting 12-14 hours
Activity [NURACT0008] CONTINUOUS, Routine
AD LIB:
AMBULATE: with assistance
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Apply IPOC Template [NURCOM0074] Name of IPOC template to apply? Stroke, Ischemic
IPOC
Ischemic Stroke - IMC or General Care [122976]
Page 4 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:20:21 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Vital Signs [NURMON0013] SEE COMMENTS, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 4 hours times 6, then every 8 hours.
Assess Neurologic Status using UWHC
Abbreviated NIHSS Flowsheet [NURMON0006]
SEE COMMENTS, Routine, Assess neurologic
status using "UWHC Abbreviated NIHSS Flowsheet"
- Every 4 hours times 6, then every 8 hours
Notify Provider [NURCOM0001] Provider to Notify: Provider
Notify based on: Blood Pressure,Temperature,Blood
Glucose,Other
Other: Patient requiring more than 2 labetalol doses
(20 milligrams) in a 4 hour period,Any decrease in
neurologic status
If blood glucose > (mg/dL): 200
If blood glucose < (mg/dL): 70
If temperature > (C): 38.0
If temperature < (C):
If systolic blood pressure > (mmHg): 220
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg): 120
If diastolic blood pressure < (mmHg):
labetalol injection [800192] 10 mg, Intravenous, EVERY 10 MINUTES PRN, See
Admin Instructions
Administer for systolic blood pressure greater than
220 mmHg. Hold if heart rate less than 52 beats per
minute.
AST/SGOT [AST] 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?
NOTE: Draw 12 hours after initiation of NPO diet
order
LIPID PANEL [LIPID] NEXT AM, Starting today For 1 Occurrences,
Routine, Test includes Cholesterol, Total; HDL
Cholesterol; Triglyceride; LDL cholesterol,
calculated; and non-HDL cholesterol.
Patient must fast for a minimum of 10 hours and be
heparin free for 48 hours prior to specimen
collection. The patient can only have water during
the fasting period.
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
NOTE: Draw 12 hours after initiation of NPO diet
order
Patient should be fasting 12-14 hours
Page 5 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:20:21 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Activity [NURACT0008] CONTINUOUS, Routine
AD LIB:
AMBULATE: with assistance
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Apply IPOC Template [NURCOM0074] Name of IPOC template to apply? Stroke, Ischemic
IPOC
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) [123287]
Page 6 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:20:21 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: STROKE
Rationale for LOS greater than 2 midnights:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status (Single Response) [123289]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: STROKE
Rationale for LOS greater than 2 midnights:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Discharge Status [150813]
Anticipated Discharge Date [ADT0016] Anticipated Discharge Date:
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [130119]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
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) 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:
VTE Prophylaxis (Single Response) [150156]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
Page 7 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:20:21 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

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
Nutrition [9327]
Strict NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: Strict NPO
Bedside Meal Instructions:
Room Service Class:
NPO for Procedure - Hold Diet [DIE0007] EFFECTIVE MIDNIGHT, Starting today For 12 Hours,
Routine
NPO For Which Procedure? Lipid panel
Modifiers: STRICT NPO
Dietary Approaches to Stop Hypertension (DASH)
Diet [NUT9999]
EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Heart Healthy
Heart Healthy Options: DASH
Bedside Meal Instructions:
Room Service Class:
Diabetes Meal Plan [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Diabetes
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:
Respiratory [123034]
Oxygen Therapy [RT0032] PRN, Starting today For 24 Hours, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow: 2
Titrate oxygen to maintain O2 sat at (%): 92
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Page 8 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:20:21 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Pulse Oximetry [NURMON0009] PRN, Starting today For 24 Hours, Routine,
Discontinue after 24 hours.
Respiratory Therapy per Protocol [RT0035] Routine
Protocol Type:
Non-Categorized Patient Care Orders [123037]
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
INTERMITTENT (MAY REMOVE WHEN OFF
UNIT/BATHING), Routine
Indication: Post stroke
Notify Provider:
Functional Cardiac Defibrillator Present:
Urinary Catheterization-Intermittent
[NURELM0018]
EVERY 6 HOURS PRN, Starting today, Routine, For
post void residual greater than 500 mL
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting today, 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] ONCE, Starting today For 1 Occurrences, Routine
Weigh With?
Weigh when?
Standing weight preferred
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
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 [123152]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS For Until specified, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
sodium chloride 0.9 % infusion [64367] at 75 mL/hr, Intravenous, CONTINUOUS
May discontinue fluids after 12 hours from arrival to
the unit if patient has general diet ordered.
Medications
Non-Categorized [223238]
Page 9 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:20:21 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

NOTE: No medication via ORAL route to be
ordered/verified/administered prior to
documentation of passing dysphagia screen.
[950018]
2 X DAILY
NOTE: No medication via ORAL route to be
ordered/verified/administered prior to documentation
of passing dysphagia screen.
Antiplatelets [128583]
aspirin chew tab [720014] 81 mg, Nasogastric Tube, 1 X DAILY
Start 24 hours after completion of thrombolysis if
applicable
aspirin chew tab [720014] 81 mg, Oral, 1 X DAILY
Start 24 hours after completion of thrombolysis if
applicable
aspirin rectal suppository [34799] 300 mg, Rectal, 1 X DAILY
Start 24 hours after completion of thrombolysis if
applicable
clopidogrel (PLAVIX) tab [720168] 75 mg, Nasogastric Tube, 1 X DAILY
Start 24 hours after completion of thrombolysis if
applicable
clopidogrel (PLAVIX) tab [720168] 75 mg, Oral, 1 X DAILY
Start 24 hours after completion of thrombolysis if
applicable
Platelet Inhibitors (or other Antithrombotics)
Reason Not Ordered [COR0040]
ONCE, Routine
Reason Not Ordered:
Platelet Inhibitors (or other Antithrombotics)
Already Ordered. This does NOT generate a
medication order. [COR0041]
ONCE, Routine
Analgesics - Acetaminophen - PRN (Single Response) [123156]
acetaMINOPHEN (TYLENOL) tab RANGE
[750000]
325-650 mg, Oral, EVERY 4 HOURS PRN, pain/fever,
Temperature greater than 38 Celsius or 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
acetaMINOPHEN (TYLENOL) suppository
[34153]
650 mg, Rectal, EVERY 4 HOURS PRN, pain/fever,
Temperature greater than 38 Celsius or 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 - Opioids - Oral - PRN [220076]
oxycodone-acetaminophen (PERCOCET) 5-325
MG per tab [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
Analgesics - Opioids - Intravenous - PRN [124109]
MORPHine PF injection [750057] 1-2 mg, Intravenous, EVERY 2 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-needed Analgesics.
for 4 Minutes
Anti-emetics [123153]
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 24 HOURS PRN,
nausea/vomiting
Bowel Management [123155]
Adult - Bowel Management - Scheduled
[240446]
senna-docusate (SENOKOT S) 8.6-50 MG per
tab [60530]
2 tab, Oral, 2 X DAILY
Page 10 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:20:21 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

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
Laboratory
Labs - Next Draw [128585]
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?
CBC WITH DIFFERENTIAL [CBC] NEXT DRAW 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 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 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 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 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?
HEMOGLOBIN A1C [HA1C] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Labs - Urine [128586]
Page 11 of 14
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12/2017CCKM@uwhealth.org

HCG, QUALITATIVE, URINE [UPREG] ONCE For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
DRUG SCREEN, URINE [HCUPNL] NEXT AM For 1 Occurrences, Routine, Test includes:
Amphetamines/Methamphetamines, Barbiturates,
Benzodiazepine, Cocaine, and Opiates (primarily
targets morphine, codeine, and heroin).
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Consults
Swallow Consult (Single Response) [151860]
Consult Swallow Therapy (Inpatient) [CON0079] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Evaluate and Treat Patient
May the Speech Pathologist and Registered Dietician
place diet orders on your behalf? Yes
Is this a potential new stroke patient? Yes
UW Health Bedside Dysphagia Screen
[NURACT0011]
ONCE For 1 Occurrences
No Swallow Consult Needed - Reason Not
Ordered [COR0065]
ONCE, Starting today For 1 Occurrences, Routine
Reason Not Ordered:
Consults [123275]
Stroke Prevention Exercise Program (SPEP)
Analysis Consult to Physical Therapy [CON0173]
ONCE, Starting today For 1 Occurrences
New Left Bundle Branch Block (BBB)?
New Q-Waves?
New Atrial Fibrillation or Uncontrolled Rate?
Patient Unable to Tolerate 4 METs?
Cardiovascular Risk Based on Above Screen on
Metabolic Capacity and EKG Findings:
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
New Onset Stroke
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult: Mobility
Training
New Onset Stroke
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: COUNSELING
Indication: Stroke
Consult Speech Therapy (Inpatient) Eval and
Treat [CON0077]
ONCE, Starting today For 1 Occurrences, Routine
Patient Type: Adult
Reason for Speech Therapy Consult:
New Onset Stroke
Consult Rehab Medicine (Inpatient) [CON0068] ONCE
Purpose of Consult: Evaluate for Admission
Call back number:
Consult Neurosurgery (Inpatient) [CON0042] ONCE
Intent: Consult and Recommend (No Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Evaluate new onset
stroke
Diabetes Consult Order Panel (Adult) [188497]
Page 12 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:20:21 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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):
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?
Page 13 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:20:21 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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?
On Day 2 [123045]
Consult Nutrition (Inpatient) [CON0043] ONCE, Routine
Reason for Consult: Nutrition Assessment w/
Recommendations
Delegate to Initiate and Manage Tube Feeding: Yes
Delegate to Initiate Feeding Tube Placement Order
Set: Yes
Delegate to Manage Diet Order/Supplement Order:
Yes
Delegate to Dysphagia Diet Order Progression: Yes
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.
Page 14 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:20:21 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org