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/clinical/cckm-tools/content/order-sets/inpatient/ophthalmology/name-98120-en.cckm

201709272

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UWHC,UWMF,

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

IP – Ophthalmology –Retina Service – Adult – Postoperative [2850]

IP – Ophthalmology –Retina Service – Adult – Postoperative [2850] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Ophthalmology


IP - Ophthalmology - Retina Service - Adult - Postoperative [2850]
for Adult Patients OnlyIntended
Admission Status
Level of Care (Single Response) [187485]
*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:
Post-Op/Phase II
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admission Status [112483]
Page 1 of 8
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

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:
Post-Op/Phase II
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admission Status [84059]
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:
Post-Op/Phase II
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [131999]
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]
Page 2 of 8
Printed by WILLIAMS, HEATHER R [HRS0] at 9/25/2017 1:54:35 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
Post-Op/Phase II
Moderate VTE Risk with Low Bleed Risk (Single
Response) [209954]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Post-Op/Phase II
High VTE with Low Bleed Risk [211018]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 HOURS, Post-
Op/Phase II
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
Post-Op/Phase II
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Post-Op/Phase II
VTE Prophylaxis (Single Response) [150176]
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
Post-Op/Phase II
Moderate VTE Risk with Low Bleed Risk (Single
Response) [209954]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Post-Op/Phase II
High VTE with Low Bleed Risk [211018]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Post-Op/Phase II
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Page 3 of 8
Printed by WILLIAMS, HEATHER R [HRS0] at 9/25/2017 1:54:35 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@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
Post-Op/Phase II
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Post-Op/Phase II
Patient Care Orders
Vital Signs [88646]
Vital Signs [NURMON0013] EVERY 4 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Post-Op/Phase II
Activity [88647]
Bed Rest with Bathroom Privileges
[NURACT0008]
CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: with bathroom privileges
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
Elevate Head Of Bed [NURACT0002] Equal to (degrees):
Greater than (degrees):
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting today, Post-
Op/Phase II
Page 4 of 8
Printed by WILLIAMS, HEATHER R [HRS0] at 9/25/2017 1:54:35 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Chair with Assistance [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:
Post-Op/Phase II
Ambulate [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE: ad lib
CHAIR:
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
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:
Post-Op/Phase II
Patient Position While Seated Upright [88648]
May Sit Upright with Face Down [NURACT0011] CONTINUOUS, Starting today, Post-Op/Phase II
May Sit Upright with Chin Left [NURACT0011] CONTINUOUS, Starting today, Post-Op/Phase II
May Sit Upright with Chin Right [NURACT0011] CONTINUOUS, Starting today, Post-Op/Phase II
No Positioning Required [NURACT0011] CONTINUOUS, Starting today, Post-Op/Phase II
Other [NURCOM0022] CONTINUOUS, ***, Post-Op/Phase II
Patient Position While in Bed [88649]
Patient to Lie on Stomach (Face Down)
[NURACT0011]
CONTINUOUS, Starting today, Post-Op/Phase II
Patient to Lie on Left Side [NURACT0011] CONTINUOUS, Starting today, Post-Op/Phase II
Patient to Lie on Right Side [NURACT0011] CONTINUOUS, Starting today, Post-Op/Phase II
No Positioning Required [NURACT0011] CONTINUOUS, Starting today, Post-Op/Phase II
Nutrition [88650]
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
Page 5 of 8
Printed by WILLIAMS, HEATHER R [HRS0] at 9/25/2017 1:54:35 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

General Diet - No Added Salt [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Sodium Controlled
Sodium: NAS (2400 mg)
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
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:
Post-Op/Phase II
Wound/Procedure Site Care [88651]
Eye Patch and Shield [NURWND0018] CONTINUOUS, Starting today, To which eye(s): ***
Patch and shield to be removed by physician., Post-
Op/Phase II
Contingency Parameters [88652]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 160
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg): 100
If diastolic blood pressure < (mmHg): 50
If temperature > (C): 38.2
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 60
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Gauze patch is saturated,Pain not controlled
with ordered analgesics or ordered interventions
Post-Op/Phase II
Intravenous Therapy
Premedications for Needle Insertion [106327]
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.
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Post-Op/Phase II
Page 6 of 8
Printed by WILLIAMS, HEATHER R [HRS0] at 9/25/2017 1:54:35 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

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
Post-Op/Phase II
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
Post-Op/Phase II
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
Post-Op/Phase II
IV Fluids [88654]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Post-Op/Phase II
lactated ringers infusion [38890] Intravenous, CONTINUOUS, Post-Op/Phase II
dextrose 5%-NaCl 0.9% infusion [51641] Intravenous, CONTINUOUS, Post-Op/Phase II
sodium chloride 0.9% flush 10 mL injection
[785055]
Flush, PRN, flush/line care, Post-Op/Phase II
Medications
Analgesics - Opioid [202838]
hydrocodone-acetaMINOPHEN (NORCO) 5-325
MG per tab RANGE [750021]
1-2 tab, Oral, EVERY 4 HOURS PRN, pain, moderate
to severe pain, Post-Op/Phase II
MORPHine PF injection RANGE [750057] 1-4 mg, Intravenous, EVERY 3 HOURS PRN, pain,
moderate to severe pain
Do not give oral and IV opioids concomittantly
for 4 Minutes, Post-Op/Phase II
Analgesics - Non-Opioid [95099]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain, mild pain,
Post-Op/Phase II
Anti-emetics - First Line Therapy [202839]
ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
4 mg, Oral, EVERY 24 HOURS PRN, nausea/vomiting
Administer as first line therapy
Post-Op/Phase II
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 24 HOURS PRN,
nausea/vomiting
Administer as first line therapy
Post-Op/Phase II
Page 7 of 8
Printed by WILLIAMS, HEATHER R [HRS0] at 9/25/2017 1:54:35 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Anti-emetics - Second Line Therapy [202840]
promethazine (PHENERGAN) tab RANGE
[750037]
12.5-25 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
Administer second line when unresponsive to first line
therapy within 30 minutes
Post-Op/Phase II
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
If ordered IV; push slowly, max rate 5 mg/minute
Administer second line when unresponsive to first line
therapy within 30 minutes and unable to take orally.
Post-Op/Phase II
Ophthalmics - Start on Postoperative Day 1 [88659]
prednisolone (PRED FORTE) 1% ophthalmic
susp [41271]
1 drop, 4 X DAILY Starting tomorrow
Start after evaluation by physician on postoperative
day 1
Post-Op/Phase II
atropine 1% ophthalmic soln [34849] 1 drop, 2 X DAILY Starting tomorrow
Start after evaluation by physician on postoperative
day 1
Post-Op/Phase II
polymyxin-trimethoprim (POLYTRIM) ophthalmic
soln [46801]
1 drop, 4 X DAILY Starting tomorrow
Start after evaluation by physician on postoperative
day 1
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 8 of 8
Printed by WILLIAMS, HEATHER R [HRS0] at 9/25/2017 1:54:35 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org