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/clinical/cckm-tools/content/order-sets/inpatient/ophthalmology/name-98121-en.cckm

201709272

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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 – Preoperative [2718]

IP – Ophthalmology – Retina Service – Adult – Preoperative [2718] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Ophthalmology


IP - Ophthalmology - Retina Service - Adult - Preoperative [2718]
for Adult Patients OnlyIntended
Admission Status
Level of Care (Single Response) [187484]
*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 [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] 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:
Pre-Op Day Of Procedure
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Pre-Op Day Of Procedure
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Pre-Op Day Of Procedure
Admission Status [84058]
Page 1 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 9/26/2017 8:45:20 AM
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:
Pre-Op Day Of Procedure
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Pre-Op Day Of Procedure
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Pre-Op Day Of Procedure
Patient Care Orders
Vital Signs [85089]
Vital Signs [NURMON0013] EVERY 8 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Pre-Op Day Of Procedure
Nutrition [85090]
NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: Strict NPO
Bedside Meal Instructions:
Room Service Class:
Pre-Op Day Of Procedure
Non-Categorized Patient Care Orders [85091]
Glucose, POC [IPGLUCOSE] ONCE, Starting today For 1 Occurrences, 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?
Upon arrival., Pre-Op Day Of Procedure
Contingency Parameters [85092]
Page 2 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 9/26/2017 8:45:20 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

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:
Pre-Op Day Of Procedure
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [211048]
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
Pre-Op Day Of Procedure
Moderate VTE Risk with Low Bleed Risk (Single
Response) [209954]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Pre-Op
Day Of Procedure
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Pre-Op Day Of Procedure
High VTE with Low Bleed Risk [211018]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Pre-Op
Day Of Procedure
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Pre-Op Day Of Procedure
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
Pre-Op Day Of Procedure
No VTE Prophylaxis [130084]
Page 3 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 9/26/2017 8:45:20 AM
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:
Pre-Op Day Of Procedure
VTE Prophylaxis (Single Response) [209976]
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
Pre-Op Day Of Procedure
Moderate VTE Risk with Low Bleed Risk (Single
Response) [209954]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Pre-Op
Day Of Procedure
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Pre-Op Day Of Procedure
High VTE with Low Bleed Risk [211018]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Pre-Op
Day Of Procedure
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 HOURS, Pre-
Op Day Of Procedure
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
Pre-Op Day Of Procedure
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Pre-Op Day Of Procedure
Intravenous Therapy
Premedications for Needle Insertion [106313]
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?
Pre-Op Day Of Procedure
Page 4 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 9/26/2017 8:45:20 AM
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
Pre-Op Day Of Procedure
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
Pre-Op Day Of Procedure
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
Pre-Op Day Of Procedure
IV Fluids [85094]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Pre-Op Day Of Procedure
lactated ringers infusion [38890] Intravenous, CONTINUOUS, Pre-Op Day Of
Procedure
dextrose 5%-NaCl 0.9% infusion [51641] Intravenous, CONTINUOUS, Pre-Op Day Of
Procedure
sodium chloride 0.9% flush 10 mL injection
[785055]
Flush, PRN, flush/line care, Pre-Op Day Of Procedure
Medications - Pre-operative
Ophthalmics - RIGHT Eyes [233416]
cyclopentolate (CYCLOGYL) 1% ophthalmic soln
[36271]
1 drop, Eye (Right), EVERY 5 MINUTES For 3 Doses
Administer FIRST set of eye drops as soon as patient
is called to the operating room. Please send drops
with the patient to the operating room.
Pre-Op Day Of Procedure
tropicamide (MYDRIACYL) 1% ophthalmic soln
[43208]
1 drop, Eye (Right), EVERY 5 MINUTES For 3 Doses
Administer FIRST set of eye drops as soon as patient
is called to the operating room. Please send drops
with the patient to the operating room.
Pre-Op Day Of Procedure
phenylEPHRINE 2.5% ophthalmic soln [41006] 1 drop, Eye (Right), EVERY 5 MINUTES For 3 Doses
Administer FIRST set of eye drops as soon as patient
is called to the operating room. Please send drops
with the patient to the operating room.
Pre-Op Day Of Procedure
Page 5 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 9/26/2017 8:45:20 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Ophthalmics - LEFT Eye [85096]
cyclopentolate (CYCLOGYL) 1% ophthalmic soln
[36271]
1 drop, Eye (Left), EVERY 5 MINUTES For 3 Doses
Administer FIRST set of eye drops as soon as patient
is called to the operating room. Please send drops
with the patient to the operating room.
Pre-Op Day Of Procedure
tropicamide (MYDRIACYL) 1% ophthalmic soln
[43208]
1 drop, Eye (Left), EVERY 5 MINUTES For 3 Doses
Administer FIRST set of eye drops as soon as patient
is called to the operating room. Please send drops
with the patient to the operating room.
Pre-Op Day Of Procedure
phenylEPHRINE 2.5% ophthalmic soln [41006] 1 drop, Eye (Left), EVERY 5 MINUTES For 3 Doses
Administer FIRST set of eye drops as soon as patient
is called to the operating room. Please send drops
with the patient to the operating room.
Pre-Op Day Of Procedure
Ophthalmics - BOTH Eyes [233415]
cyclopentolate (CYCLOGYL) 1% ophthalmic soln
[36271]
1 drop, Eyes (Each), EVERY 5 MINUTES For 3 Doses
Administer FIRST set of eye drops as soon as patient
is called to the operating room. Please send drops
with the patient to the operating room.
Pre-Op Day Of Procedure
tropicamide (MYDRIACYL) 1% ophthalmic soln
[43208]
1 drop, Eyes (Each), EVERY 5 MINUTES For 3 Doses
Administer FIRST set of eye drops as soon as patient
is called to the operating room. Please send drops
with the patient to the operating room.
Pre-Op Day Of Procedure
phenylEPHRINE 2.5% ophthalmic soln [41006] 1 drop, Eyes (Each), EVERY 5 MINUTES For 3 Doses
Administer FIRST set of eye drops as soon as patient
is called to the operating room. Please send drops
with the patient to the operating room.
Pre-Op Day Of Procedure
Laboratory
Collect Now [85098]
CBC WITHOUT DIFFERENTIAL [HEMO] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
PROTHROMBIN TIME/INR [PT] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
ELECTROLYTES [LYTE] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
BUN [BUN] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
Page 6 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 9/26/2017 8:45:20 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

CREATININE [CRET] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
GLUCOSE [GLU] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
CALCIUM [CA] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
Conditional Labs [85099]
GLUCOSE [GLU] CONDITIONAL For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Obtain STAT if
bedside glucose is less than 40 or greater than 400
mg/dL
Pre-Op Day Of Procedure
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [85101]
ECG - 12 Lead [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
BestPractice
No Hospital Problems have yet been identified. [107349]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing., Pre-Op Day Of Procedure
Page 7 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 9/26/2017 8:45:20 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org