/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/orthopedicsrehab/,

/clinical/cckm-tools/content/order-sets/inpatient/orthopedicsrehab/name-98110-en.cckm

20180104

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Orthopedics/Rehab

IP - Total Knee Arthroplasty - Adult - Postoperative [2728]

IP - Total Knee Arthroplasty - Adult - Postoperative [2728] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Orthopedics/Rehab


IP - Total Knee Arthroplasty - Adult - Postoperative [2728]
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 [84057]
Page 1 of 15
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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) [152599]
Orthopedic VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97529-en.cckm
No VTE Prophylaxis Indicated [130084]
Page 2 of 15
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01/2018CCKM@uwhealth.org

VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Post-Op/Phase II
Moderate VTE Risk w/ Low Bleed Risk [205527]
aspirin chew tab [720164] 81 mg, Oral, 2 X DAILY
aspirin EC delayed release tab [34794] 325 mg, Oral, 2 X DAILY
warfarin (COUMADIN) tab [720161] Oral, 1 X DAILY (HS)
Note: Warfarin Dose Varies Daily [950001] 1 X DAILY (HS)
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 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
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type:
High VTE Risk w/ Low Bleed Risk [206290]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
warfarin (COUMADIN) tab [720161] Oral, 1 X DAILY (HS)
Note: Warfarin Dose Varies Daily [950001] 1 X DAILY (HS)
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:
High Bleed Risk (Single Response) [206000]
Sequential Compression Device (SCD) / Foot
Pump [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type:
VTE Prophylaxis (Single Response) [151533]
Orthopedic VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97529-en.cckm
No VTE Prophylaxis Indicated [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Post-Op/Phase II
Moderate VTE Risk w/ Low Bleed Risk [205527]
aspirin chew tab [720164] 81 mg, Oral, 2 X DAILY
aspirin EC delayed release tab [34794] 325 mg, Oral, 2 X DAILY
warfarin (COUMADIN) tab [720161] Oral, 1 X DAILY (HS)
Page 3 of 15
Printed by O'BRIEN, RYLEY P [RPO249] at 1/3/2018 2:09:45 PM
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01/2018CCKM@uwhealth.org

Note: Warfarin Dose Varies Daily [950001] 1 X DAILY (HS)
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 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
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type:
High VTE Risk w/ Low Bleed Risk [206290]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
warfarin (COUMADIN) tab [720161] Oral, 1 X DAILY (HS)
Note: Warfarin Dose Varies Daily [950001] 1 X DAILY (HS)
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:
High Bleed Risk (Single Response) [206000]
Sequential Compression Device (SCD) / Foot
Pump [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type:
Patient Care Orders
Vital Signs [85347]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 2 hours times 4, then every 8 hours., Post-
Op/Phase II
Activity [85389]
Elevate Head Of Bed At Least 45 Degrees
[NURACT0002]
Equal to (degrees):
Greater than (degrees): 45
Less than (degrees): 90
Other options:
Routine, CONTINUOUS, PACU
Lock Foot of Bed to Flat Position in PACU
[NURACT0011]
CONTINUOUS, PACU
Lock Foot of Bed to Flat Position on Nursing Unit
[NURACT0011]
ONCE, Post-Op/Phase II
Page 4 of 15
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01/2018CCKM@uwhealth.org

No Pillow Under Operative Knee in PACU
[NURACT0011]
CONTINUOUS, PACU
No Pillow Under Operative Knee on Nursing Unit
[NURACT0011]
ONCE, Post-Op/Phase II
Activity [NURACT0008] CONTINUOUS, Starting today, Routine
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:
Dangle on day of surgery.
Chair on day of surgery.
Ambulate 3 times daily, first ambulation with PT on
day of surgery. If PT unavailable, ambulate with
nursing., Post-Op/Phase II
Reposition as needed to avoid skin breakdown
[NURCOM0022]
SEE COMMENTS, Starting today, Every 2 hours.,
Post-Op/Phase II
Continuous Passive Motion (CPM) Machine
Panel (TREATMENT AND SUPPLY) [206112]
Continuous Passive Motion Machine
(TREATMENT) [NURACT0020]
CONTINUOUS, Routine
Location:
Extension Setting:
Flexion Setting:
Frequency:
Duration:
Maximum Extension:
Maximum Flexion:
CPM Unit (SUPPLY) [EQP0010] CONTINUOUS, Routine
Nutrition [85349]
Clear Liquid Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Liquid
Liquid: Clear Liquid
No Red or Purple Dye:
Liquid Thickness: Thin
Bedside Meal Instructions:
Room Service Class:
Advance diet as tolerated to general., 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
Respiratory [85391]
Page 5 of 15
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Oxygen Therapy [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 92
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Post-Op/Phase II
Pulse Oximetry [NURMON0009] SEE COMMENTS, Starting today For Until specified,
Routine, With vital signs., Post-Op/Phase II
Incentive Spirometry [NURTRT0018] EVERY 2 HOURS, Starting today For Until specified,
Routine, Post-Op/Phase II
Cough And Deep Breathe [NURTRT0019] SEE COMMENTS, Starting today For Until specified,
Routine, Every 2 hours times 4, then every 4 hours.,
Post-Op/Phase II
Place Respiratory Therapy per Protocol order if
patient uses home inhaler [NURCOM0022]
ONCE For 1 Occurrences, Post-Op/Phase II
Place CPAP Night/Nap or BiPAP Night/Nap order
panel if patient uses CPAP/BiPAP at home
[NURCOM0022]
ONCE For 1 Occurrences, Post-Op/Phase II
Wound/Procedure Site Care [85392]
Maintain Drain [NURTAD0003] CONTINUOUS, Starting today, Routine
Type: Closed Suction (Jackson-Pratt)
Site: Extremity
Location:
Drainage Options:
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For:
Dressing Change Frequency: SEE COMMENTS
Dressing Type: Other (Comment) (Sterile dry
dressing)
Physician to change first dressing. Change as needed
if saturated., Post-Op/Phase II
Wound Vacuum [NURWND0013] CONTINUOUS, Routine
Wound Vacuum Site:
Type of Suction:
DPC (Intermittent Suction) Frequency:
Post-Op/Phase II
Intake and Output [85393]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today, Routine, Post-
Op/Phase II
Non-Categorized Patient Care Orders [85394]
Initiate Bladder Management Protocol
[NURELM0014]
CONTINUOUS, Routine, Post-Op/Phase II
Maintain Urinary Catheter [NURELM0013] CONTINUOUS, 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:
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Post-Op/Phase II
Page 6 of 15
Printed by O'BRIEN, RYLEY P [RPO249] at 1/3/2018 2:09:45 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Trapeze (Patient Helper) Patient Weight < 250
LBS [117142]
Trapeze (Patient Helper) Patient Weight < 250
Lbs - Treatment [NURTRT0056]
CONTINUOUS, Routine
Trapeze (Patient Helper) Patient Weight < 250
Lbs [EQP0029]
CONTINUOUS, Routine
What bed type needs the trapeze?
Trapeze (Patient Helper) Patient Weight > 250
LBS, Max 350 LBS [117144]
Trapeze (Patient Helper) Patient Weight > 250
Lbs, MAX 350 Lbs - Treatment [NURTRT0055]
CONTINUOUS, Routine
Trapeze (Patient Helper) Patient Weight > 250
Lbs, MAX 350 Lbs [EQP0062]
CONTINUOUS, Routine
What bed type needs the trapeze?
Neurovascular Checks [NURMON0045] SEE COMMENTS, Starting today, Routine
Location:
Every 2 hours times 4, then every 8 hours., Post-
Op/Phase II
Ankle Pumps [NURCOM0022] SEE COMMENTS, Starting today, Every 2 hours
times 4, then every 8 hours while patient is awake.,
Post-Op/Phase II
Sedation level assessment [NURCOM0022] SEE COMMENTS, Starting today, Every 2 hours
times 4, then every 4 hours., Post-Op/Phase II
Apply Cool Compress (Polar Care) to Affected
Area [NURTRT0003]
PRN, Routine
Site:
Continuous until morning of post-op day 1, then as
often as tolerated by patient. Patient able to remove
as needed., Post-Op/Phase II
Apply Ice Pack to Knee as Needed
[NURTRT0008]
PRN, Starting today For Until specified, Routine
Site: Affected Area
Post-Op/Phase II
Contingency Parameters [85395]
Notify [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 170
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg): 110
If diastolic blood pressure < (mmHg): 60
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 50
If respiratory rate >:
If respiratory rate <: 10
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Sedation score greater than or equal to
4,Naloxone administered
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 immediate.
Page 7 of 15
Printed by O'BRIEN, RYLEY P [RPO249] at 1/3/2018 2:09:45 PM
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Post-Op/Phase II
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
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.
Post-Op/Phase II
IV Fluids [85356]
Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
dextrose 5%-NaCl 0.9% infusion [51641] at 125 mL/hr, Intravenous, CONTINUOUS
Discontinue IV with adequate oral intake
Post-Op/Phase II
dextrose 5%- NaCl 0.9% with KCl 20 mEq/L
infusion [44904]
at 125 mL/hr, Intravenous, CONTINUOUS
Discontinue IV with adequate oral intake
Post-Op/Phase II
sodium chloride 0.9% infusion - NOTE: Order for
patients with diabetes [64367]
at 125 mL/hr, Intravenous, CONTINUOUS
Discontinue IV with adequate oral intake
NOTE: Order for patients with diabetes
Post-Op/Phase II
Surgical Prophylaxis
First Line (Single Response) [206646]
cefazolin (ANCEF) intraVENOUS - NOTE:
Patients who are 40-120 kg [800000]
2 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
cefazolin (ANCEF) intraVENOUS - NOTE:
Patients who are greater than 120 kg [800000]
3 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
cefuroxime (ZINACEF) intraVENOUS - NOTE:
Patients who are 40-120 kg [800030]
1.5 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
cefuroxime (ZINACEF) intraVENOUS - NOTE:
Patients who are greater than 120 kg [800030]
3 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
MRSA/Documented MRSA History or High Risk for MRSA/MRSE (Implanted Device) (Single Response)
[206645]
Patients who are 40 - 120 kg - Cefazolin and
Vancomycin [228815]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses
Maximum Dose = 2000 mg
Post-Op/Phase II
Patients who are greater than 120 kg - Cefazolin
and Vancomycin [228817]
Page 8 of 15
Printed by O'BRIEN, RYLEY P [RPO249] at 1/3/2018 2:09:45 PM
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01/2018CCKM@uwhealth.org

cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses
Maximum Dose = 2000 mg
Post-Op/Phase II
Patients who are 40 - 120 kg - Cefuroxime and
Vancomycin [228818]
cefuroxime (ZINACEF) intraVENOUS [800030] 1.5 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses
Maximum Dose = 2000 mg
Post-Op/Phase II
Patients who are greater than 120 kg -
Cefuroxime and Vancomycin [228820]
cefuroxime (ZINACEF) intraVENOUS [800030] 3 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS
[800084]
1.5 g, Intravenous, EVERY 12 HOURS For 1 Doses
Maximum Dose = 2000 mg
Post-Op/Phase II
Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies [153354]
vancomycin (VANCOCIN) intraVENOUS [800084] 20 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses
Maximum Dose = 2000 mg
Post-Op/Phase II
Medications - General
PACU Analgesics [85358]
MORPHine (MS CONTIN, ORAMORPH) ER tab
[156572]
Oral, ONCE For 1 Doses, PACU
ketOROLAC (TORODOL) injection - For patients
less than 50 kg, greater than 65 yearls old, or
CrCl less than 50 mL/min, order ketorolac 15 mg
dose [800050]
Intravenous, ONCE For 1 Doses, PACU
Scheduled Analgesics [206647]
acetaMINOPHEN (TYLENOL) tab [34150] 1,000 mg, Oral, 3 X DAILY, Post-Op/Phase II
celecoxib (CELEBREX) cap [60834] Oral, 2 X DAILY (AT MEALTIME), Post-Op/Phase II
pregabalin (LYRICA) cap [109006] 75 mg, Oral, 2 X DAILY, Post-Op/Phase II
MORPHine (MS CONTIN, ORAMORPH) ER tab
[156572]
Oral, 2 X DAILY, Post-Op/Phase II
naproxen (NAPROSYN) tab [720103] 250 mg, Oral, 2 X DAILY (AT MEALTIME), Post-
Op/Phase II
naproxen (NAPROSYN) tab [720103] 500 mg, Oral, 2 X DAILY (AT MEALTIME), Post-
Op/Phase II
PRN Analgesics (Single Response) [206648]
oxycodone tab [45976] 5-15 mg, Oral, EVERY 3 HOURS PRN, pain,
Administer for severe post-operative pain., Post-
Op/Phase II
hydrocodone-acetaMINOPHEN (NORCO) 5-325
MG per tab [71425]
Oral, EVERY 4 HOURS PRN, pain, Administer for
severe post-operative pain., Post-Op/Phase II
hydrocodone-acetaMINOPHEN (NORCO) 10-325
MG per tab [64942]
Oral, EVERY 4 HOURS PRN, pain, Administer for
severe post-operative pain., Post-Op/Phase II
Page 9 of 15
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
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01/2018CCKM@uwhealth.org

traMADOL (ULTRAM) tab [720174] Oral, EVERY 4 HOURS PRN, pain, Administer for
severe post-operative pain.
No more than 400 mg in a 24 hour period.
Post-Op/Phase II
Breakthrough Analgesics [206649]
ketOROLAC (TORODOL) injection - For patients
less than 50 kg, greater than 65 yearls old, or
CrCl less than 50 mL/min, order ketorolac 15 mg
dose [800050]
Intravenous, EVERY 6 HOURS PRN For 5 Doses,
pain
Administer for pain not controlled by oral PRN opioids.
Administer ketorolac as a first line agent for
breakthrough pain prior to giving IV hydromorphone.
Do not administer within 8 hours of scheduled
celecoxib (CELEBREX)
Post-Op/Phase II
HYDROmorphone PF (DILAUDID) injection
[800120]
0.2-0.5 mg, Intravenous, EVERY 2 HOURS PRN, pain
Administer for pain not controlled by oral PRN opioids
and IV ketorolac if ordered for breakthrough pain.
Post-Op/Phase II
Steriods [152602]
dexamethasone (DECADRON) intraVENOUS
[800037]
4 mg, Intravenous, 1 X DAILY For 2 Days, Post-
Op/Phase II
Anti-emetics [85360]
ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
4 mg, Oral, EVERY 12 HOURS PRN,
nausea/vomiting, First Line Therapy
Administer first line.
Post-Op/Phase II
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 12 HOURS PRN,
nausea/vomiting
Administer first line therapy if unable to take orally
Post-Op/Phase II
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN, nausea/vomiting
Administer second line when there is no response to
first line anti-emnetic within 30 minutes.
Post-Op/Phase II
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Administer second when unable to take orally and
there is no response to first line anti-emetic within 30
minutes.
Post-Op/Phase II
Antacids [85362]
mag-al-simeth (MYLANTA ES) 400-400-40
MG/5ML susp [44073]
15 mL, Oral, EVERY 4 HOURS PRN, dyspepsia,
Post-Op/Phase II
Bowel Management [85361]
senna-docusate (SENOKOT-S) 8.6-50 mg per tab
[60530]
2 tab, Oral, 2 X DAILY
Hold for loose stools
Post-Op/Phase II
polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 1 X DAILY PRN, constipation
Administer first line.
Post-Op/Phase II
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, Oral, 2 X DAILY PRN, constipation
Administer second line if there is no response to first
line laxative within 24 hours. May dilute with a small
amount of water prior to administration. Follow
administration with a full glass of water.
Post-Op/Phase II
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01/2018CCKM@uwhealth.org

bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal, 1 X DAILY PRN, constipation
Administer third line if there is no response to first and
second line laxatives, or when there is need for
immediate laxation.
Post-Op/Phase II
Hypnotics (Single Response) [206650]
zolpidem (AMBIEN) tab [46913] 5 mg, Oral, 1 X DAILY (HS) PRN, sleep
Use only if patient is less than 65 years old.
Offer only after failure of non-pharmacologic
interventions (see IPOC supplemental Sleep/Rest
Disturbance Adult)
Post-Op/Phase II
diphenhydramine (BENADRYL) cap [36791] 25 mg, Oral, 1 X DAILY (HS) PRN, Sleep
Use with caution in patients greater than 65 years old.
Pruritus (Single Response) [152603]
loratadine (CLARITIN) tab [45611] 10 mg, Oral, 1 X DAILY PRN, allergies, itching, Post-
Op/Phase II
diphenhydramine (BENADRYL) cap - NOTE: Do
NOT order for patients older than 65 years
[36791]
25 mg, Oral, EVERY 6 HOURS PRN, itching
NOTE: Do NOT order for patients older than 65 years
Post-Op/Phase II
diphenhydramine (BENADRYL) injection - NOTE:
Do NOT order for patients older than 65 years
[800106]
25 mg, Intravenous, EVERY 6 HOURS PRN, itching
NOTE: Do NOT order for patients older than 65 years
Post-Op/Phase II
Non-Categorized [152604]
naloxone (NARCAN) injection [800199] 0.1 mg, Intravenous, PRN, opioid overdose
Administer every 3 minutes times 4 doses as needed
for respiratory rate less than 8 breaths/minute or
sedation score of 5 or greater. Notify MD if naloxone
administered
Post-Op/Phase II
Laboratory
Draw Postoperative Day 1 [103759]
ELECTROLYTES [LYTE] 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?
Post-Op/Phase II
GLUCOSE [GLU] 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?
Post-Op/Phase II
BUN [BUN] 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?
Post-Op/Phase II
CREATININE [CRET] 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?
Post-Op/Phase II
Page 11 of 15
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01/2018CCKM@uwhealth.org

CALCIUM [CA] 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?
Post-Op/Phase II
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?
Post-Op/Phase II
PROTHROMBIN TIME/INR [PT] NEXT AM For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [85419]
X-RAY KNEE 1-2 VIEWS (Right Knee)
[R73560R]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms? Pain following knee
replacement
What specific question(s) would you like answered by
this exam? Assessment of component position
Relevant recent/past history? Status post total knee
arthroplasty
Is patient pregnant? Unknown
If being performed remotely, where? IP PACU
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Right knee. Include entire prosthesis. Obtain in
PACU., PACU
X-RAY KNEE 1-2 VIEWS (Left Knee) [R73560L] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms? Pain following knee
replacement
What specific question(s) would you like answered by
this exam? Assessment of component position
Relevant recent/past history? Status post total knee
arthroplasty
Is patient pregnant? Unknown
If being performed remotely, where? IP PACU
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Left knee. Include entire prosthesis. Obtain in PACU.,
PACU
Diagnostic Tests and Imaging - Post Operative Day 2 [107155]
Page 12 of 15
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01/2018CCKM@uwhealth.org

X-RAY KNEE 1-2 VIEWS LEFT [R73560L] ONCE-ON SPECIFIC DATE, Starting 1/5/18 For 1
Occurrences, Routine
Current signs and symptoms? Pain following knee
replacement
What specific question(s) would you like answered by
this exam? Assessment of component postition
Relevant recent/past history? Status post knee
arthroplasty
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Left knee. Include entire prosthesis. Obtain
postoperative day 2
X-RAY KNEE 1-2 VIEWS RIGHT [R73560R] ONCE-ON SPECIFIC DATE, Starting 1/5/18 For 1
Occurrences, Routine
Current signs and symptoms? Pain following knee
replacement
What specific question(s) would you like answered by
this exam? Assessment of component position
Relevant recent/past history? Status post knee
arthroplasty
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Right knee. Include entire prosthesis. Obtain
postoperative day 2.
Consults
Consults [85421]
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult: Mobility
Training
Gait training and range of motion, Post-Op/Phase II
Consult Hospitalist (Inpatient) [CON0134] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Post-Op/Phase II
Diabetes Consult Order Panel (Adult) [188497]
Page 13 of 15
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01/2018CCKM@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):
Post-Op/Phase II
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?
Post-Op/Phase II
Page 14 of 15
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01/2018CCKM@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?
Post-Op/Phase II
Consult Infectious Disease (Inpatient) [CON0037] ONCE
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Post-Op/Phase II
Consult Case Management (Inpatient) [CON0013] ONCE, Routine
Location?
Can this consult be done via video?
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 15 of 15
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
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01/2018CCKM@uwhealth.org