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/clinical/cckm-tools/content/order-sets/inpatient/pain-management/name-98079-en.cckm

20170362

page

100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Pain Management

IP – Intrathecal Analgesia Therapy – Adult – Postprocedure [2128]

IP – Intrathecal Analgesia Therapy – Adult – Postprocedure [2128] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Pain Management


IP - Intrathecal Analgesia Therapy - Adult - Postprocedure [2128]
for Adult Patients OnlyIntended
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 [7248]
Page 1 of 7
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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:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status (Single Response) [82665]
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 [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Patient Care Orders
Vital Signs [29650]
Measure Heart Rate [NURMON0056] SEE COMMENTS, Starting today, Routine, Every one
hour for the first 4 hours, then every 4 hours.
Measure Blood Pressure [NURMON0019] SEE COMMENTS, Starting today, Routine
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every one hour for the first 4 hours, then every 4
hours.
Page 2 of 7
Printed by STRAKA, KEVIN F [KFS1] at 2/27/2017 9:45:46 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

Measure Temperature [NURMON0029] EVERY 8 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
Measure Respiratory Rate (Full Minute)
[NURMON0028]
SEE COMMENTS, Starting today, Routine, Every one
hour times 24, then every 4 hours.
Assess for Orthostatic Changes in Blood
Pressure and Heart Rate [NURMON0060]
ONCE, Starting today For 1 Occurrences, Prior to first
ambulation.
Patient Monitoring [29651]
Level of Awareness/Sedation Score URL: https://uconnect.wisc.edu/clinical/references/adult-
sedation/level-of-awarenesssedation-score/
Assess Patient's Pain Rating [NURMON0060] SEE COMMENTS, Starting today, Every 4 hours
while awake and as needed if patient develops pain
at insertion site, diffuse back pain, spinal headache,
or if inadequate pain control.
Assess Sedation Level [NURMON0060] SEE COMMENTS, Starting today, Every 1 hour times
24, then every 4 hours. (Note: Awaken only if unable
to distinguish between normal sleep and sedation).
Assess for Changes in Sensation and Strength of
Extremities [NURMON0060]
SEE COMMENTS, Starting today, Every 4 hours
while awake.
For Patients on Ziconotide (PRIALT) Therapy [29683]
Assess for Changes in Cognitive Impairment,
Hallucinations, Mood or Consciousness
[NURMON0060]
SEE COMMENTS, Starting today, Every 4 hours
while awake.
Activity [29684]
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:
No Turning, Twisting, Bending, Reaching,
Pushing, Pulling, Straining, Coughing or
Sneezing [NURACT0011]
CONTINUOUS, Starting today
Bed Rest with Strict Logroll [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: strict logroll
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Nutrition [29685]
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Intake and Output [29686]
Page 3 of 7
Printed by STRAKA, KEVIN F [KFS1] at 2/27/2017 9:45:46 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

Urinary Catheterization-Intermittent
[NURELM0018]
EVERY 6 HOURS PRN, Starting today, Routine, As
needed if unable to void and bladder scan is greater
than 400 mL.
Respiratory [29687]
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today, Routine, Continuous
for 24 hours.
Procedure Site Care [29688]
Maintain Regional Analgesia Catheter
[NURVAD0054]
CONTINUOUS, Starting today, Routine
Type of catheter:
Location:
Apply Brace, Spine [NURTRT0014] CONTINUOUS, Starting today, Routine
Type: Abdominal Binder
Wearing schedule:
Use to secure catheter and dressing.
Physician or Mid-Level Provider to Change
Dressing [NURWND0018]
CONTINUOUS, Starting today
RN to Reinforce Dressing with Gauze
[NURWND0018]
CONTINUOUS, Starting today
Assess Site [NURWND0018] SEE COMMENTS, Starting today, Every 8 hours for
the first 24 hours and as needed, then every day.
Contingency Parameters [29689]
Notify Provider [NURCOM0001] CONTINUOUS
Provider to Notify: Provider
If systolic blood pressure > (mmHg): 160
If systolic blood pressure < (mmHg): 80
If diastolic blood pressure > (mmHg): 90
If diastolic blood pressure < (mmHg): 50
If temperature > (C): 38
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <: 8
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Greater than 20% orthostatic
changes,Uncontrolled pain or pain greater than 8-9/
(1-10 scale),Sedation score greater than or equal to 4
or progressive sedation,New back pain or tenderness,
head or neck pain,Progressive loss of sensation and
strength in lower extremities,Catheter dislodgement
or other problems related to infusion,Increased
discharge or bleeding at catheter insertion site,Side
effects unrelieved by prescribed treatment,Changes
in cognitive impairment, hallucinations, mood or
consciousness
Intravenous Therapy
IV Fluids [29961]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today For Until specified,
Routine
Peripheral IV Size: 20 Gauge
Does this need to be inserted/placed?
Page 4 of 7
Printed by STRAKA, KEVIN F [KFS1] at 2/27/2017 9:45:46 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

sodium chloride 0.9% infusion [64367] Intravenous, CONTINUOUS
dextrose 5% infusion [36633] Intravenous, CONTINUOUS
Flushes [29948]
Initiate Venous Access Device Flushing Protocol
[NURVAD0053]
ONCE, Starting today For 1 Occurrences
Medications - Intrathecal Analgesia
Single Shot Intrathecal (Trial) Administered [31035]
Single Shot Regional Analgesia Opioid
Administered [NURTRT0059]
ONCE, Routine, Single shot intrathecal MORPHine
*** mg given on (date) *** at (time) ***
Single Shot Regional Analgesia Opioid
Administered [NURTRT0059]
ONCE, Routine, Single shot intrathecal baclofen
(LIORESAL) *** mcg given on (date) *** at (time) ***
Continuous Infusion Trial and Catheter Placement [30176]
Maintain Regional Analgesia Catheter
[NURVAD0054]
CONTINUOUS, Starting today For Until specified,
Routine
Type of catheter: Intrathecal
Location:
infusion [700416] Intrathecal, CONTINUOUS
Titrate every 8 hours as follows: Increase intrathecal
infusion rate to *** mL/hr if pain rating is *** with
sedation score ***. Decrease rate to *** mL/hr if pain
rating is *** with sedation score ***. Maintain rate at
*** mL/hr if pain rating is *** with sedation score ***
Pump Implantation/Refill [30571]
Implanted Infusion Pump Settings
[NURCOM0022]
CONTINUOUS, Starting today For Until specified
Type of catheter: Intrathecal
Location:
Infusion mode:
intraTHECAL injection [700393] Intrathecal, ONCE For 1 Doses
intraTHECAL injection (external pharmacy) -
NOTE: Use this order for concentrated
intraTHECAL injections obtained from external
compounding pharmacy. Must be ordered at
least one week in advance [700424]
Intrathecal, ONCE For 1 Doses
Medications
Medications - Other [30168]
Note: NO other sedatives or opioid analgesics
[950018]
EVERY 8 HOURS
NO other sedatives or opioid analgesics are to be
given unless approved by the designated pain
management service
Note: [950018] EVERY 8 HOURS
NO anticoagulants unless approved by the
designated pain management service. Approved:
Subcutaneous unfractionated heparin, up to 5000
units/dose 3 times a day, aspirin up to 325 mg 2 times
a day, or non-steroidal anti-inflammatory medications.
NOT Approved: warfarin, IV heparin, dalteparin,
enoxaparin, fondaparinux, clopidogrel, ticlopidine,
cilostazol, lepirudin, bivalirudin, argatroban,
abciximab, eptifibatide, tirofiban. (Note: May use
heparin lock flushes.)
Anti-emetics [30173]
ondansetron (ZOFRAN ODT) dispersible tab
[64224]
4 mg, Oral, EVERY 12 HOURS PRN,
nausea/vomiting
First line therapy
Page 5 of 7
Printed by STRAKA, KEVIN F [KFS1] at 2/27/2017 9:45:46 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 12 HOURS PRN,
nausea/vomiting
First line therapy. Administer if patient unable to
tolerate orally
metoclopramide (REGLAN) injection [800059] 10 mg, Intravenous, EVERY 4 HOURS PRN,
nausea/vomiting
Second line therapy. Administer when no response
to first line therapy within 30 minutes
If ordered IV: Administer over 2 minutes
scopolamine (TRANSDERM-SCOP) 1
MG/3DAYS 72hr patch [166671]
1 patch, Transdermal, EVERY 72 HOURS PRN,
nausea/vomiting
Apply to either mastoid area. For third line therapy
Bowel Management [219235]
senna-docusate (SENOKOT S) 8.6-50 MG per
tab [60530]
2 tab, Oral, 2 X DAILY
Hold for loose stools
polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 1 X DAILY PRN, constipation
Dissolve in 8 ounces of water, Use as first line
therapy
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, Oral, 2 X DAILY PRN, constipation
Second line therapy. Administer if no response to
first line laxative within 24 hours
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal, 1 X DAILY PRN, constipation
Third line therapy. Administer if there is no response
to first and second line laxatives, or when there is
need for immediate laxation
Side Effect Management [30174]
naloxone (NARCAN) injection [800199] 0.1 mg, Intravenous, PRN, opioid overdose
terazosin (HYTRIN) cap [50162] Oral, 1 X DAILY (HS) PRN, urinary retention
Laboratory
Laboratory [29690]
CK, TOTAL [CPK] 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, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
GLUCOSE [GLU] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BUN [BUN] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 6 of 7
Printed by STRAKA, KEVIN F [KFS1] at 2/27/2017 9:45:46 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

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?
CALCIUM [CA] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTHROMBIN TIME/INR [PT] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PTT [PTT] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
URINALYSIS, NO MICROSCOPY [UACHEM] ONCE, 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?
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [29691]
ECG - 12 Lead [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
Consults
Consults [29693]
Consult Chartwell (Inpatient) [CON0114] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Home infusion management for
intrathecal therapy analgesia
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 7 of 7
Printed by STRAKA, KEVIN F [KFS1] at 2/27/2017 9:45:46 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org