/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/pain-management/,

/clinical/cckm-tools/content/order-sets/inpatient/pain-management/name-98085-en.cckm

201708223

page

100

UWHC,UWMF,

Tools,

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

IP - Lidocaine Intravenous Trial Infusion - Adult - Supplemental [1374]

IP - Lidocaine Intravenous Trial Infusion - Adult - Supplemental [1374] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Pain Management


IP - Lidocaine Intravenous Trial Infusion - Adult - Supplemental [1374]
Policy 8.76 Pain Management URL: https://uconnect.wisc.edu/policies/clinical/uwhc-
clinical/uwhc-wide/patient-care/876.policy
Patient Care Orders
Vital Signs [18567]
Vital Signs (Temperature, Blood Pressure, Pulse
Rate, Respiratory Rate) [NURMON0013]
ONCE, Starting today For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Prior to Infusion.
Vital Signs (Blood Pressure, Pulse Rate,
Respiratory Rate) [NURMON0013]
SEE COMMENTS, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 10 minutes during infusion (temperature not
needed).
Vital Signs (Blood Pressure, Pulse Rate,
Respiratory Rate) [NURMON0013]
SEE COMMENTS, Starting today with First
Occurrence As Scheduled For Until specified, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Once 30 minutes after completion of infusion
(temperature not needed).
Vital Signs [223727]
Vital Signs (Temperature, Blood Pressure, Pulse
Rate, Respiratory Rate) [NURMON0013]
ONCE, Starting today For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Prior to Infusion., Pre-Op Day Of Procedure
Vital Signs (Blood Pressure, Pulse Rate,
Respiratory Rate) [NURMON0013]
SEE COMMENTS, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 10 minutes during infusion (temperature not
needed)., Pre-Op Day Of Procedure
Page 1 of 4
Printed by STRAKA, KEVIN F [KFS1] at 8/9/2017 3:19:36 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Vital Signs (Blood Pressure, Pulse Rate,
Respiratory Rate) [NURMON0013]
SEE COMMENTS, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Once 30 minutes after completion of infusion
(temperature not needed)., Pre-Op Day Of Procedure
Patient Monitoring [18568]
Assess Pain Rating Prior to Infusion
[NURMON0060]
SEE COMMENTS, Starting today with First
Occurrence As Scheduled For Until specified, Assess
pain rating once prior to infusion.
Assess Pain Rating Every 10 Minutes
[NURMON0060]
SEE COMMENTS, Starting today with First
Occurrence As Scheduled For Until specified, Assess
pain rating every 10 minutes during infusion.
Assess Pain Rating 30 Minutes After Infusion
[NURMON0060]
SEE COMMENTS, Starting today with First
Occurrence As Scheduled For Until specified, Assess
pain rating once 30 minutes after completion of
infusion.
Assess for Lidocaine Adverse Effects 30 Minutes
After Infusion [NURMON0060]
SEE COMMENTS, Starting today For Until specified,
Assess for Lidocaine adverse effects every 10 minutes
during infusion.
Assess for Lidocaine Adverse Effects 30 Minutes
After Infusion [NURMON0060]
SEE COMMENTS, Starting today For Until specified,
Assess for Lidocaine advers effects 30e minutes after
completion of infusion.
Cardio-Respiratory Monitor - Pediatric - With
Rhythm [139419]
Cardio-Respiratory Monitor - Pediatric - With
Rhythm [NURMON0014]
ONCE, Routine, Most pediatric patients do NOT
require rhythm analysis. Please complete the Notify
Provider order below, including specification for
apnea > *** seconds. If indicated, order pulse
oximetry separately.
Device Present:
Device Mode:
Device Low Rate Limit (BPM):
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Notify [NURCOM0001] Provider to Notify: Provider
Notify based on:
Notify provider for apnea > 20 seconds
Patient Monitoring [223728]
Assess Pain Rating Prior to Infusion
[NURMON0060]
SEE COMMENTS, Starting today For Until specified,
Assess pain rating once prior to infusion., Pre-Op Day
Of Procedure
Assess Pain Rating Every 10 Minutes
[NURMON0060]
SEE COMMENTS, Starting today For Until specified,
Assess pain rating every 10 minutes during infusion.,
Pre-Op Day Of Procedure
Assess Pain Rating 30 Minutes After Infusion
[NURMON0060]
SEE COMMENTS, Starting today For Until specified,
Assess pain rating once 30 minutes after completion
of infusion., Pre-Op Day Of Procedure
Assess for Lidocaine Adverse Effects Every 10
Minutes [NURMON0060]
SEE COMMENTS, Starting today For Until specified,
Assess for Lidocaine adverse effects every 10 minutes
during infusion., Pre-Op Day Of Procedure
Page 2 of 4
Printed by STRAKA, KEVIN F [KFS1] at 8/9/2017 3:19:36 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Assess for Lidocaine Adverse Effects 30 Minutes
After Infusion [NURMON0060]
SEE COMMENTS, Starting today For Until specified,
Assess for Lidocaine advers effects 30e minutes after
completion of infusion., Pre-Op Day Of Procedure
Cardio-Respiratory Monitor - Pediatric - With
Rhythm [139419]
Cardio-Respiratory Monitor - Pediatric - With
Rhythm [NURMON0014]
ONCE, Routine, Most pediatric patients do NOT
require rhythm analysis. Please complete the Notify
Provider order below, including specification for
apnea > *** seconds. If indicated, order pulse
oximetry separately.
Device Present:
Device Mode:
Device Low Rate Limit (BPM):
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Pre-Op Day Of Procedure
Notify [NURCOM0001] Provider to Notify: Provider
Notify based on:
Notify provider for apnea > 20 seconds, Pre-Op Day
Of Procedure
Infusion Reaction [151892]
Infusion Reaction [NURCOM0022] ONCE, If mild or moderate adverse effects develop
hold infusion for 15 minutes or until resolved,
whichever is sooner. Resume infusion at 1/2 rate. If
adverse effects have not resolved in 10-15 minutes,
discontinue infusion. If adverse effects re-surface
when infusion restarted, discontinue infusion.
Document total dose infused, any adverse effects and
other pertinent information using the lidocaine test
dose note template.
Infusion Reaction [223724]
Infusion Reaction [NURCOM0022] ONCE, If mild or moderate adverse effects develop
hold infusion for 15 minutes or until resolved,
whichever is sooner. Resume infusion at 1/2 rate. If
adverse effects have not resolved in 10-15 minutes,
discontinue infusion. If adverse effects re-surface
when infusion restarted, discontinue infusion.
Document total dose infused, any adverse effects and
other pertinent information using the lidocaine test
dose note template., Pre-Op Day Of Procedure
Intravenous Therapy
IV Fluids [18793]
sodium chloride 0.9 % infusion [64367] at 10 mL/hr, Intravenous, CONTINUOUS
To keep vein open
IV Fluids [223725]
sodium chloride 0.9 % infusion [64367] at 10 mL/hr, Intravenous, CONTINUOUS
To keep vein open
Pre-Op Day Of Procedure
Medications
Infusion Agent - Trial [19083]
lidocaine PF in sodium chloride 0.9 % 100 mL
bag - Maximum Dose = 500 mg First Dose
[700391]
5 mg/kg, Intravenous, ONCE For 1 Doses
Document total dose infused, any adverse effects and
other pertinent information.
Infusion Agent - Trial [223730]
Page 3 of 4
Printed by STRAKA, KEVIN F [KFS1] at 8/9/2017 3:19:36 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

lidocaine PF in sodium chloride 0.9 % 100 mL
bag - Maximum Dose = 500 mg First Dose
[700391]
5 mg/kg, Intravenous, ONCE For 1 Doses
Document total dose infused, any adverse effects and
other pertinent information.
Pre-Op Day Of Procedure
Page 4 of 4
Printed by STRAKA, KEVIN F [KFS1] at 8/9/2017 3:19:36 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org