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IP - Regional Anesthesia Therapy - Home Going Catheter - Adult - Procedure [4645]

IP - Regional Anesthesia Therapy - Home Going Catheter - Adult - Procedure [4645] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Pain Management


SmartSet: IP - REGIONAL ANESTHESIA THERAPY - HOME GOING
CATHETER - ADULT - PROCEDURE (ID:4645)
General Information
Display name: IP - Regional Anesthesia Therapy - Home Going Catheter - Adult - Procedure
Type: General
Merge priority: 0
Version comment:
Content source:
Synonyms: 1. PAIN
2. EPIDURAL
3. NEURAXIAL
4. .ANESTHESIOLOGY
SmartSet notes:
Description: Intended for Adult Patients Only
Only Anesthesiology Acute Pain Service (APS) or Anesthesiology staff may
initiate, modify or discontinue epidural therapy. Refer to policy number: 8.92
Web information: Title URL
1.
Questionnaire:
Configuration
Patient Care Orders
Vital Signs
Measure Respiratory Rate, Depth And
Regularity
SEE COMMENTS, Starting S, Routine, EVERY 2
HOURS for 12 HOURS and then EVERY 4 HOURS.
Measure for 1 full minute.
Patient Monitoring
Assess Sedation Level SEE COMMENTS, Starting S, EVERY 2 HOURS for
12 HOURS and then EVERY 4 HOURS. (Note:
Awaken only if unable to distinguish between normal
sleep and sedation, or if change in respiratory pattern
(regularity) or depth of respiration.)
Page 1 of 5
Printed by STRAKA, KEVIN F [KFS1] at 2/21/2017 2:59:58 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Assess for Changes in Sensation and Strength
of Extremities
SEE COMMENTS, Starting S, EVERY 4 HOURS
while awake.
Assess Patient's Pain Rating SEE COMMENTS, Starting S, Every 4 hours while
awake and as needed if patient develops pain at
insertion site or if inadequate pain control.
Respiratory
Pulse Oximetry CONTINUOUS, Starting S For 24 Hours, Routine
Procedure Site Care
Assess Perineural Catheter Insertion Site CONTINUOUS, Starting S, Routine
Wound Type: Other (Comment) (Catheter insertion
site)
Wound Site:
Wound Location:
Assess Frequency: EVERY 8 HOURS (And as
needed)
Care Frequency:
Wash With:
Irrigate/Rinse With:
Apply (Must also enter separate medication order to
obtain drug): bacitracin ointment
Primary Dressing:
Secondary Dressing:
Catheter Questions Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, If you have questions or concerns
about your catheter, CALL 608-263-6400 and ask for
the anesthesiology resident on acute pain call.
Non-Categorized Patient Care Orders
Page 2 of 5
Printed by STRAKA, KEVIN F [KFS1] at 2/21/2017 2:59:58 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Notify Acute Pain Service. If the patient is
located at The American Center, notify the On-
Call Anesthesiologist
Provider to Notify: Other (Comment)
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Notify Acute Pain Service with any problems,
questions or troubleshooting. Notify Acute Pain
Service Resident at #7246 or "PAIN". If there is no
response after paging #7246, call paging or the
anesthesiology on-call resident (or faculty); or call the
I
Phone: 608-438-0915. If unable to reach Fellow page
Acute Pain Service Resident at: #7246 or "PAIN". If
there is no response after paging #7246, call paging
or the anesthesiology on-call resident (or faculty); or
call the Inpatient Operating Room at 263-8595.
If the patient is located at The American Center,
notify the On-Call Anesthesiologist.
Infusion Location ONCE, Infusion Location: {INFUSION
LOCATION:3000949}
Contingency Parameters
Page 3 of 5
Printed by STRAKA, KEVIN F [KFS1] at 2/21/2017 2:59:58 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Notify Anesthesiology Acute Pain Service. If the
patient is located at The American Center, notify
the On-Call Anesthesiologist
Provider to Notify: Other (Comment)
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
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: All pain questions and analgesic side effect
issues
"Pager #: 7246 or "PAIN" (for patients at CSC)
If patient located at The American Center, page the
TAC Anesthesiologist on-call in U-Connect
(WebXchange) using the on-call schedule search for
"TAC Anesthesiologist".
If there is no response after paging #7246, call
paging or the anesthesiology on-call resident (or
faculty); or call the Inpatient Operating Room at 263-
8595.
Regional Analgesia Therapy
Regional Analgesia Therapy
ropivacaine 0.2% home perineural infusion Peripheral Nerve, CONTINUOUS
For PERINEURAL use only
Basal rate = *** mL/hour
Patient initiated dose *** mL
Lockout Interval = 30 minutes
Maintain Regional Analgesia Catheter CONTINUOUS, Routine
Type of catheter: Perineural
Hospital Location:
Note: Send Medications To: ONCE For 1 Doses, IntraOp
Note: RPh Release Regional Analgesia Infusion
(s) and Maintain Regional Analgesia Catheter
Orders.
ONCE For 1 Doses, IntraOp
naloxone (NARCAN) injection 0.1 mg, Intravenous, PRN, opioid overdose
Administer every 3 minutes times 4 doses as needed
for respiratory rate less than 8 breaths/minute. Notify
physician if administered.
Criteria
Suggestions: UWOR ANE SUGGESTED ORDER SETS[33000000]
Page 4 of 5
Printed by STRAKA, KEVIN F [KFS1] at 2/21/2017 2:59:58 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Filter: UWIP ORDER SET RESTRICTION - HOSPITAL ENCOUNTERS EXCEPT ED -
NOT IP DC[3000400]
Restrict SmartSet:
Settings
Discontinue action:
Deselect sections for
Pended/Held orders:
Pended/Held orders
display:
Release date: Use System Definitions Setting
Disallow user override:
Page 5 of 5
Printed by STRAKA, KEVIN F [KFS1] at 2/21/2017 2:59:58 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org