/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/plastics/,

/clinical/cckm-tools/content/order-sets/inpatient/plastics/name-123589-en.cckm

201712352

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Plastics

IP - Plastics - Vaginoplasty - Adult - Postoperative [6633]

IP - Plastics - Vaginoplasty - Adult - Postoperative [6633] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Plastics


IP - Plastics - Vaginoplasty - Adult - Postoperative [6633]
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 17
Printed by WILLIAMS, HEATHER R [HRS0] at 12/15/2017 12:29:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@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:
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) [131999]
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]
Page 2 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 12/15/2017 12:29:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
Post-Op/Phase II
Moderate VTE Risk with Low Bleed Risk (Single
Response) [209954]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Post-Op/Phase II
High VTE with Low Bleed Risk [211018]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 8 HOURS, Post-
Op/Phase II
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
Post-Op/Phase II
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Post-Op/Phase II
VTE Prophylaxis (Single Response) [150176]
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
Post-Op/Phase II
Moderate VTE Risk with Low Bleed Risk (Single
Response) [209954]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Post-Op/Phase II
High VTE with Low Bleed Risk [211018]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Post-Op/Phase II
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Page 3 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 12/15/2017 12:29:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

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
Post-Op/Phase II
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Post-Op/Phase II
PACU Normoglycemia Management
Normoglycemia Management (Single Response) [217140]
Patients withOUT Diabetes and NOT on Insulin
Infusion [228192]
Glucose, POC [IPGLUCOSE] ONCE 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?
PACU
If Glucose POC 200 mg/dL or Greater Initiate
Perioperative Normoglycemia for Surgical
Patients Adult Delegation Protocol
[NURMON0167]
CONTINUOUS For 24 Hours, Routine, Use order set
Perioperative Normoglycemia for Surgical Patients
Delegation Protocol order set [6133] to place orders,
PACU
Patients WITH Diabetes and NOT on Insulin
Infusion [228194]
Glucose, POC [IPGLUCOSE] ONCE 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?
PACU
If Glucose POC is 180 mg/dL or Greater Initiate
Perioperative Normoglycemia for Surgical
Patients Adult Delegation Protocol
[NURMON0167]
ONCE For 1 Occurrences, Routine, Use order set
Perioperative Normoglycemia for Surgical Patients
Delegation Protocol order set [6133] to place orders,
PACU
Patient ON Insulin Infusion [217180]
insulin infusionSupplemental order set [1345] to order -Adult -Insulin Infusion -IP Use
Confirm Time and Value of Last Glucose POC
and Insulin Infusion Column [NURCOM0022]
ONCE, PACU
Hypoglycemia Management [216855]
URL:
Hypoglycemia Management (Adult) [191576]
Page 4 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 12/15/2017 12:29:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting today For Until specified,
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?
PACU
Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA
TREATMENT, Starting today For Until specified,
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?
Per hypoglycemia treatment algorithm Recheck
glucose 15 minutes after providing treatment until
glucose is greater than or equal to 70 mg/dL. If
patient has been critically low (i.e., glucose less than
40 mg/dL), recheck glucose after 1 hour to ensure
glucose remains greater than or equal to 70mg/dL.
After resolution of mild hypoglycemia (i.e., glucose
40-69 mg/dL), consider rechecking after 1 hour if
patient has signs/symptoms of hypoglycemia or is at
risk for a subsequent hypoglycemic event (e.g.,
previously administered insulin still active, altered
renal status, altered mental status, NPO or
interrupted nutrition, or any other condition that
increases hypoglycemia risk), PACU
Notify Provider [NURCOM0001] Provider to Notify: Provider
Notify based on: Blood Glucose,Other
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
Other: Nutritional status changes
PACU
Hypoglycemia Treatment for blood glucose less
than 40 mg/dL and patient able to eat/swallow
safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If blood glucose less
than 40mg/dL and patient able to eat/swallow safely.
Give 30 grams of carbohydrate (8 oz. of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater., PACU
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If glucose is 40-69
mg/dL and patient able to eat/swallow safely
Give 15 grams of carbohydrate (4 oz of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater., PACU
glucose-vitamin C chew tab [50690] 16 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose 40-
69 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
PACU
Page 5 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 12/15/2017 12:29:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

glucose-vitamin C chew tab [50690] 32 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose
less than 40 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
PACU
glucagon injection kit [107799] 1 mg, Subcutaneous, PRN, For blood glucose less
than 69 mg/dL and patient unable to eat/swallow
safely AND has NO IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
PACU
dextrose injection [800233] 12.5 g, Intravenous, PRN, For blood glucose 40-69
mg/dL and patient unable to eat/swallow safely AND
has IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
PACU
dextrose injection [800233] 25 g, Intravenous, PRN, For blood glucose less than
40 mg/dL and patient unable to eat/swallow safely
AND has IV access.
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
PACU
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
PACU
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting 12/23/17 For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
PACU
Post-OP Normoglycemia Management
Normoglycemia Management (Single Response) [216839]
Patients withOUT Diabetes and NOT on Insulin
Infusion [228199]
Glucose, POC [IPGLUCOSE] CONDITIONAL For 8 Hours, 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?
Check once on arrival if PACU Glucose POC is >/=
180 mg/dL
Recheck in 4 hours if initial floor Glucose POC is
180-199 mg/dL, Post-Op/Phase II
Page 6 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 12/15/2017 12:29:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Glucose Monitoring and Response
[NURCOM0022]
ONCE For 1 Occurrences, If Glucose POC obtained
on arrival is:
< 180 mg/dL - no further action needed.
180-199 mg/dL - recheck and contact provider to
order the following: if patient is NPO, provider to
order glucose POC every 6 hours; if eating glucose
POC before meals and at bedtime. Provider should
order an A1c if not performed in the last 90 days.
200 mg/dL or greater - initiate Perioperative
Normoglycemia Delegation Protocol, Post-Op/Phase
II
If Glucose POC is 200 mg/dL or Greater Initiate
Perioperative Normoglycemia for Surgical
Patients Adult Delegation Protocol
[NURMON0167]
CONTINUOUS For 24 Hours, Routine, Use order set
Perioperative Normoglycemia for Surgical Patients
Delegation Protocol order set [6133] to place orders,
Post-Op/Phase II
Patients WITH Diabetes and NOT on Insulin
Infusion [228200]
Glucose, POC [IPGLUCOSE] ONCE 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?
Post-Op/Phase II
Glucose Monitoring and Response
[NURCOM0022]
ONCE For 1 Occurrences, If Glucose POC obtained
on arrival is:
<180 mg/dL - contact provider to order the following:
if patient is NPO, provider to order glucose POC
every 6 hours; if eating glucose POC before meals
and at bedtime. Provider should order an A1c if not
performed in the last 90 days.
180 mg/dL or greater - initiate Perioperative
Normoglycemia Delegation Protocol, Post-Op/Phase
II
If Glucose POC 180 mg/dL or Greater Initiate
Perioperative Normoglycemia for Surgical
Patients Adult Delegation Protocol
[NURMON0167]
CONTINUOUS, Routine, Use order set Perioperative
Normoglycemia for Surgical Patients Delegation
Protocol order set [6133] to place orders, Post-
Op/Phase II
Patient ON Insulin Infusion [217180]
insulin infusionSupplemental order set [1345] to order -Adult -Insulin Infusion -IP Use
Confirm Time and Value of Last Glucose POC
and Insulin Infusion Column [NURCOM0022]
ONCE, Post-Op/Phase II
Hypoglycemia Management [217170]
Hypoglycemia Management (Adult) [191576]
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting today For Until specified,
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?
Post-Op/Phase II
Page 7 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 12/15/2017 12:29:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA
TREATMENT, Starting today For Until specified,
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?
Per hypoglycemia treatment algorithm Recheck
glucose 15 minutes after providing treatment until
glucose is greater than or equal to 70 mg/dL. If
patient has been critically low (i.e., glucose less than
40 mg/dL), recheck glucose after 1 hour to ensure
glucose remains greater than or equal to 70mg/dL.
After resolution of mild hypoglycemia (i.e., glucose
40-69 mg/dL), consider rechecking after 1 hour if
patient has signs/symptoms of hypoglycemia or is at
risk for a subsequent hypoglycemic event (e.g.,
previously administered insulin still active, altered
renal status, altered mental status, NPO or
interrupted nutrition, or any other condition that
increases hypoglycemia risk), Post-Op/Phase II
Notify Provider [NURCOM0001] Provider to Notify: Provider
Notify based on: Blood Glucose,Other
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
Other: Nutritional status changes
Post-Op/Phase II
Hypoglycemia Treatment for blood glucose less
than 40 mg/dL and patient able to eat/swallow
safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If blood glucose less
than 40mg/dL and patient able to eat/swallow safely.
Give 30 grams of carbohydrate (8 oz. of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater., Post-Op/Phase II
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If glucose is 40-69
mg/dL and patient able to eat/swallow safely
Give 15 grams of carbohydrate (4 oz of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater., Post-Op/Phase II
glucose-vitamin C chew tab [50690] 16 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose 40-
69 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
Post-Op/Phase II
glucose-vitamin C chew tab [50690] 32 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose
less than 40 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
Post-Op/Phase II
Page 8 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 12/15/2017 12:29:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

glucagon injection kit [107799] 1 mg, Subcutaneous, PRN, For blood glucose less
than 69 mg/dL and patient unable to eat/swallow
safely AND has NO IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
Post-Op/Phase II
dextrose injection [800233] 12.5 g, Intravenous, PRN, For blood glucose 40-69
mg/dL and patient unable to eat/swallow safely AND
has IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
Post-Op/Phase II
dextrose injection [800233] 25 g, Intravenous, PRN, For blood glucose less than
40 mg/dL and patient unable to eat/swallow safely
AND has IV access.
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
Post-Op/Phase II
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
Post-Op/Phase II
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting 12/23/17 For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
Post-Op/Phase II
Patient Care Orders
Vitals [237278]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 1 hour times 2, then every 2 hours times 2, then
every 4 hours, Post-Op/Phase II
Activity [237279]
Page 9 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 12/15/2017 12:29:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Bedrest first 24 hours. [NURACT0008] SEE COMMENTS, 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:
Bedrest for the first 24 hours postoperatively, then up
to chair as directed, Post-Op/Phase II
Up to Chair after 24 hours [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE: with assistance,other (comment)
CHAIR: other (comment)
DANGLE:
BEDREST:
RESTRICTIONS: Other (Comment)
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Bedrest for the first 24 hours and then up to chair.
Must sit on soft pillow or foam donut. OK to walk to
bathroom, but do not ambulate in halls until advised by
MD for increased activity., Post-Op/Phase II
Nutrition [237280]
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:
Post-Op/Phase II
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
Nourishments & Supplements [NUT0005] EFFECTIVE NOW, Starting today, Routine
Medical Food / Oral Supplement(s):
Nourishment / Snack Item(s):
Schedule: BREAKFAST, LUNCH, DINNER
Post-Op/Phase II
Respiratory [85693]
Respiratory Therapy per Protocol [RT0035] Routine
Protocol Type:
Post-Op/Phase II
Deep Breathe [NURTRT0019] EVERY 30 MINUTES, Starting today, Routine, While
awake., Post-Op/Phase II
Page 10 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 12/15/2017 12:29:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Incentive Spirometry [NURTRT0018] EVERY 30 MINUTES, Routine, While awake., Post-
Op/Phase II
Pulse Oximetry [NURMON0009] SEE COMMENTS, Starting today, Routine, Every 2
hours times 2, then every 4 hours times 6, then every
8 hours., Post-Op/Phase II
Pulse Oximetry - Continuous [NURMON0009] CONTINUOUS, Routine, Post-Op/Phase II
Oxygen Therapy [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 88
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Post-Op/Phase II
Wound/Procedure Site Care [237281]
Wound Care - Vaginoplasty [NURWND0015] CONTINUOUS, Routine
Wound Type: Other (Comment) (neovagina)
Wound Site: Other (Comment) (perineum)
Wound Location: Other (Comment) (perineum)
Assess Frequency: EVERY 4 HOURS
Care Frequency: 2X DAILY
Wash With:
Irrigate/Rinse With:
Apply (Must also enter separate medication order to
obtain drug):
Location:
Vaginal packing is sewn in place. Packing must stay
in place until post-op day 5, when MD will remove it.
DO NOT REMOVE vaginal packing for any reason.
Change gauze fluff on outside layer and mesh panties
twice daily and as needed with drainage. Notify MD if
drainage is greater than moderate/heavy menses or
problems with packing.
Patient May NOT Shower [NURCOM0022] SEE COMMENTS, Patient may NOT shower until MD
has removed vaginal packing. Patient should sponge
bathe until packing is removed (commonly on or after
post-op day five), Post-Op/Phase II
Patient hygiene education [NURCOM0022] SEE COMMENTS, After indwelling urinary catheter is
removed by MD order, please teach/review with
patient how to properly wipe front-to-back after voiding
and defecation.
Drains [237303]
Maintain Drain - Jackson-Pratt [NURTAD0003] CONTINUOUS, Routine
Type: Closed Suction (Jackson-Pratt)
Site: Perineum
Location: Perineum
Drainage Options: Bulb
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip: EVERY 4 HOURS
Strip For:
Dressing Change Frequency:
Dressing Type: Gauze
Post-Op/Phase II
Page 11 of 17
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Maintain Drain - Jackson-Pratt [NURTAD0003] CONTINUOUS, Routine
Type: Closed Suction (Jackson-Pratt)
Site: Perineum
Location: Perineum
Drainage Options: Bulb
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip: EVERY 4 HOURS
Strip For:
Dressing Change Frequency:
Dressing Type: Gauze
Post-Op/Phase II
Maintain Drain - Penrose [NURTAD0003] CONTINUOUS, Routine
Type: Soft Open Tube (Penrose)
Site: Perineum
Location: Perineum
Drainage Options: Dependent Drainage
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip: EVERY 4 HOURS
Strip For:
Dressing Change Frequency:
Dressing Type: Gauze
Post-Op/Phase II
Maintain Drain - Penrose [NURTAD0003] CONTINUOUS, Routine
Type: Soft Open Tube (Penrose)
Site: Perineum
Location: Perineum
Drainage Options: Dependent Drainage
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip: EVERY 4 HOURS
Strip For:
Dressing Change Frequency:
Dressing Type: Gauze
Post-Op/Phase II
Measure Drain Output [NURTAD0005] EVERY 8 HOURS, Routine, Post-Op/Phase II
Intake and Output [85695]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today, Routine, Post-
Op/Phase II
Non-Categorized Patient Care Orders [237343]
Page 12 of 17
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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: Indwelling Single Lumen
Indication for Placement: Postoperative Requirements
of Specific Procedure
Initiate Urinary Catheter Removal Protocol?
Details: To Dependent Drainage
Does this need to be inserted/placed?
DO NOT REMOVE INDWELLING CATHETER for any
reason. Notify MD for questions/concerns.
Contingency Parameters [237344]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 160
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.3
If temperature < (C):
If heart rate > (bpm): 110
If heart rate < (bpm): 50
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 88
If urine output < (mL): 250 mL / 8 hours
Other: mental status changes,MAP <
65,questions/concerns regarding vaginal
packing,,questions/concerns regarding indwelling
urinary catheter,Any acute changes
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.
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
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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 [214712]
dextrose 5%-NaCl 0.45% infusion [51613] at 125 mL/hr, Intravenous, CONTINUOUS, Post-
Op/Phase II
sodium chloride 0.45 % infusion [42187] at 125 mL/hr, Intravenous, CONTINUOUS, Post-
Op/Phase II
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L
infusion [44910]
at 125 mL/hr, Intravenous, CONTINUOUS, Post-
Op/Phase II
sodium chloride 0.9 % infusion [64367] at 125 mL/hr, Intravenous, CONTINUOUS, Post-
Op/Phase II
lactated ringers infusion [38890] at 100 mL/hr, Intravenous, CONTINUOUS
Reduce IV Rate to 20 mL/Hour When Patient
Tolerating Oral Intake [NURCOM0022]
ONCE For 1 Occurrences, Post-Op/Phase II
Note:Reduce IV Rate to 20 mL/Hour When
Patient Tolerating Oral Intake [950018]
4 X DAILY (NOTE ACKNOWLEDGE), Post-Op/Phase
II
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Post-Op/Phase II
Medications - Anti-infective (Prophylactic)
First Line (Single Response) [236766]
cefazolin (ANCEF) intraVENOUS - NOTE:
Patients who are 40-120 kg [800000]
2 g, Intravenous, EVERY 8 HOURS For 3 Doses,
Post-Op/Phase II
cefazolin (ANCEF) intraVENOUS - NOTE:
Patients who are 121 kg or greater [800000]
3 g, Intravenous, EVERY 8 HOURS For 3 Doses,
Post-Op/Phase II
Documented MRSA or history of MRSA or MRSE risk [236767]
vancomycin (VANCOCIN) intraVENOUS - NOTE:
Maximum Dose = 2000 mg [800084]
15 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses
Patients with IgE-mediated or severe reaction to beta-lactam [219787]
vancomycin (VANCOCIN) intraVENOUS (Max
dose 2000 mg) [800084]
15 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Medications - General
Analgesics - Acetaminophen - Scheduled (Single Response) [237235]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 6 HOURS For 24 Hours, Post-
Op/Phase II
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Oral, EVERY 6 HOURS For 24 Hours, Post-
Op/Phase II
acetaMINOPHEN (TYLENOL) suppository
[34153]
650 mg, Rectal, EVERY 6 HOURS For 24 Hours,
Post-Op/Phase II
Analgesics - Acetaminophen - PRN (Single Response) [237236]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN Starting H+24
Hours, pain/fever
Temperature greater than 39 degrees Celsius or See
Pain Management Algorithm for the Selection of As-
Needed Analgesics.
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
Post-Op/Phase II
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acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Oral, EVERY 4 HOURS PRN Starting H+24
Hours, pain/fever
Temperature greater than 39 degrees Celsius or See
Pain Management Algorithm for the Selection of As-
Needed Analgesics.
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
Post-Op/Phase II
acetaMINOPHEN (TYLENOL) suppository
[43994]
650 mg, Rectal, EVERY 4 HOURS PRN Starting H+24
Hours, pain/fever
Temperature greater than 39 degrees Celsius or See
Pain Management Algorithm for the Selection of As-
Needed Analgesics.
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
Post-Op/Phase II
Analgesics - NSAID - Scheduled [237237]
naproxen (NAPROSYN) tab [720103] 500 mg, Oral, 2 X DAILY (AT MEALTIME) Starting
12/17/17 For 7 Days, Post-Op/Phase II
ketOROLAC (TORADOL) injection - NOTE: Do
NOT order ketorolac if patient is 65 years or older,
50 kg or less, or serum creatinine 1.2 mg/dL or
more [800050]
15 mg, Intravenous, EVERY 6 HOURS For 48 Hours,
Post-Op/Phase II
Analgesics - NSAID - PRN [219803]
ibuprofen (MOTRIN) tab - Note: Ibuprofen should
not be ordered if ketOROLAC is ordered [38353]
800 mg, Oral, EVERY 8 HOURS PRN, pain, See Pain
Management Algorithm for the Selection of As-
Needed Analgesics, Post-Op/Phase II
Analgesics - Opioids - Oral - PRN (Single Response) [237241]
hydrocodone-acetaMINOPHEN (NORCO) 5-325
mg per tab RANGE [750021]
1-2 tab, Oral, EVERY 4 HOURS PRN Starting H+24
Hours, pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesics.
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
Post-Op/Phase II
Analgesics - Opioids - Intravenous - PRN (Single Response) [237243]
MORPHine PF injection [750057] Intravenous, EVERY 2 HOURS PRN Starting H+24
Hours, pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesics.
for 4 Minutes, Post-Op/Phase II
Anti-emetics [237245]
ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
4 mg, Oral, EVERY 12 HOURS PRN,
nausea/vomiting, First line therapy, Post-Op/Phase II
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 12 HOURS PRN,
nausea/vomiting, First Line Therapy when unable to
take orally., Post-Op/Phase II
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting, Second Line Therapy, Administer
when there is no response to first line antiemetics
within 30 minutes AND unable to take orally., Post-
Op/Phase II
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting, Second Line Therapy, Administer
when there is no response to first line antiemetics
within 30 minutes., Post-Op/Phase II
Hypnotics [182694]
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traZODONE (DESYREL) tab [720150] 25-50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions.
Post-Op/Phase II
Antipruritics [219804]
diphenhydramine (BENADRYL) cap [36791] 25-50 mg, Oral, EVERY 6 HOURS PRN, itching, Post-
Op/Phase II
diphenhydramine (BENADRYL) injection [800106] 25 mg, Intravenous, EVERY 6 HOURS PRN, itching
If unable to tolerate oral administration.
Post-Op/Phase II
Antacids [219807]
calcium carbonate (TUMS) chew tab [44477] 1,000 mg, Oral, EVERY 4 HOURS PRN, dyspepsia
First Line Therapy
Post-Op/Phase II
mag-al-simeth (MYLANTA ES) 400-400-40
MG/5ML susp [44073]
15 mL, Oral, EVERY 4 HOURS PRN, dyspepsia
If failure of first line therapy after four hour
Post-Op/Phase II
Bowel Management [237247]
Note: No Bowel Management Medications
Allowed [950018]
4 X DAILY (NOTE ACKNOWLEDGE)
Non-Categorized [237246]
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. Notify
physician if administered.
Post-Op/Phase II
nalbuphine (NUBAIN) injection [39994] 10 mg, Intravenous, EVERY 6 HOURS PRN, itching
Administer as first line agent for opioid related itching.
for 3 Minutes, Post-Op/Phase II
Note to pharmacy - Hold estrogen for 3 weeks
post operatively [950018]
ONCE For 1 Doses, Post-Op/Phase II
Laboratory
Draw Postoperatively Day #1 [237346]
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
CBC WITHOUT DIFFERENTIAL [HEMO] 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
Consults
Consults [85717]
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: DISCHARGE PLANNING
Can this consult be done via video?
Post-Op/Phase II
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult:
Post-Op/Phase II
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Routine
Reason for Occupational Therapy Consult:
Post-Op/Phase II
BestPractice
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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 17 of 17
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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