/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-98056-en.cckm

201708230

page

100

UWHC,UWMF,

Tools,

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

IP - Plastic Surgery - Pediatric - Postoperative [2949]

IP - Plastic Surgery - Pediatric - Postoperative [2949] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Plastics


IP - Plastic Surgery - Pediatric - Postoperative [2949]
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 [95528]
Page 1 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 8/15/2017 4:29:45 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@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 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
Patient Care Orders
Vital Signs [90938]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
every 1 hr x 2, every 2 hrs x 2, then every 4 hrs, Post-
Op/Phase II
Patient Monitoring [90939]
Page 2 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 8/15/2017 4:29:45 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Measure Visual Acuity [NURMON0059] EVERY 4 HOURS, Routine, Post-Op/Phase II
Neurovascular Checks [NURMON0045] EVERY 4 HOURS, Routine, Post-Op/Phase II
Monitor Microvascular Flap [NURMON0060] SEE COMMENTS, Starting today For Until specified,
Monitor microvascular flap every *** hours by
assessing arterial/venous doppler, color, turgor,
capillary refill and tempurature., Post-Op/Phase II
Assess Neurologic Status [NURMON0006] EVERY 4 HOURS, Starting today For Until specified,
Routine, Post-Op/Phase II
Measure Weight [NURMON0015] 1X DAILY, Routine
Weigh With?
Weigh when?
Post-Op/Phase II
Measure Caloric Intake [NURDIE0011] CONTINUOUS For 7 Days, Routine, Post-Op/Phase II
Pulse Oximetry [NURMON0009] ONCE, Starting today For 1 Occurrences, Routine,
Post-Op/Phase II
Pulse Oximetry [NURMON0009] EVERY 4 HOURS, Starting today For Until specified,
Routine, Post-Op/Phase II
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today For Until specified,
Routine, Post-Op/Phase II
Activity [90940]
Ad Lib [NURACT0008] CONTINUOUS, Starting today For Until specified,
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:
Post-Op/Phase II
Ambulate [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB:
AMBULATE: other (comment)
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Post-Op/Phase II
Page 3 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 8/15/2017 4:29:45 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Chair [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB:
AMBULATE:
CHAIR: other (comment)
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Post-Op/Phase II
Bedrest [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: other (comment)
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Post-Op/Phase II
Elevate Head Of Bed [NURACT0002] Equal to (degrees):
Greater than (degrees): 30
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting today For Until
specified, Post-Op/Phase II
Nutrition [90941]
Strict NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: NPO
NPO Diet: Strict NPO
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
NPO except Medications [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: NPO
NPO Diet: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
Clear Liquid Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
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
Page 4 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 8/15/2017 4:29:45 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Full Liquid Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: Diet Modifications
Diet Modifications: Liquid
Liquid: Full Liquid
No Red or Purple Dye:
Liquid Thickness:
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
Pureed Diet for Wired Jaw [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: Diet Modifications
Diet Modifications: Consistency
Solid Consistency: Pureed
Liquid Thickness:
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
Mechanical Soft / Surgical Soft Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: Diet Modifications
Diet Modifications: Consistency
Solid Consistency: Mechanical Soft
Liquid Thickness:
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
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: ALL MEAL AND NOURISHMENT TIMES
available with all meals and snacks, Post-Op/Phase II
Surgical Site Care [90943]
Wound Care [NURWND0015] CONTINUOUS, Starting today For Until specified,
Routine
Wound Type:
Wound Site:
Wound Location:
Assess Frequency:
Care Frequency:
Wash With:
Irrigate/Rinse With:
Apply (Must also enter separate medication order to
obtain drug):
Primary Dressing:
Secondary Dressing:
Post-Op/Phase II
Page 5 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 8/15/2017 4:29:45 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Wound Care - Maxillofacial [NURWND0015] CONTINUOUS, Routine
Wound Type: Closed - Incision
Wound Site: Head/Neck
Wound Location: Anterior
Assess Frequency: EVERY 8 HOURS
Care Frequency: EVERY 8 HOURS
Wash With: Soap and Water
Irrigate/Rinse With: sodium chloride 0.9%
Apply (Must also enter separate medication order to
obtain drug): bacitracin ointment
Primary Dressing:
Secondary Dressing:
Change nasal drip pad PRN and ***. Apply ice pack
to affected area for 20 minutes every hour while
awake. Rinse mouth with warm water or chlorhexidine
oral rinse 4x day and at bedtime and after
meals/snacks., Post-Op/Phase II
Wound Care - Skin Graft [NURWND0015] CONTINUOUS, Routine
Wound Type: Skin Graft
Wound Site:
Wound Location:
Assess Frequency: EVERY 8 HOURS
Care Frequency:
Wash With:
Irrigate/Rinse With:
Apply (Must also enter separate medication order to
obtain drug):
Primary Dressing:
Secondary Dressing:
Post-Op/Phase II
Wound Care - Skin Graft Donor Site
[NURWND0015]
CONTINUOUS, Routine
Wound Type: Donor Site
Wound Site: Leg
Wound Location:
Assess Frequency: EVERY 8 HOURS
Care Frequency: 1X DAILY
Blow dry on cool setting for 15 minutes, 4 times a
day?
Wash With:
Irrigate/Rinse With:
Apply (Must also enter separate medication order to
obtain drug):
Primary Dressing:
Secondary Dressing:
Maintain current dressing. OK to reinforce PRN.,
Post-Op/Phase II
Yankauer suction at bedside at all times
[NURTAD0017]
PRN, Routine
Location:
Post-Op/Phase II
Wire cutter or scissors at bedside at all times
[NURCOM0052]
ONCE, Routine
Order Name (Only necessary if something other than
"Nursing Communcation" is preferred.):
Post-Op/Phase II
Tubes and Drains [226881]
Page 6 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 8/15/2017 4:29:45 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Maintain Drain [NURTAD0003] CONTINUOUS, Routine
Type:
Site:
Location:
Drainage Options:
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For:
Dressing Change Frequency:
Dressing Type:
Post-Op/Phase II
Measure Drain Output [NURTAD0005] EVERY 4 HOURS, Routine, Post-Op/Phase II
Intake and Output [90944]
Measure Intake And Output [NURMON0005] EVERY 4 HOURS, Starting today For Until specified,
Routine, Post-Op/Phase II
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today For Until specified,
Routine, Post-Op/Phase II
Contingency Parameters for Patients Less than 6 Months Old [224429]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 100
If systolic blood pressure < (mmHg): 65
If diastolic blood pressure > (mmHg): 65
If diastolic blood pressure < (mmHg): 45
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 180
If heart rate < (bpm): 90
If respiratory rate >: 50
If respiratory rate <: 25
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 95
If urine output < (mL):
Other: Pain not controlled with ordered analgesics.
Nausea / vomiting not controlled by medications.
Vision changes. Frank blood from mouth or nose.
Post-Op/Phase II
Contingency Parameters for Patients 7 Months through 2 Years Old [224430]
Page 7 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 8/15/2017 4:29:45 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 118
If systolic blood pressure < (mmHg): 85
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 160
If heart rate < (bpm): 80
If respiratory rate >: 40
If respiratory rate <: 20
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other: Pain not controlled with ordered analgesics.
Nausea / vomiting not controlled by medications.
Vision changes. Frank blood from mouth or nose.
Post-Op/Phase II
Contingency Parameters for Patients 3 through 6 Years Old [224431]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 118
If systolic blood pressure < (mmHg): 87
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 140
If heart rate < (bpm): 75
If respiratory rate >: 30
If respiratory rate <: 18
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other: Pain not controlled with ordered analgesics.
Nausea / vomiting not controlled by medications.
Vision changes. Frank blood from mouth or nose.
Post-Op/Phase II
Contingency Parameters for Patients 7 through 10 Years Old [224432]
Page 8 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 8/15/2017 4:29:45 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 125
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 70
If respiratory rate >: 24
If respiratory rate <: 14
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other: Pain not controlled with ordered analgesics.
Nausea / vomiting not controlled by medications.
Vision changes. Frank blood from mouth or nose.
Post-Op/Phase II
Contingency Parameters for Patients 11 Years and Older [224433]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 140
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 110
If heart rate < (bpm): 60
If respiratory rate >: 22
If respiratory rate <: 12
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other: Pain not controlled with ordered analgesics.
Nausea / vomiting not controlled by medications.
Vision changes. Frank blood from mouth or nose.
Post-Op/Phase II
Intravenous Therapy
IV Fluids [90947]
Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today For Until specified,
Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
May cap peripheral IV with adequate oral intake per
nursing judgement, Post-Op/Phase II
dextrose 5%-NaCl 0.2% infusion [51615] Intravenous, CONTINUOUS, Post-Op/Phase II
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS, Post-Op/Phase II
Premedication for Needle Insertion [84317]
Lidocaine [152737]
Page 9 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 8/15/2017 4:29:45 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, prior to needle sticks
to reduce pain. See "LMX Use Instructions" order in
Active Orders report or the Admin Instructions for
application details
FOR PATIENTS 5 Kg OR LESS: Do NOT apply to
area greater than 100 square centimeters.
(maximum 1 g/site; maximum 1 site per hour, 6
times per day).
FOR PATIENTS 5.1-10 Kg: Do NOT apply to area
greater than 100 square centimeters. (maximum 1
g/site; maximum 2 sites per hour, 6 times per day).
FOR PATIENTS GREATER THAN 10 Kg: Do NOT
apply to area greater than 200 square centimeters.
(maximum 2.5 g/site; maximum 4 sites per hour, 6
times per day).
For patients less than 1 year old do NOT leave on
longer than 1 hour. For patients 1 year or older do
NOT leave on longer than 2 hours
Post-Op/Phase II
LMX Use Instructions for Premedication Prior to
Needle Insertion [NURCOM0095]
Post-Op/Phase II
Anti-infectives
First Line - NON maxillofacial patients (Single Response) [223831]
cephalexin (KEFLEX) 250 MG/5ML susp - NOTE:
recommended dose = 25 to 50 mg/kg/day (max
500 mg/dose) divided every 8 hours [44596]
Oral, EVERY 8 HOURS
NOTE: recommended dose = 25 to 50 mg/kg/day
(max 500 mg/dose) divided every 8 hours
Post-Op/Phase II
cefazolin (ANCEF) intraVENOUS [800000] 16.7 mg/kg, Intravenous, EVERY 8 HOURS, Post-
Op/Phase II
First Line - maxillofacial patients (Single Response) [223833]
amoxicillin-clavulanate (AUGMENTIN) 400-57
MG/5ML susp- NOTE: For Infants ?3 months,
Children, and Adolescents <40 kg [70055]
12.5 mg/kg, Oral, 2 X DAILY (AT MEALTIME), Post-
Op/Phase II
amoxicillin-clavulanate (AUGMENTIN) 875-125
MG per tab - NOTE: For Children and
Adolescents ?40 kg [70053]
1 tab, Oral, 2 X DAILY (AT MEALTIME), Post-
Op/Phase II
ampicillin/sulbactam (UNASYN) intraVENOUS
[800010]
75 mg/kg, Intravenous, EVERY 6 HOURS
Non-maxillofacial patients with IgE-mediated or severe reaction to beta-lactam (Single Response)
[223835]
vancomycin (VANCOCIN) intraVENOUS [800084] 15 mg/kg, Intravenous, EVERY 8 HOURS, Post-
Op/Phase II
Maxillofacial patients with IgE-mediated or severe reaction to beta-lactam (Single Response) [223836]
clindamycin (CLEOCIN) intraVENOUS [800033] 10 mg/kg, Intravenous, EVERY 8 HOURS, Post-
Op/Phase II
clindamycin (CLEOCIN) 75 MG/5ML soln [74681] 10 mg/kg, Oral, 3 X DAILY, Post-Op/Phase II
Medications - General
Analgesics - Acetaminophen - Scheduled (Single Response) [131815]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 15 mg/kg
(Maximum 650 mg/dose) [800005]
15 mg/kg, Oral, EVERY 6 HOURS For 72 Hours,
Post-Op/Phase II
acetaMINOPHEN (TYLENOL) tab [34149] Oral, EVERY 6 HOURS For 72 Hours, Post-Op/Phase
II
Page 10 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 8/15/2017 4:29:45 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

acetaMINOPHEN (TYLENOL) suppository -
NOTE: Suggested dose 20 mg/kg. Must order in
whole suppository size (maximum 650 mg/dose)
[43994]
Rectal
Use if unable to tolerate oral medications
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 (Single Response) [187906]
ketOROLAC (TORADOL) injection - NOTE:
Suggested dose 0.5 mg/kg (Maximum 15
mg/dose) [800050]
0.5 mg/kg, Intravenous, EVERY 6 HOURS For 72
Hours, Post-Op/Phase II
ibuprofen (MOTRIN) susp - NOTE: Suggested
dose 10 mg/kg (Maximum 600 mg/dose) [45376]
10 mg/kg, Oral, EVERY 6 HOURS For 72 Hours,
Post-Op/Phase II
Analgesics - Acetaminophen - PRN (Starting in 72 hours) (Single Response) [187907]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 15 mg/kg
(Maximum 650 mg/dose) [800005]
15 mg/kg, Oral, EVERY 4 HOURS PRN Starting
8/18/17, pain, Mild pain or multimodal therapy., Post-
Op/Phase II
acetaMINOPHEN (TYLENOL) tab - NOTE:
Suggested dose 15 mg/kg (maximum 650
mg/dose) [34149]
Oral, EVERY 4 HOURS PRN Starting 8/18/17, pain,
Mild pain or multimodal therapy, Post-Op/Phase II
acetaMINOPHEN (TYLENOL) suppository -
NOTE: Suggested dose 20 mg/kg. Must order in
whole suppository size (Maximum 650 mg/dose)
[43994]
Rectal, EVERY 6 HOURS PRN Starting 8/18/17, pain,
Mild pain or multimodal therapy
Use if unable to tolerate oral medications
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 - PRN (Starting in 72 hours) [187870]
ibuprofen (MOTRIN) susp - NOTE: Suggested
dose 10 mg/kg (Maximum 600 mg/dose) [45376]
10 mg/kg, Oral, EVERY 6 HOURS PRN Starting
8/18/17, pain, Mild to Moderate Pain or Multimodal
therapy, Post-Op/Phase II
Analgesics - Opioids (Oral) - PRN (Single Response) [187909]
oxycodone 5 MG/5ML soln RANGE – (Maximum
20 mg/dose) [750031]
0.1-0.2 mg/kg, Oral, EVERY 4 HOURS PRN, pain,
Moderate/Severe Pain, Post-Op/Phase II
oxycodone tab RANGE – NOTE: Suggested dose
0.1-0.2 mg/kg (Maximum 20mg/dose) [750032]
Oral, EVERY 4 HOURS PRN, pain, Moderate/Severe
Pain, Post-Op/Phase II
Analgesics - Opioids (Intravenous) - PRN (Single Response) [187910]
morphine PF injection – NOTE: suggested dose
0.05 – 0.1 mg/kg (Maximum 2 mg/dose) [800122]
0.05-0.1 mg/kg, Intravenous, EVERY 2 HOURS PRN,
pain, Moderate/Severe Pain and unable to take oral
opioid
Use if unable to tolerate oral medications
Post-Op/Phase II
HYDROmorphone PF (DILAUDID) injection -
NOTE: suggested dose 0.01-0.02 mg/kg
(Maximum 0.4 mg/dose) [800120]
0.01-0.02 mg/kg, Intravenous, EVERY 2 HOURS
PRN, pain, Moderate/Severe Pain and unable to take
oral opioid
Use if unable to tolerate oral medications
Post-Op/Phase II
Bowel Management - First Line [223849]
polyethylene glycol (MIRALAX) oral packet
[61829]
Oral
Dissolve in *** ounces of liquid. Hold for loose stools
Post-Op/Phase II
Bowel Management - Second Line [223850]
senna-docusate (SENOKOT-S) 8.6-50 mg per tab
[60530]
Oral, Post-Op/Phase II
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal
Administer if oral agents fail
Post-Op/Phase II
sennosides (SENNA) 8.8 MG/5ML syrup [50880] Oral, Post-Op/Phase II
Bowel Management - Third Line [223851]
Page 11 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 8/15/2017 4:29:45 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

glycerin (PEDIATRIC) rectal suppository [153728] 1 suppository, Rectal, 1 X DAILY PRN, constipation
Administer if first line agent fails.
Post-Op/Phase II
phosphate (FLEET PEDIATRIC) enema - NOTE:
Order for children 2-11 years [37522]
1 enema, Rectal, 1 X DAILY PRN, constipation
Administer if first line agent fails
Post-Op/Phase II
phosphate (FLEET) enema - NOTE: Order for
children 12 years or older [37517]
1 enema, Rectal, 1 X DAILY PRN, constipation
Administer if first line agent fails
Post-Op/Phase II
magnesium hydroxide (MILK OF MAGNESIA)
susp - NOTE: Suggested dose 0.5 mL/kg
(Maximum dose 30 mL) [65443]
0.5 mL/kg, Oral, 1 X DAILY PRN, constipation, Post-
Op/Phase II
Bowel Management - As Needed - Second Line [145776]
glycerin (PEDIATRIC) rectal suppository [153728] 1 suppository, Rectal, 1 X DAILY PRN, constipation
Administer if first line agent fails.
phosphate (FLEET PEDIATRIC) enema - NOTE:
Order for children 2-11 years [37522]
1 enema, Rectal, 1 X DAILY PRN, constipation
Administer if first line agent fails
phosphate (FLEET) enema - NOTE: Order for
children 12 years or older [37517]
1 enema, Rectal, 1 X DAILY PRN, constipation
Administer if first line agent fails
magnesium hydroxide (MILK OF MAGNESIA)
susp - NOTE: Suggested dose 0.5 mL/kg
(Maximum dose 30 mL) [65443]
0.5 mL/kg, Oral, 1 X DAILY PRN, constipation
Anti-Emetics [223852]
ondansetron (ZOFRAN) injection - NOTE:
Suggested dose 0.1 mg/kg (Maximum 4 mg/dose)
[800202]
0.1 mg/kg, Intravenous, EVERY 12 HOURS PRN,
nausea/vomiting
if unable to tolerate oral medications
NOTE: Suggested dose 0.1 mg/kg (Maximum 4
mg/dose)
Post-Op/Phase II
ondansetron (ZOFRAN) soln [54843] Oral, Post-Op/Phase II
Sucrose for Oral Analgesia [110668]
sucrose (SWEET-EASE) 24% buccal soln
[794009]
Oral, PRN, pain, mild pain or potentially painful
procedures. See Admin Instructions, Post-Op/Phase II
Non-Categorized [222597]
bacitracin ointment [49271] Topical, 2 X DAILY
apply to surgical site in thin layer
Post-Op/Phase II
sodium chloride (SALINE) 0.65 % nasal spray
[41865]
2 spray, Nostril (Each), EVERY 4 HOURS WHILE
AWAKE, Post-Op/Phase II
sodium chloride (SALINE) 0.65 % nasal spray
[41865]
Nostril (Each), PRN, Post-Op/Phase II
multivitamin w/iron (POLYVITAMIN/IRON) soln -
NOTE: for maxillofacial patients with
compromised oral intake [41159]
Oral
multivitamin chew tab PEDS - NOTE: for
maxillofacial patients with compromised oral
intake [800238]
Oral
diphenhydramine (BENADRYL) injection RANGE
PEDS [750064]
Intravenous, for 15 Minutes
diphenhydramine (BENADRYL) cap RANGE
[750014]
Oral
diphenhydramine (BENADRYL) elixir RANGE
[750015]
Oral
Consults
Consults [90955]
Page 12 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 8/15/2017 4:29:45 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Consult Pediatrics - General (Inpatient)
[CON0104]
ONCE
Purpose of Consult: EVALUATE AND TREAT
PATIENT
Consulting Provider:
Reason for Consult:
Post-Op/Phase II
Consult Nutrition (Inpatient) [CON0043] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Delegate to Initiate and Manage Tube Feeding:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
Can this consult be done via video?
Post-Op/Phase II
Consult Swallow Therapy (Inpatient) [CON0079] ONCE, Routine
Reason for Consult: Evaluate and Treat Patient
May the Speech Pathologist and Registered Dietician
place diet orders on your behalf?
Is this a potential new stroke patient?
Post-Op/Phase II
Consult Child Life Specialist (Inpatient)
[CON0014]
ONCE For 1 Occurrences, Routine
Activity Level:
Reason for Consult:
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 13 of 13
Printed by WILLIAMS, HEATHER R [HRS0] at 8/15/2017 4:29:45 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org