/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-98064-en.cckm

20170389

page

100

UWHC,UWMF,

Tools,

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

IP - Plastic Surgery - General - Adult - Admission [2741]

IP - Plastic Surgery - General - Adult - Admission [2741] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Plastics


IP - Plastic Surgery - General - Adult - Admission [2741]
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 (Single Response) [82665]
Page 1 of 9
Printed by STRAKA, KEVIN F [KFS1] at 3/29/2017 2:18:08 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@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:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status [95528]
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
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [211046]
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
Moderate VTE Risk with Low Bleed Risk (Single
Response) [209954]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS
High VTE with Low Bleed Risk [211018]
Page 2 of 9
Printed by STRAKA, KEVIN F [KFS1] at 3/29/2017 2:18:08 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 HOURS
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
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
VTE Prophylaxis (Single Response) [211047]
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
Moderate VTE Risk with Low Bleed Risk (Single
Response) [209954]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS
High VTE with Low Bleed Risk [211018]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS
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
No VTE Prophylaxis [130084]
Page 3 of 9
Printed by STRAKA, KEVIN F [KFS1] at 3/29/2017 2:18:08 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Patient Care Orders
Vital Signs [85806]
Vital Signs [NURMON0013] EVERY 8 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 2 hours times 4, then every 4 hours.
Drains [162258]
Maintain Drain [NURTAD0003] CONTINUOUS, Routine
Type: Closed Suction (Jackson-Pratt)
Site:
Location:
Drainage Options: Bulb
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip: EVERY 4 HOURS
Strip For:
Dressing Change Frequency: DAILY
Dressing Type: Gauze
Maintain Drain [NURTAD0003] CONTINUOUS, Routine
Type: Closed Suction (Jackson-Pratt)
Site:
Location:
Drainage Options: Bulb
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip: EVERY 4 HOURS
Strip For:
Dressing Change Frequency: DAILY
Dressing Type: Gauze
Measure Drain Output [NURTAD0005] EVERY 8 HOURS, Routine
Measure Drain Output [NURTAD0005] EVERY 8 HOURS, Routine
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Routine
Activity [85807]
Page 4 of 9
Printed by STRAKA, KEVIN F [KFS1] at 3/29/2017 2:18:08 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

Bedrest [NURACT0008] CONTINUOUS, Starting today, 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:
Ambulate with Assistance [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE: with assistance
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Ambulate Ad Lib [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE: ad lib
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Nutrition [85808]
NPO Except Medications [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
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:
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Wound/Procedure Site Care [219636]
Page 5 of 9
Printed by STRAKA, KEVIN F [KFS1] at 3/29/2017 2:18:08 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

Wound Care [NURWND0015] CONTINUOUS, 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:
Contingency Parameters [85810]
Notify Provider [NURCOM0001] CONTINUOUS
Provider to Notify: Provider
If systolic blood pressure > (mmHg): 160
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): 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: Hemoglobin less than 8 g/dL,Unable to void
Intravenous Therapy
Premedications for Needle Insertion [106310]
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 within 1 minute. Choice of medication should be based on patient’s previous
experience/preference, history of lidocaine allergy and ease of access.
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
lidocaine (XYLOCAINE) 1% injection [39034] 0.1-0.4 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. Choice of medication should be based on
patient’s previous experience/preference, history of
lidocaine allergy and ease of access
Page 6 of 9
Printed by STRAKA, KEVIN F [KFS1] at 3/29/2017 2:18:08 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

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. Choice of medication should be based on
patient’s previous experience/preference, history of
lidocaine allergy and ease of access
Intravenous Therapy [219364]
Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today For Until specified,
Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Discontinue intravenous fluids and cap peripheral line
when tolerating oral intake.
Reduce IV Fluid to 20 mL/Hour When Tolerating
Oral Intake [NURCOM0022]
ONCE For 1 Occurrences
dextrose 5%-NaCl 0.45% infusion [51613] at 125 mL/hr, Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L
infusion [44910]
at 125 mL/hr, Intravenous, CONTINUOUS
sodium chloride 0.45 % infusion [42187] at 125 mL/hr, Intravenous, CONTINUOUS
sodium chloride 0.9 % infusion [64367] at 125 mL/hr, Intravenous, CONTINUOUS
Medications - General
Analgesics - Acetaminophen - Scheduled (Single Response) [219303]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 6 HOURS
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Oral, EVERY 6 HOURS
acetaMINOPHEN (TYLENOL) suppository
[43994]
650 mg, Rectal, EVERY 6 HOURS
Analgesics - Acetaminophen - As Needed (Single Response) [219304]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain, Mild to
moderate pain or temperature greater than 39
degrees Celsius or multimodal therapy.
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Oral, EVERY 4 HOURS PRN, pain/fever,
Mild to moderate pain or temperature greater than 39
degrees Celsius or multimodal therapy.
acetaMINOPHEN (TYLENOL) suppository
[43994]
650 mg, Rectal, EVERY 4 HOURS PRN, pain/fever,
Mild to moderate pain or temperature greater than 39
degrees Celsius or multimodal therapy.
Analgesics - NSAIDS - Scheduled (Single Response) [219305]
ibuprofen (MOTRIN) tab [38353] 800 mg, Oral, EVERY 8 HOURS
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
Analgesics - NSAIDS - PRN [219306]
ibuprofen (MOTRIN) tab [38353] 800 mg, Oral, EVERY 8 HOURS PRN, pain, Mild to
moderate pain or multimodal therapy
Analgesics - Oral Opioids - PRN (Single Response) [219307]
oxycodone tab [45976] 5-15 mg, Oral, EVERY 3 HOURS PRN, pain, Severe
Pain
hydrocodone-acetaMINOPHEN (NORCO) 5-325
mg per tab RANGE [750021]
1-2 tab, Oral, EVERY 4 HOURS PRN, pain, Severe
Pain
Page 7 of 9
Printed by STRAKA, KEVIN F [KFS1] at 3/29/2017 2:18:08 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

Analgesics - Opioids - Intravenous - PRN (Single Response) [219308]
MORPHine PF injection [750057] Intravenous, EVERY 2 HOURS PRN, pain, Severe
pain when unable to take orally
Do NOT administer both oral and IV opioids.
for 4 Minutes
HYDROmorphone PF (DILAUDID) injection
[750050]
0.2-0.5 mg, Intravenous, EVERY 2 HOURS PRN,
pain, Severe pain when unable to take orally OR for
procedural pain, for 3 Minutes
Spasmolytic [219310]
diazepam (VALIUM) tab [36679] 5 mg, Oral, EVERY 8 HOURS PRN, muscle spasms
Anti-emetics [219311]
ondansetron (ZOFRAN ODT) dispersible tab
[64224]
4 mg, Oral, EVERY 12 HOURS PRN,
nausea/vomiting, First line therapy
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 12 HOURS PRN,
nausea/vomiting, First Line Therapy when unable to
take orally.
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.
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.
Bowel Management - Scheduled [219340]
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
Bowel Management - First Line [219356]
polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 1 X DAILY PRN, constipation,
Constipation if NOT on scheduled MiraLAX
Dissolve in 8 ounces water
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal, 1 X DAILY PRN, constipation,
Administer if there is no response to scheduled
laxatives within 24 hours, or when there is need for
immediate laxation.
Hypnotics [219357]
traZODONE (DESYREL) tab [720150] 25 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see IPOC supplemental Sleep/Rest
Disturbance Adult)
Antipruritics [219358]
diphenhydramine (BENADRYL) cap [36791] 25-50 mg, Oral, EVERY 6 HOURS PRN, itching
diphenhydramine (BENADRYL) injection
[800106]
25 mg, Intravenous, EVERY 6 HOURS PRN, itching
If unable to tolerate oral administration.
Antacids [219359]
calcium carbonate (TUMS) chew tab [44477] 1,000 mg, Oral, EVERY 4 HOURS PRN, dyspepsia
First Line Therapy
mag-al-simeth (MYLANTA ES) 400-400-40
MG/5ML susp [44073]
15 mL, Oral, EVERY 4 HOURS PRN, dyspepsia
If no response to First Line Therapy in 60 minutes
Non-categorized [219360]
bacitracin ointment [49271] Topical, 2 X DAILY PRN, surgical site care
Apply to ***
BestPractice
Page 8 of 9
Printed by STRAKA, KEVIN F [KFS1] at 3/29/2017 2:18:08 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org

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 9 of 9
Printed by STRAKA, KEVIN F [KFS1] at 3/29/2017 2:18:08 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org