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IP - PERCUTANEUOUS MITRAL VALVE REPAIR - ADULT - PREPROCEDURE [6226]

IP - PERCUTANEUOUS MITRAL VALVE REPAIR - ADULT - PREPROCEDURE [6226] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Radiology


SmartSet: IP - PERCUTANEUOUS MITRAL VALVE REPAIR - ADULT -
PREPROCEDURE (ID:6226)
General Information
Display name: IP - PERCUTANEUOUS MITRAL VALVE REPAIR - ADULT - PREPROCEDURE
Type: General
Merge priority: 0
Version comment:
Content source:
Synonyms: 1. CARDIOLOGY
2. .CARDIOLOGY
SmartSet notes:
Description: Intended for Adult Patients Only
Web information: Title URL
1.
Questionnaire:
Configuration
Admission Status
Level of Care
Place Patient on General Care 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) 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) 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)
Page 1 of 10
Printed by STRAKA, KEVIN F [KFS1] at 12/9/2016 2:38:16 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Admit To Inpatient 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)
Admit To Observation Attending:
Admitting Resident:
Requested Floor:
Service:
Admit to Outpatient Short Stay (Single
Response)
Admit To Outpatient Short Stay Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status
Admit To Inpatient Attending:
Admitting Resident:
Requested Floor: F4M5
Service: CARDIOVASCULAR CATH PROCEDURE
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:
Admission Status
Admit To Inpatient Status Attending:
Admitting Resident:
Requested Floor: F4M5
Service: CARDIOVASCULAR CATH PROCEDURE
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:
Page 2 of 10
Printed by STRAKA, KEVIN F [KFS1] at 12/9/2016 2:38:16 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Admit To Observation Status Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay Attending:
Admitting Resident:
Requested Floor:
Service:
Isolation Status
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis
High Bleed Risk with Any VTE Risk
Sequential Compression Device (SCD)
(TREATMENT)
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY)
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis
VTE Prophylaxis - Reason Not Ordered ONCE, Routine
Reason Not Ordered:
VTE Prophylaxis
High Bleed Risk with Any VTE Risk
Sequential Compression Device (SCD)
(TREATMENT)
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY)
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis
VTE Prophylaxis - Reason Not Ordered ONCE, Routine
Reason Not Ordered:
Patient Care Orders
Vital Signs
Page 3 of 10
Printed by STRAKA, KEVIN F [KFS1] at 12/9/2016 2:38:16 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Vital Signs EVERY 8 HOURS, Starting S, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Patient Monitoring
Glucose, POC AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting S, 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?
Glucose, POC EVERY 6 HRS IF NPO/ CONT. TUBE FEEDING/ OR
TPN, Starting S, 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?
ACTIVATED CLOTTING TIME, POC ONCE, Routine
If Conditional, What Condition?
Cardiac Rhythm Monitoring - Adult CONTINUOUS, Starting S, Routine
Notify Provider: Symptomatic Change in Rhythm
Functional Cardiac Defibrillator Present:
Discontinue telemetry on-call to OR
Activity
Activity CONTINUOUS, Starting S, 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:
Nutrition
NPO - Except Medications EFFECTIVE NOW, Starting S, Routine
Patient Type: Adult
Diet Type: NPO
NPO: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
Respiratory
Oxygen Therapy CONTINUOUS, Starting S, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 92
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Pulse Oximetry ONCE For 1 Occurrences, Routine
Page 4 of 10
Printed by STRAKA, KEVIN F [KFS1] at 12/9/2016 2:38:16 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Intake and Output
Measure Intake And Output EVERY 8 HOURS, Starting S, Routine
Non-Categorized
Measure Height ONCE, Starting S For 1 Occurrences, Routine, On
admission
Measure Weight ONCE For 1 Occurrences, Routine
Weigh With?
Weigh when?
On admission
Insert and Maintain Urinary Catheter 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:
Indication for Placement: Monitor Volume in ICU
Patient and Unable to Use Alternative Methods
Initiate Urinary Catheter Removal Protocol? (NP/PA
Must Select "No"):
Details: To Dependent Drainage
Does this need to be inserted/placed?
Please use Coude catheter for patient over age 50.
Urinary Catheter Removal Protocol does NOT apply
to Urology, Gynecology, spinal cord injured patients,
patients with catheters placed by Urology on prior
admission, or to patients with chronic Foley catheters.
Not appropriate for Pediatric patients.
Contingency Parameters
Notify Provider 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): 39
If temperature < (C):
If heart rate > (bpm): 110
If heart rate < (bpm): 50
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
If pain score >:
Pulse Oximetry < (%): 92%
If urine output < (mL): 30
Other: Patient is having chest pain
Intravenous Therapy
Premedications for Needle Insertion
Page 5 of 10
Printed by STRAKA, KEVIN F [KFS1] at 12/9/2016 2:38:16 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

lidocaine (LMX) 4% topical dressing kit 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 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
sodium chloride (bacteriostatic) 0.9 % injection 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
IV Fluids
sodium chloride 0.9% infusion Intravenous, CONTINUOUS
sodium chloride 0.45% infusion Intravenous, CONTINUOUS
Insert and Maintain Peripheral IV - Second Line CONTINUOUS, Starting S For Until specified,
Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Insert and Maintain Peripheral IV CONTINUOUS, Starting S For Until specified,
Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Second Line
Medications - General
Medications
aspirin chew tab 325 mg, Oral, 1 X DAILY
clopidogrel (PLAVIX) tab 75 mg, Oral, ONCE Starting S For 1 Doses
clopidogrel (PLAVIX) tab 75 mg, Oral, 1 X DAILY Starting S
clopidogrel (PLAVIX) tab 300 mg, Oral, ONCE Starting S For 1 Doses
acetaMINOPHEN (TYLENOL) tab 650 mg, Oral, EVERY 4 HOURS PRN, pain, Pain or
temperature greater than 39 degrees Celsius
atropine injection 0.5 mg, Intravenous, PRN Starting S, bradycardia,
Heart rate less than 50 beats/min and systolic blood
pressure less than 90mmHg
Over 1 minute
Page 6 of 10
Printed by STRAKA, KEVIN F [KFS1] at 12/9/2016 2:38:16 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Medications - Preprocedure
Preprocedure
prednisone (DELTASONE) tab 50 mg, Oral, ON CALL For 1 Doses
hydrocortisone sod suc in sodium chloride 0.9%
injection
100 mg, Intravenous, ON CALL For 1 Doses
Give 1 hour prior to OR
diphenhydramine (BENADRYL) cap 25 mg, Oral, ON CALL For 1 Doses
Give 1 hour prior to OR
diphenhydramine (BENADRYL) injection 25 mg, Intravenous, ON CALL For 1 Doses
Give 1 hour prior to OR
diphenhydramine (BENADRYL) cap 50 mg, Oral, ON CALL For 1 Doses
Give 1 hour prior to OR.
diphenhydramine (BENADRYL) injection 50 mg, Intravenous, ON CALL For 1 Doses
Give 1 hour prior to OR.
ranitidine (ZANTAC) tab 150 mg, Oral, ON CALL For 1 Doses
Give 1 hour prior to OR.
Medications - Anti-infectives
First Line
Patients who are 40-159 kg
cefuroxime (ZINACEF) intraVENOUS 1.5 g, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients who are 160 kg or greater
cefuroxime (ZINACEF) intraVENOUS 3 g, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS 20 mg/kg, Intravenous, ON CALL For 1 Doses
Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies:
vancomycin (VANCOCIN) intraVENOUS 20 mg/kg, Intravenous, ON CALL For 1 Doses
Laboratory
Laboratory
AST/SGOT NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BUN NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CBC WITHOUT DIFFERENTIAL NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 7 of 10
Printed by STRAKA, KEVIN F [KFS1] at 12/9/2016 2:38:16 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

CREATININE NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
GLUCOSE NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
GLUCOSE, WHOLE BLOOD CONDITIONAL - RN COLLECT, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Stat every time blood
glucose monitoring (bedside) is less than 40 or
greater than 400 mg/dL.
MAGNESIUM NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTHROMBIN TIME/INR NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PTT NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTEIN, URINE ONCE, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
URINALYSIS WITH MICROSCOPY ONCE, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Blood Bank
Tests
TYPE AND SCREEN NEXT DRAW, Starting S For 1 Occurrences, Routine,
As good clinical practice and for patient safety, the
Transfusion Service will automatically crossmatch 2
packed RBCs on all patients with antibodies to
ensure blood would be available in the event it is
needed. If you would like to opt out of this automatic
order for this patient please contact the UWHC Blood
Bank at (608) 263-8367 or The American Center Lab
at (608) 234-6600 as appropriate.
Blood Products
Page 8 of 10
Printed by STRAKA, KEVIN F [KFS1] at 12/9/2016 2:38:16 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Blood Products
Red Blood Cells (Adult) 1 UNIT, Starting S For 1 Occurrences, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Plasma (Adult) Starting S, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Platelets (Adult) 1 SINGLE, Starting S For 1 Occurrences, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Cryoprecipitate (Adult) Starting S, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Fibrin Glue, mLs Needed:
Diagnostic Tests and Imaging
Page 9 of 10
Printed by STRAKA, KEVIN F [KFS1] at 12/9/2016 2:38:16 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Diagnostic Tests and Imaging
ECG - 12 Lead - Pre-Operative ONCE, Starting S For 1 Occurrences, Routine
Reason for exam: PRE-OPERATIVE
Consults
Consults
Consult Cardiac Rehab/Preventive Cardiology
(Inpatient)
ONCE, Routine
Reason for consult:
Can this consult be done via video?
BestPractice
No Hospital Problems have yet been identified.
Specify Hospital Problem(s) You will be prompted to specify a hospital problem on
signing.
Criteria
Suggestions:
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:
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Printed by STRAKA, KEVIN F [KFS1] at 12/9/2016 2:38:16 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org