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/clinical/cckm-tools/content/order-sets/inpatient/radiology/name-113256-en.cckm

20170247

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100

UWHC,UWMF,

Tools,

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

IP - Body - Percutaneous Ablation - Adult - Postprocedure [1608]

IP - Body - Percutaneous Ablation - Adult - Postprocedure [1608] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Radiology


IP - Body - Percutaneous Ablation - Adult - Postprocedure [1608]
Intended for Adult Patients Only
Admission Status
Admission Status (Single Response) [147234]
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:
Patient Care Orders
Vitals Signs [22249]
Vital Signs [NURMON0013] EVERY 15 MINUTES, Starting today For 4 Occurrences,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Then every 30 minutes times 2, then every hour times 4, then
every 2 hours
Activity [22004]
Ad Lib [NURACT0008] CONTINUOUS, Starting today, 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 [22250]
Page 1 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 12/16/2015 4:39:22 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
12/2015Lee Vermeulen, CCKM@uwhealth.org

NPO [NUT0001] EFFECTIVE NOW, Starting today For 2 Hours, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
STRICT NPO
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail):
Tube Feeding Management:
Room Service Class:
For 2 hours.
Page 2 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 12/16/2015 4:39:22 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
12/2015Lee Vermeulen, CCKM@uwhealth.org

Clear Liquid Diet [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24): CLEAR LIQUID;
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail):
Tube Feeding Management:
Room Service Class:
Beginning 2 hours after procedure and advance as tolerated.
Page 3 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 12/16/2015 4:39:22 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
12/2015Lee Vermeulen, CCKM@uwhealth.org

General Diet [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet: GENERAL;
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail):
Tube Feeding Management:
Room Service Class:
Beginning 4 hours after procedure.
Non-Categorized Patient Care Orders [22252]
Urinary Catheterization-Intermittent [NURELM0018] EVERY 6 HOURS PRN, Starting today, Routine, If unable to
urinate
Nursing Communication [NURCOM0022] ONCE, Starting today For 1 Occurrences, Discontinue urinary
catheter when patient taking oral fluids well
Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type:
Respiratory [22251]
Titrate supplemental [RT0032] CONTINUOUS, Starting today For Until specified, Routine
FiO2 (%):
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 92
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen?
Discontinue supplemental [RT0032] CONTINUOUS, Routine
FiO2 (%):
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device:
Attempt to Wean Off Oxygen? Yes
Discontinue supplemental oxygen by weaning to room air
while maintaining saturation equal to or greater than *** %
Cough And Deep Breathe [NURTRT0019] EVERY 1 HOUR, Starting today, Routine, While awake
Incentive Spirometry [NURTRT0018] EVERY 1 HOUR, Starting today, Routine, While awake
Wound Care [22253]
Page 4 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 12/16/2015 4:39:22 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
12/2015Lee Vermeulen, CCKM@uwhealth.org

Assess dressing [NURWND0015] CONTINUOUS, Starting today, Routine
Wound Type:
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:
Contingency Parameters [22254]
Notify - Radiologist [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C): 38.5
If heart rate > (bpm): 100
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other:
Intravenous Therapy
IV Fluids [22393]
sodium chloride 0.9% infusion [64367] at 125 mL/hr, Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS
Medications - Postprocedure
For PCA ordering, please use Order Set 1441 IP- Intravenous Patient Controlled Analgesia (PCA) - Adult - Supplemental
PCA Equipment [147980]
Patient Controlled Analgesia-PCA (Module) [EQP0019] CONTINUOUS, Routine
Analgesics - opoids (Single Response) [22398]
hydrocodone-acetaMINOPHEN (NORCO) 5-325 mg per
tab RANGE [750021]
1-2 tab, Oral, EVERY 4 HOURS PRN, pain
oxycodone tab RANGE [750032] 5-10 mg, Oral, EVERY 3 HOURS PRN, pain
Analgesics - non-opoids (Single Response) [119423]
ketOROLAC (TORADOL) injection - NOTE: Do NOT
order ketorolac if patient 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 4 Doses
Antihistamines [22438]
diphenhydramine (BENADRYL) cap RANGE [750014] 25-50 mg, Oral, EVERY 6 HOURS PRN, itching
diphenhydramine (BENADRYL) injection RANGE
[750044]
25-50 mg, Intravenous, EVERY 6 HOURS PRN, itching, Give
only if unable to take orally., for 1 Minutes
Anti-emetics - First Line (Single Response) [22447]
metoclopramide (REGLAN) injection [800059] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
First line anti-emetic
If ordered IV: Administer over 2 minutes
Page 5 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 12/16/2015 4:39:22 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
12/2015Lee Vermeulen, CCKM@uwhealth.org

metoclopramide (REGLAN) tab [39630] 10 mg, Oral, EVERY 6 HOURS PRN, GI motility,
nausea/vomiting
First line anti-emetic.
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
First line anti-emetic
If ordered IV: push slowly, max rate 5 mg/minute.
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN, nausea/vomiting
First line anti-emetic.
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 24 HOURS PRN,
nausea/vomiting
First line anti-emetic
ondansetron (ZOFRAN ODT) disintegrating tab [64224] 4 mg, Oral, EVERY 24 HOURS PRN, nausea/vomiting
First line anti-emetic
Anti-emetics - Second Line (Single Response) [119420]
metoclopramide (REGLAN) injection [800059] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Second line anti-emetic
If ordered IV: Administer over 2 minutes
metoclopramide (REGLAN) tab [39630] 10 mg, Oral, EVERY 6 HOURS PRN, GI motility,
nausea/vomiting
Second line anti-emetic.
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Second line anti-emetic
If ordered IV: push slowly, max rate 5 mg/minute.
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN, nausea/vomiting
Second line anti-emetic.
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 24 HOURS PRN,
nausea/vomiting
Second line anti-emetic
ondansetron (ZOFRAN ODT) disintegrating tab [64224] 4 mg, Oral, EVERY 24 HOURS PRN, nausea/vomiting
Second line anti-emetic
Anti-emetics - Third Line (Single Response) [119421]
metoclopramide (REGLAN) injection [800059] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Third line anti-emetic
If ordered IV: Administer over 2 minutes
metoclopramide (REGLAN) tab [39630] 10 mg, Oral, EVERY 6 HOURS PRN, GI motility,
nausea/vomiting
Third line anti-emetic.
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Third line anti-emetic
If ordered IV: push slowly, max rate 5 mg/minute.
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN, nausea/vomiting
Third line anti-emetic.
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 24 HOURS PRN,
nausea/vomiting
Third line anti-emetic.
ondansetron (ZOFRAN ODT) disintegrating tab [64224] 4 mg, Oral, EVERY 24 HOURS PRN, nausea/vomiting
Third line anti-emetic
Laboratory
Draw in AM - Postoperative Day 1 [22255]
HEMATOCRIT [HCT] NEXT AM, Starting tomorrow 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 6 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 12/16/2015 4:39:22 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
12/2015Lee Vermeulen, CCKM@uwhealth.org

ELECTROLYTES [LYTE] NEXT AM, Starting tomorrow 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 [BUN] NEXT AM, Starting tomorrow For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
CREATININE [CRET] NEXT AM, Starting tomorrow For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Diagnostic Tests and Imaging
Diagnostic Test and Imaging [117263]
X-RAY CHEST AP VIEW - Upright [R71010] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by this
exam? Post procedure, assess for pneumothorax
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
1 hour postprocedure
X-RAY CHEST AP VIEW - Upright [R71010] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by this
exam? Post procedure, assess for pneumothorax
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
3 hour postprocedure
Page 7 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 12/16/2015 4:39:22 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
12/2015Lee Vermeulen, CCKM@uwhealth.org