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IP - IR - Admission Gastrostomy Tube Placement - Alimentation - Adult - Admission [3269]

IP - IR - Admission Gastrostomy Tube Placement - Alimentation - Adult - Admission [3269] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Radiology


IP - IR - Admission Gastrostomy Tube Placement - Alimentation - Adult -
Admission [3269]
Admission Status
Level of Care (Single Response) [187515]
*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 [98941]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Change Attending [ADT0006] Attending:
Service:
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [130119]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
Page 1 of 4
Printed by O'BRIEN, RYLEY P [RPO249] at 7/18/2017 4:41:12 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response) [129777]
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 Bleed Risk with High VTE 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:
Patient Care Orders
Activity [188758]
Activity [NURACT0008] CONTINUOUS, 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 (Single Response) [188759]
[1406]Supplemental -Adult -Tube Feeding -tube feeding refer to: IP For
Diet NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
Diet Liquid [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Liquid
Liquid: Full Liquid
No Red or Purple Dye:
Liquid Thickness:
Bedside Meal Instructions:
Room Service Class:
Page 2 of 4
Printed by O'BRIEN, RYLEY P [RPO249] at 7/18/2017 4:41:12 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
07/2017CCKM@uwhealth.org

Diet - Tube Feed [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Room Service Class:
Diet Type: Tube Feed
Bedside Meal Instructions:
Tube Feed Diet: Tube Feed with Diet Modifications
Diet Modifications: Liquid
Tube Feed Route: G-Tube
Tube Feed Product: Boost Plus (Carton, 8oz)
Liquid Thickness:
Liquid: Full Liquid
No Red or Purple Dye:
G-Tube Frequency: Bolus
Gastric Feeding Patient Monitoring: N/A
Gastric Feeding Residual Guidelines: N/A
Hold Gastric Tube Feeding: N/A
Infusion Instructions: -
Bolus Volume (mL):
Number of Cans to Bolus:
Bolus Frequency/Instructions:
Flush With: Tap Water
Flush Volume (mL): 30
Flush Frequency: after tube feeding
Bolus Frequency/Instructions:
Before discharge for education purposes, infuse 1 can
via gravity method over 30 minutes or more. Time to
be cooordinated between patient/family and RN.
Medications
Analgesics - Acetaminophen - PRN [226883]
acetaMINOPHEN (TYLENOL) tab RANGE
[750000]
325-650 mg, Oral, EVERY 4 HOURS PRN, pain/fever,
Administer for moderate to severe pain
Analgesics - Opioids - Oral - PRN (Single Response) [226886]
oxycodone-acetaMINOPHEN (PERCOCET)
5-325 MG per tab RANGE [750033]
1-2 tab, Oral, EVERY 4 HOURS PRN, pain,
Administer for severe pain
oxycodone 5 MG/5ML soln RANGE [750031] 5-10 mg, Oral, EVERY 4 HOURS PRN, pain,
Administer for severe pain
Analgesics - Opioids - Intravenous - PRN (Single Response) [98936]
MORPHine PF injection RANGE [750057] 1-2 mg, Intravenous, EVERY 1 HOUR PRN, pain,
Administer for severe pain
Administer if unable to take enterally.
for 4 Minutes
HYDROmorphone PF (DILAUDID) injection
RANGE [750050]
0.2-0.5 mg, Intravenous, EVERY 1 HOUR PRN,
Administer for severe pain, for 3 Minutes
Anti-emetics [226892]
ondansetron (ZOFRAN) tab [45939] 4 mg, Oral, EVERY 24 HOURS PRN, nausea/vomiting
Administer as first line therapy.
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 24 HOURS PRN,
nausea/vomiting
Administer as first line therapy if unable to take orally.
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN, nausea/vomiting
Administer as second line therapy.
Page 3 of 4
Printed by O'BRIEN, RYLEY P [RPO249] at 7/18/2017 4:41:12 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
07/2017CCKM@uwhealth.org

prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Administer as second line therapy if unable to take
orally
If ordered IV: push rate 5 mg/minute.
Consults
Consults [14316]
Consult Case Management (Inpatient) [CON0013] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: DISCHARGE PLANNING
( Discharge supplies, new G-tube placed during
admission)
Discharge supplies and enternal nutrition, new G-tube
placed during admission
Consult Nutrition (Inpatient) [CON0043] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Nutrition Assessment w/
Recommendations
Delegate to Initiate and Manage Tube Feeding: Yes
Delegate to Initiate Feeding Tube Placement Order
Set:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
For tube feeding recommendations, new G-tube
placed during admission
Page 4 of 4
Printed by O'BRIEN, RYLEY P [RPO249] at 7/18/2017 4:41:12 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
07/2017CCKM@uwhealth.org