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IP - IR - Pre Gastrostomy Tube Placement - Adult - Preprocedure [1123]

IP - IR - Pre Gastrostomy Tube Placement - Adult - Preprocedure [1123] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Radiology


IP - IR - Pre Gastrostomy Tube Placement - Adult - Preprocedure [1123]
Patient Care Orders
Vital Signs [143135]
Vital Signs [NURMON0013] ONCE For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
On arrival.
Patient Monitoring [143139]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Insert and Maintain Urinary Catheter
[NURELM0013]
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: Indwelling Single Lumen
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Nutrition [14328]
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:
Patient may have solid food until 6 hours prior to
procedure. May continue to take clear liquids until 4
hours prior to procedure. Then NPO except
medications with sips of water.
Hold Nasogastric Tube Feeding for 6 Hours Prior
to Procedure [NURDIE0013]
SEE COMMENTS, Starting today, Hold Nasogastric
Tube Feeding for 6 Hours Prior to Procedure
Intake and Output [143141]
Void Prior to Transport [NURELM0061] ONCE For 1 Occurrences
Non-Categorized Patient Care Orders [14329]
Nursing Communication [NURCOM0022] ONCE, Starting today For 1 Occurrences, Procedure
to be performed ***.
Education, Procedure/Treatment * See Health
Facts for You Materials (#5891) [NURCOM0022]
ONCE, Starting today For 1 Occurrences
For Diabetic Patients [120287]
Glucose, POC [IPGLUCOSE] CONDITIONAL - RN COLLECT For 5 Occurrences,
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? On Arrival and every
60 minutes for prior glucose less than 60 or greater
than 300 mg/dL
Page 1 of 3
Printed by O'BRIEN, RYLEY P [RPO249] at 5/18/2017 2:52:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2017CCKM@uwhealth.org

GLUCOSE [GLU] CONDITIONAL - RN COLLECT For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Obtain if POC
glucose less than 40 mg/dL or greater than 400
mg/dL
Contingency Parameters [14330]
Notify Interventional Radiology Provider
[NURCOM0001]
CONTINUOUS
Provider to Notify: Other (Comment)
If systolic blood pressure > (mmHg): 180
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg): 100
If diastolic blood pressure < (mmHg): 60
If temperature > (C):
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 50
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): 300
If blood glucose < (mg/dL): 90
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: International normalized ratio (INR) is greater
than 1.5,Platelet count less than 50,000 per microliter
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 2 of 3
Printed by O'BRIEN, RYLEY P [RPO249] at 5/18/2017 2:52:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@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
IV Fluids [142823]
dextrose 5%-NaCl 0.45% infusion [51613] at 150 mL/hr, Intravenous, CONTINUOUS
sodium chloride 0.9% infusion [64367] at 150 mL/hr, Intravenous, CONTINUOUS
Medications
Non-categorized [142824]
lidocaine (XYLOCAINE JELLY) 2% gel [39030] Topical, ONCE For 1 Doses
Apply to nares with NG tube placement.
glucagon 1 mg injection kit [107799] 0.5-1 mg, Intravenous, ONCE For 1 Doses
For use in IR suite to induce gastroparesis
intraprocedurely per physician discretion.
lidocaine (STERILE UROJECT) 2% gel 20 mL
[785049]
Urethral, ONCE For 1 Doses
Laboratory
Labs [14331]
WHITE CELL COUNT [WBC] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEMATOCRIT [HCT] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PLATELET COUNT [PLT] STAT - RN COLLECT, Starting today 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 [PT] STAT - RN COLLECT, Starting today 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 [HEMO] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HCG, QUALITATIVE, URINE [UPREG] CONDITIONAL - RN COLLECT, Starting today,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 3 of 3
Printed by O'BRIEN, RYLEY P [RPO249] at 5/18/2017 2:52:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org