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/clinical/cckm-tools/content/order-sets/inpatient/radiology/name-97998-en.cckm

201706177

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UWHC,UWMF,

Tools,

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

IP - IR - Pre TIPS-Transjugular Intrahepatic Portosystemic Shunt - Adult - Preprocedure [1134]

IP - IR - Pre TIPS-Transjugular Intrahepatic Portosystemic Shunt - Adult - Preprocedure [1134] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Radiology


IP - IR - Pre TIPS Transjugular Intrahepatic Portosystemic Shunt - Adult -
Preprocedure [1134]
Patient Care Orders
Vital Signs [143149]
Vital Signs [NURMON0013] ONCE, Starting today For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
On arrival
Patient Monitoring [143152]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: 18 Gauge
Does this need to be inserted/placed? Yes
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? Yes
Nutrition [14412]
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:
Outpatient ONLY: May have clear liquid diet up to 4
hours prior to procedure as per anesthesia guidelines
for outpatients.
Intake and Output [143151]
Void Prior to Transport [NURELM0061] ONCE For 1 Occurrences
Non-Categorized Patient Care Orders [14413]
Nursing Communication [NURCOM0022] ONCE, Starting today For 1 Occurrences, Procedure
to be performed ***.
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
For Diabetic Patients [142889]
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 7
Printed by O'BRIEN, RYLEY P [RPO249] at 6/20/2017 4:22:47 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@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 [106742]
Notify Interventional Radiology Provider
[NURCOM0001]
Provider to Notify: Provider
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 is less than 50,000/microliter
Intravenous Therapy
Premedications for Needle Insertion [124125]
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 7
Printed by O'BRIEN, RYLEY P [RPO249] at 6/20/2017 4:22:47 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@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 [16586]
sodium chloride 0.9 % infusion [64367] Intravenous, CONTINUOUS
Medications - Non-categorized
Non-Categorized [118974]
lidocaine (STERILE UROJECT) 2 % gel [785049] Urethral, ONCE For 1 Doses
Surgical Prophylaxis
IR Delivery Note [140285]
Note: Pharmacy: Please tube anti-infective to
Radiology Prep/Recovery at #434 [950018]
ONCE For 1 Doses
First Line (Single Response) [142965]
ceftriaxone (ROCEPHIN) intraVENOUS - NOTE:
Patient who is 40-120 kg [800027]
1 g, Intravenous, ON CALL For 1 Doses
ceftriaxone (ROCEPHIN) intraVENOUS - NOTE:
Patient who is greater than 120 kg [800027]
2 g, Intravenous, ON CALL For 1 Doses
Patients with MRSA (Single Response) [142966]
Patient who is 40-120 kg [225367]
ceftriaxone (ROCEPHIN) intraVENOUS [800027] 1 g, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patient who is greater than 120 kg [225369]
ceftriaxone (ROCEPHIN) intraVENOUS [800027] 2 g, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients with MRSA and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies
(Single Response) [142938]
Patient who is 40 kg or greater [225366]
gentamicin (GARAMYCIN) intraVENOUS
[800049]
5 mg/kg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Patients with Immediate/Severe Rxn to PCN and Ceph Allergies and MRSA Negative [224936]
Patient who is 40 kg or greater [224088]
gentamicin (GARAMYCIN) intraVENOUS
[800049]
5 mg/kg, Intravenous, ON CALL For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Laboratory
Labs to be Done the Morning of Procedure [14414]
Page 3 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 6/20/2017 4:22:47 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

ALBUMIN [ALB] STAT - 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?
ALKALINE PHOSPHATASE [ALKP] STAT - 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?
ALT/SGPT [ALT] STAT - 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?
AST/SGOT [AST] STAT - 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?
AMMONIA [GM2200] STAT - 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?
Transport specimen to laboratory immediately.
Whole blood specimen must arrive in the Core Lab
within 30 minutes of collection if not on ice pack. If in
question, transport on ice pack.
Ice packed specimens greater than 60 minutes old or
specimens not on ice pack greater than 30 minutes
old when received by laboratory are not acceptable.
BILIRUBIN, TOTAL [TBIL] STAT - 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?
CBC WITHOUT DIFFERENTIAL [HEMO] STAT - 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?
CREATININE [CRET] STAT - 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?
ELECTROLYTES [LYTE] STAT - 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?
HCG, QUALITATIVE, URINE [UPREG] STAT - 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?
PROTHROMBIN TIME/INR [PT] STAT - 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?
Blood Bank
Tests [143153]
Page 4 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 6/20/2017 4:22:47 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

TYPE AND SCREEN [HCTS] STAT - RN COLLECT, Starting today 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 [12026]
Red Blood Cells (Adult) [BLB0006] 1 UNIT, Starting today 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) [BLB0003] Starting today, 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) [BLB0004] 1 SINGLE, Starting today 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:
Page 5 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 6/20/2017 4:22:47 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Cryoprecipitate (Adult) [BLB0005] Starting today, 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:
Blood Product [12027]
Red Blood Cells (Pediatric) [BLB0013] 1 UNIT, Starting today For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
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 (Pediatric) [BLB0010] Starting today, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
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:
Page 6 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 6/20/2017 4:22:47 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Platelets (Pediatric) [BLB0011] Starting today, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
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 (Pediatric) [BLB0012] Starting today, 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:
Page 7 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 6/20/2017 4:22:47 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org