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/clinical/cckm-tools/content/order-sets/inpatient/transplant/name-122487-en.cckm

201711313

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IP - Fecal Microbiota Transplant (FMT) - Adult - Supplemental [6553]

IP - Fecal Microbiota Transplant (FMT) - Adult - Supplemental [6553] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Transplant


IP - Fecal Microbiota Transplant (FMT) - Adult - Supplemental [6553]
for Adult Patients OnlyIntended
Fecal Microbiota Transplant (FMT) via nursing, no GI procedure
Fecal Microbiota Transplant (FMT) via nursing, no GI procedure (Single Response) [235633]
FMT Capsule/Oral Delivery [236372]
Adult Clear Liquid Diet, starting at midnight/
effective midnight [NUT9999]
EFFECTIVE MIDNIGHT, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Liquid
Liquid: Clear Liquid
No Red or Purple Dye:
Liquid Thickness:
Bedside Meal Instructions:
Room Service Class:
NPO for Procedure - Hold diet 4 hours [DIE0007] CONTINUOUS NPO For 1 Occurrences, Routine
NPO For Which Procedure? Planned FMT
Modifiers:
NPO for planned FMT. NPO for 2 hours before and
2 hours after procedure.
pantoprazole (PROTONIX) delayed release tab
[62661]
40 mg, Oral, 2 X DAILY For 2 Doses
Premedication for upper delivery FMT
fecal microbiota transplant oral delivery (FMT) 30
cap kit [794032]
1 Kit, Oral, ONCE For 1 Doses
Note: Notify Pharmacy [950015] PRN, Fecal Microbiota Transplant
Notify pharmacy and MD if patient not able to
tolerate/retain FMT
FMT Upper Delivery with NG [236373]
NG Tube Placement - Adult [120994]
Insert and Maintain Nasogastric Tube
[NURTAD0014]
CONTINUOUS, Routine
Options:
Flush with:
Flush Frequency: EVERY 8 HOURS
Clamp NG Tube:
Check Residual:
Does this need to be inserted/placed?
Device Status:
Refer to Policy 2.20 Enteral Tubes Used for
Instillation of Fluids, Medications, or Feeding
Recommendations for flush quantity:
For adult patients, 30 mLs of fluid should be
sufficient.
lidocaine-oxymetazoline 4%-0.05% (ADULT)
nasal spray [785081]
2 spray, Nasal, ONCE For 1 Doses
For numbing prior to feeding tube insertion.
Slowly spray the chosen nostril once, if required
may repeat x1 in opposite nostril. Angle toward
back of throat spraying the anterior nostril and wait
30-60 seconds before introducing more local
anesthetic into the nostril. Caution: Entire bottle
should not be used for insertion of tube. Discard
excess solution when procedure completed.
Page 1 of 4
Printed by WILLIAMS, HEATHER R [HRS0] at 11/6/2017 3:34:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

X-RAY ABDOMEN AP VIEW (KUB) [R74000] CONDITIONAL For 3 Days, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered
by this exam? Evaluate nasogastric tube placement
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
If Conditional, What Condition? Evaluate
nasogastric tube placement. The location of
nasogastric tube should be confirmed prior to the
instillation of fluids, medications, or feedings. Refer
to Policy 2.20 Enteral Tubes Used for Instillation of
Fluids, Medications, or Feeding
Adult Clear Liquid Diet, starting at midnight
[NUT9999]
EFFECTIVE MIDNIGHT, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Liquid
Liquid: Clear Liquid
No Red or Purple Dye:
Liquid Thickness:
Bedside Meal Instructions:
Room Service Class:
NPO for Procedure - Hold diet 4 hours [DIE0007] CONTINUOUS NPO For 1 Occurrences, Routine
NPO For Which Procedure? Planned FMT
Modifiers:
NPO for planned FMT. NPO for 2 hours before and
2 hours after procedure
pantoprazole (PROTONIX) delayed release tab
[62661]
40 mg, Oral, 2 X DAILY For 2 Doses
Premedication for upper delivery FMT
fecal microbiota transplant upper delivery (FMT)
soln [794033]
30 mL, Other, ONCE For 1 Doses
Delivered via NG tube
Note: Notify Pharmacy [950015] PRN, Fecal Microbiota Transplant
Notify pharmacy and MD if patient not able to
tolerate/retain FMT
FMT Lower Delivery with Retention Enema
[236374]
No Dietary Restrictions [NURCOM0022] ONCE, No dietary restritions needed for planned
FMT via enema
phosphate (FLEET) enema [37517] 1 enema, Rectal, ONCE For 1 Doses
Administer 1-2 hours before planned fecal microbiota
transplant (FMT).
fecal microbiota transplant lower delivery (FMT)
soln [794034]
250 mL, Rectal, ONCE For 1 Doses
Goal for patient to retain FMT liquid for one hour.
Administer with patient on left side, remain on left
side for 15 minutes. Rotate patient to supine
position and remain for 15 minutes. Turn patient to
right side and remain for 15 minutes. Sit up and
remain for 15
Minutes then expel FMT enema.
Page 2 of 4
Printed by WILLIAMS, HEATHER R [HRS0] at 11/6/2017 3:34:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Patient Postioning During and After Retention
Emena [NURCOM0022]
ONCE, Goal for patient to retain FMT liquid for one
hour. Administer with patient on left side, remain on
left side for 15 minutes. Rotate patient to supine
position and remain for 15 minutes. Turn patient to
right side and remain for 15 minutes. Sit up and
remain for 15 minutes then expel FMT enema.
Note: Notify Pharmacy [950015] PRN, Fecal Microbiota Transplant
Notify pharmacy and MD if patient not able to
tolerate/retain FMT
Fecal Microbiota Transplant (FMT) with GI procedure
Fecal Microbiota Transplant (FMT) with GI procedure (Single Response) [235635]
FMT Upper Delivery with
Esophagogastroduodenoscopy (EGD) [236375]
Adult clear liquid diet, effective when bowel prep
has started [NUT9999]
EFFECTIVE _____, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Liquid
Liquid: Clear Liquid
No Red or Purple Dye:
Liquid Thickness:
Bedside Meal Instructions:
Room Service Class:
Effective when bowel prep has started.
NPO for Procedure - Hold diet 4 hours [DIE0007] CONTINUOUS NPO, Routine
NPO For Which Procedure? EGD with FMT
Modifiers:
Hold diet 4 hours
G.I. lavage (GOLYTELY) 236 G soln [103976] 4 L, Oral, ONCE For 1 Doses
Esophagogastroduodenoscopy (EGD) [GI0003] ONCE, Routine
Reason for Exam: Inpatient FMT
fecal microbiota transplant upper delivery (FMT)
soln [794033]
30 mL, Other, ONCE For 1 Doses
Delivered via EGD
FMT Lower Delivery with Flexible Sigmoidoscopy
(Flex Sig) [232194]
Adult clear liquid diet, effective when bowel prep
has started [NUT9999]
EFFECTIVE _____, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Liquid
Liquid: Clear Liquid
No Red or Purple Dye:
Liquid Thickness:
Bedside Meal Instructions:
Room Service Class:
Effective when bowel prep has started
NPO for Procedure - Hold diet 4 hours [DIE0007] CONTINUOUS NPO, Routine
NPO For Which Procedure? Flex Sig with FMT
Modifiers:
Hold diet 4 hours
G.I. lavage (GOLYTELY) 236 G soln [103976] 4 L, Oral, ONCE For 1 Doses
Flexible Sigmoidoscopy [GI0006] ONCE, Routine
Reason for Exam: Inpatient FMT
fecal microbiota transplant lower delivery (FMT)
soln [794034]
250 mL, Rectal, ONCE For 1 Doses
FMT Lower Delivery with Colonoscopy [232195]
Page 3 of 4
Printed by WILLIAMS, HEATHER R [HRS0] at 11/6/2017 3:34:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Adult clear liquid diet, effective when bowel prep
has started [NUT9999]
EFFECTIVE _____, Routine
Patient Type:
Effective when bowel prep has started
NPO for Procedure - Hold diet 4 hours [DIE0007] CONTINUOUS NPO For 1 Occurrences, Routine
NPO For Which Procedure? Colonoscopy with FMT
Modifiers:
Hold diet 4 hours
G.I. lavage (GOLYTELY) 236 G soln [103976] 4 L, Oral, ONCE For 1 Doses
Colonoscopy [GI0002] ONCE, Routine
Reason for Exam: Inpatient FMT
fecal microbiota transplant lower delivery (FMT)
soln [794034]
250 mL, Rectal, ONCE For 1 Doses
Page 4 of 4
Printed by WILLIAMS, HEATHER R [HRS0] at 11/6/2017 3:34:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org