/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/inpatient/,/clinical/cckm-tools/content/order-sets/inpatient/transplant/,

/clinical/cckm-tools/content/order-sets/inpatient/transplant/name-97915-en.cckm

201709269

page

100

UWHC,UWMF,

Tools,

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

IP - Lung Transplant - Adult - Postoperative [2830]

IP - Lung Transplant - Adult - Postoperative [2830] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Transplant


IP - Lung Transplant - Adult - Postoperative [2830]
for Adult Patients OnlyIntended
Admission Status
Level of Care (Single Response) [186484]
*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 [87988]
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:
Page 1 of 25
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status [87989]
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:
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [131999]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
Post-Op/Phase II
Moderate VTE Risk with Low Bleed Risk (Single
Response) [209954]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Post-Op/Phase II
High VTE with Low Bleed Risk [211018]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 HOURS, Post-
Op/Phase II
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
High Bleed 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
Page 2 of 25
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
Post-Op/Phase II
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Post-Op/Phase II
VTE Prophylaxis (Single Response) [150176]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
Post-Op/Phase II
Moderate VTE Risk with Low Bleed Risk (Single
Response) [209954]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Post-Op/Phase II
High VTE with Low Bleed Risk [211018]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Post-Op/Phase II
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
High Bleed 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
Post-Op/Phase II
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Post-Op/Phase II
Patient Care Orders
Vital Signs [87995]
Page 3 of 25
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 15 minutes times 4, then every 30 minutes
times 4, then every hour while on ICU status. Every 4
hours while on intermediate care (IMC) or general
care status., Post-Op/Phase II
Patient Monitoring [87997]
Measure Hemodynamic Parameters
[NURMON0023]
CONTINUOUS, Starting today, Routine
Pulmonary Artery Systolic Pressure (mmHg):
(Continuous)
Pulmonary Artery Diastolic Pressure (mmHg):
(Continuous)
Pulmonary Artery Mean Pressure (mmHg): Other
(Comment) (Continuous)
Pulmonary Artery Wedge Pressure (mmHg):
Central Venous Pressure (mmHg):
Central Venous Pressure (mmH2O): Other (Comment)
(Continuous)
Cardiac Output: Q4 Hours (And as needed)
Cardiac Output Method:
Cardiac Index: Q4 Hours (And as needed)
Systemic Vascular Resistance: Q4 Hours (And as
needed)
Pulmonary Vascular Resistance: Q4 Hours (And as
needed)
Pulmonary Vascular Resistance Index:
Stroke Volume (mL/beat):
Stroke Volume Index:
Systemic Vascular Resistance Index:
Left Cardiac Work Index:
Right Cardiac Work Index:
Left Ventricular Stroke Work Index:
Right Ventricular Stroke Work Index:
Pulmonary Capillary Wedge Pressure (mmHg):
Measure with FloTrac? No
Every 15 minutes times 4, then every 30 minutes
times 4, then every hour. If no Drip every 2 hours.,
Post-Op/Phase II
Measure Arterial Line [NURMON0060] CONTINUOUS, Post-Op/Phase II
Activity [87998]
Elevate Head Of Bed [NURACT0002] Equal to (degrees): 30
Greater than (degrees):
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting today, Post-
Op/Phase II
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Activity Bedrest While Intubated [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: other (comment)
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Increase activity to dangle once patient is extubated.,
Post-Op/Phase II
Reposition Patient [NURACT0005] Type:
Routine, SEE COMMENTS, Every 2 hours, Post-
Op/Phase II
Dangle with Leg Extension Exercises After
Extubation [NURACT0008]
CONTINUOUS, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE: 3x daily
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Once extubated, increase activity to dangle., Post-
Op/Phase II
Activity Chair [NURACT0008] CONTINUOUS, Routine
AD LIB:
AMBULATE:
CHAIR: 3x daily
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
To chair if tolerate dangling., Post-Op/Phase II
Activity Ambulate [NURACT0008] CONTINUOUS, Routine
AD LIB:
AMBULATE: 4x daily
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Once pulmonary artery catheter is removed., Post-
Op/Phase II
Nutrition [87999]
Page 5 of 25
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Strict NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: Strict NPO
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
Respiratory [88000]
Respiratory Therapy per Protocol for New Post-
Op Lung Transplants [RT0035]
Routine
Protocol Type:
Respiratory Therapy per Protocol for New Post-Op
Lung Transplants, Post-Op/Phase II
Suction Airway [NURTAD0017] EVERY 4 HOURS, Starting today, Routine
Location: Tracheal
And as needed., Post-Op/Phase II
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today, Routine, Document
every 15 minutes times 4, then every 30 minutes times
4, then every hour while on ICU status. Every 4 hours
while on intermediate care (IMC) or general care
status., Post-Op/Phase II
Respiratory - Post-Extubation [88002]
Oxygen Therapy [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 90
O2 Delivery Device:
Attempt to Wean Off Oxygen?
Post-extubation, Post-Op/Phase II
Turn, Cough And Deep Breathe [NURTRT0022] EVERY 2 HOURS, Starting today, Routine, Post-
Op/Phase II
Incentive Spirometry [NURTRT0018] EVERY 1 HOUR, Routine, Every 1 hour while awake
& every 4 hours while asleep, Post-Op/Phase II
Ventilator [88001]
Mechanical Ventilation - Adult [117146]
Provide Manual Resuscitator at Bedside
[RT0039]
CONTINUOUS, Routine, Post-Op/Phase II
Page 6 of 25
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Mechanical Ventilation [RT0028] Routine, For ADULT patients order chlorihexidene
gluconate (PERIDEX) 0.12% soln 15 mL to swab
oral cavity 2x daily while on ventilation.
Is this a modification to a current vent order?
Ventilator Management:
Wean:
Set Rate/Min:
PEEP (cmH2O):
Mode:
Tidal Volume Multiplier: 6
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Pressure Support:
Pressure Control:
P High (cmH20):
P Low (PEEP) (cmH20):
T High (sec):
T Low (T PEEP) (sec):
PS above P High (cmH2O):
PS above PEEP (cmH2O):
NAVA Level (µV):
Pressure Support Trial when patient outcomes are
as follows:
Awake,
Pain Controlled,
Respiratory Rate/Tidal Volume (RR/TV) less than
100,
Pulse oximetry greater than 90% on FiO2 40%,
PEEP less than or equal to 5 centimeters of water
pressure,
Titrate the Pressure Support (PS) to keep Tidal
Volume (TV) 3-5 milliliters/kilogram ideal body
weight (IBW).
Post-Op/Phase II
chlorhexidine (PERIDEX) 0.12 % soln
MULTIDOSE [792004]
15 mL, Mouth/Throat, 2 X DAILY Starting today
Use to swab oral cavity. D/C when patient no longer
on ventilation.
Post-Op/Phase II
Wound/Procedure Site Care [88003]
Wound Care - Closed Incision (Adult)
[NURWND0055]
CONTINUOUS, Routine
Wound Site:
Wound Location:
Assess Frequency: EVERY 8 HOURS
Incision Closed With: Other (Comment) (Dermabond)
Maintain OR Dressing: Minimum of 48 hours
Remove OR Dressing after 48 hours: Yes
Removal of OR Dressing performed by: RN
Cleansing with Removal of OR Dressing: CHG
Primary Dressing (after 48 hours): Dry Gauze
Incision Care (after 48 hours): Cleanse daily with CHG
If dressing becomes saturated in 48 hours, sterile
dressing change? Yes - Notify provider
Post-Op/Phase II
Chest Tube Care [88004]
Page 7 of 25
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Maintain Chest Tube -20 cm Wall Suction
[NURTAD0001]
CONTINUOUS, Starting today, Routine
Location: Other (Comment Required)
Position: Lateral
Drainage Options: -20 cm wall suction
Site Assessment Frequency: EVERY 8 HOURS
Care Frequency: 1 X DAILY
Wash With: Chlorhexidine Sponge
Primary Dressing: Gauze
Secondary Dressing:
Pleural. Applies to all chest tubes, Post-Op/Phase II
Intake and Output [88005]
Measure Intake And Output [NURMON0005] SEE COMMENTS, Starting today, Routine, Every 15
minutes times 4, then every 30 minutes times 4, then
every hour while on ICU status. Every 4 hours while
on intermediate care (IMC) or general care status.,
Post-Op/Phase II
Measure Chest Tube Output [NURTAD0013] EVERY 8 HOURS, Routine, Every 15 minutes times 4,
then every 30 minutes times 4, then every hour while
on ICU status. Every 4 hours while on intermediate
care (IMC) or general care status., Post-Op/Phase II
Equipment and Supplies [88007]
Use Warm Air Blanket [NURTRT0027] PRN, Starting today, Routine, Warming blanket
immediately postoperative for temperature less than
36.0 degrees Celsius., Post-Op/Phase II
Apply Cool Compress to Affected Area
[NURTRT0003]
PRN, Starting today, Routine
Site: Affected Area
Cooling blanket for temperature greater than 38.6
degrees Celsius., Post-Op/Phase II
Provide Patient With Non-Invasive Blood
Pressure Cuff and Oral Thermometer for
Discharge [NURCOM0022]
ONCE For 1 Occurrences, Post-Op/Phase II
Order Blue Duck Bill Mask [NURCOM0022] ONCE For 1 Occurrences, Order 2 boxes of masks.
Central Supply # 1213037.
medication box (medium) [785079] Other, ONCE For 1 Doses, Post-Op/Phase II
Non-Categorized Patient Care Orders [88008]
Insulin InfusionSupplemental" Order Set for Patients on -Adult -to "Insulin Infusion Refer
Monitoring and Insulin Supplemental" Order Set for all Glucose -Adult -to "Diabetes Management Refer
Therapy
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With?
Weigh when?
Post-Op/Phase II
Strict Handwashing [NURCOM0022] SEE COMMENTS, Starting today For Until specified,
Strict handwashing per Precautions for
Immunocompromised Patients Policy 13.06., Post-
Op/Phase II
Page 8 of 25
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Maintain Urinary Catheter [NURELM0013] CONTINUOUS, Starting today, 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: Postoperative Requirements
of Specific Procedure
Initiate Urinary Catheter Removal Protocol? (NP/PA
Must Select "No"): No
Details: To Dependent Drainage
Does this need to be inserted/placed?
Post-Op/Phase II
OG Tube Placement - Adult [120995]
Insert and Maintain Orogastric Tube
[NURTAD0015]
CONTINUOUS, Routine
Options:
Flush with:
Flush Frequency: EVERY 8 HOURS
Check Residual:
Does this need to be inserted/placed?
Device Status:
Refer to Policy 2.20AP Care & Maintenance of
Enteral Tubes (Adult & Pediatric)
Recommendations for flush quantity:
For adult patients, 30 mLs of fluid should be
sufficient.
Remove when patient is extubated., Post-Op/Phase
II
X-RAY ABDOMEN AP VIEW (KUB) [R74000] CONDITIONAL For 3 Days, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? Orogastric tube
placement
What specific question(s) would you like answered
by this exam? Evaluate orogastric tube placement
Relevant recent/past history? Cardiac Surgery
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 orogastric
tube placement. The location of orogastric 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
Post-Op/Phase II
RT to Provide Patient with AM1 Spirometer and
Supplies for Home Use [RT0068]
ONCE, Routine
Contingency Parameters [88009]
Page 9 of 25
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 160
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg): 90
If diastolic blood pressure < (mmHg): 40
If temperature > (C): 38.3
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 60
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 90
If urine output < (mL): 30 mL/hour
Other: Cardiac Index (CI) less than *** or greater than
*** liters/minute,Mean arterial pressure less than *** or
greater than *** mmHg,Hematocrit less than
30%,Change in cardiac rhythm,Systemic vascular
resistance (SVR) less than *** or greater than ***
mmHg,Partial pressure of oxygen in arterial blood
(PaO2) less than *** mmHg,Partial pressure of carbon
dioxide in arterial blood (PaCO2) greater than ***
mmHg,Saturated venous oxygen (SvO2) less than ***
%,Chest tube output greater than 150
mL/hour,Calcium less than 7.5 mg/dL,Calcium less
than 7.5 mg/dL
Post-Op/Phase II
Intravenous Therapy
Premedications for Needle Insertion [106327]
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.
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Post-Op/Phase II
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
Post-Op/Phase II
Page 10 of 25
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

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
Post-Op/Phase II
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
Post-Op/Phase II
IV Fluids [88011]
dextrose 5%-NaCl 0.45% infusion [51613] at 5 mL/hr, Intravenous, CONTINUOUS
Per central venous pressure (CVP) port.
Post-Op/Phase II
sodium chloride 0.9 % infusion [64367] at 4 mL/hr, Other, CONTINUOUS
Per intraflow for arterial line
Post-Op/Phase II
Cap Unused Peripheral Intravenous
Catheters/Triple Lumen Catheters/PICCs and
Swan Ports [NURVAD0053]
ONCE, Starting today For 1 Occurrences, Post-
Op/Phase II
Medications - Anti-infectives - General
Fibrosis/Bronchiectasis NOT order for patients with Cystic Do
First Line (Single Response) [147647]
ceftriaxone (ROCEPHIN) intraVENOUS [800027] 2 g, Intravenous, EVERY 24 HOURS For 7 Days,
Post-Op/Phase II
MRSA/Documented MRSA History (Single Response) [147648]
Ceftriaxone and Vancomycin [231022]
ceftriaxone (ROCEPHIN) intraVENOUS [800027] 2 g, Intravenous, EVERY 24 HOURS For 7 Days,
Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS
[800084]
15 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Immediate/Severe Reaction to Penicillin or Known Cephalosporin Allergies [147655]
moxifloxacin (AVELOX) 400 mg in sodium
chloride 0.8% 250 mL bag [68662]
400 mg, Intravenous, EVERY 24 HOURS For 7 Days,
for 60 Minutes, Post-Op/Phase II
Medications - General
Analgesics - Acetaminophen - As Needed [205914]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain, For mild-
moderate pain or temperature greater than 38.5
degrees Celsius, Post-Op/Phase II
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Nasogastric Tube, EVERY 4 HOURS PRN,
pain/fever, For mild-moderate pain or temperature
greater than 38.5 degrees Celsius, Post-Op/Phase II
Analgesics - Opioid [88013]
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HYDROmorphone PF (DILAUDID) injection
[800120]
0.2-0.8 mg, Intravenous, EVERY 1 HOUR PRN, For
severe pain if unable to tolerate oral administration,
Post-Op/Phase II
oxycodone tab RANGE [750032] 5-15 mg, Oral, EVERY 3 HOURS PRN, pain, For
severe pain, Post-Op/Phase II
Anti-emetics [205915]
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 12 HOURS PRN,
nausea/vomiting, When unable to take orally., Post-
Op/Phase II
ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
4 mg, Oral, EVERY 12 HOURS PRN,
nausea/vomiting, First line administration, Post-
Op/Phase II
Anti-infectives [148764]
itraconazole (SPORANOX) soln [55971] 200 mg, Oral, 1 X DAILY (HS), Post-Op/Phase II
amphotericin B CONVENTIONAL neb soln
[780154]
2.5 mg, Nebulization, RT 2 X DAILY, Post-Op/Phase II
Anti-anxiety [88014]
midazolam (VERSED) injection RANGE [750056] 1-2 mg, Intravenous, EVERY 1 HOUR PRN For 48
Hours, sedation, agitation or anxiety while on
ventilator, Post-Op/Phase II
Pneumocystis Pneumonia Prophylaxis (Single Response) [95532]
sulfamethoxazole-trimethoprim 200-40 mg/5 mL
(BACTRIM) susp - 160 mg [58784]
160 mg, Nasogastric Tube, EVERY MON, WED, FRI,
Post-Op/Phase II
atovaquone (MEPRON) susp - NOTE: Order for
patients allergic to sulfonamides [50620]
750 mg, Oral, 1 X DAILY, Post-Op/Phase II
Anti-virals [88016]
ganciclovir (CYTOVENE) intraVENOUS [800188] 5 mg/kg, Intravenous, EVERY 12 HOURS
Pharmacy to order valganciclovir (VALCYTE) 900 mg
orally once a day when patient tolerating oral intake
Post-Op/Phase II
Anti-virals - CMV Mismatch: Donor (+)/Recipient (-) [88017]
immune globulin 10% (GAMMAGARD LIQ) bag
[143798]
150 mg/kg, Intravenous, EVERY 14 DAYS Starting
tomorrow at 12:00 PM For 5 Doses
Refer to IVIG Guideline for Administration
Recommendations. Does NOT require filter for
administration.
Postoperative Day 1 and weeks 2, 4, 6, and 8 post-
transplant.
Pharmacist to round dose to nearest 2.5 grams
Post-Op/Phase II
immune globulin 10% (GAMMAGARD LIQ) bag
[143798]
100 mg/kg, Intravenous, EVERY 28 DAYS Starting
12/19/17 at 12:00 PM For 2 Doses
Refer to IVIG Guideline for Administration
Recommendations. Does NOT require filter for
administration.
Weeks 12 and 16 post-transplant.
Pharmacist to round dose to nearest 2.5 grams.
Post-Op/Phase II
Bronchodilators [88018]
albuterol neb soln (3 mL) [800248] 2.5 mg, Nebulization, RT EVERY 6 HOURS
While intubated
Post-Op/Phase II
albuterol HFA 108 (90 BASE) MCG/ACT
(VENTOLIN HFA) inhaler [53730]
2 puff, Inhalation, RT 3 X DAILY
Post Extubation
Post-Op/Phase II
Bowel Management - High Risk [205916]
Page 12 of 25
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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bisacodyl (DULCOLAX) rectal suppository -
NOTE: Give on Postoperative Day #1 [35231]
10 mg, Rectal, ONCE Starting tomorrow at 8:00 AM
For 1 Doses, Post-Op/Phase II
senna-docusate (SENOKOT S) 8.6-50 MG per
tab [60530]
2 tab, Oral, 2 X DAILY Starting tomorrow
Hold for loose stool or suspected obstruction. Use
rescue therapy after first 48 hours if inadequate
response to scheduled bowel management.
Post-Op/Phase II
polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 2 X DAILY (AT MEALTIME) Starting
9/28/17
Hold for loose stool or suspected obstruction. Use
rescue therapy after first 48 hours if inadequate
response to scheduled bowel management.
Post-Op/Phase II
bisacodyl (DULCOLAX) rectal suppository - Use if
no response to first line rescue within 24 hours.
[35231]
10 mg, Rectal, 1 X DAILY PRN Starting 9/28/17 at
8:00 AM, constipation
Use as second line rescue therapy if no response to
first line rescue therapy within 24 hours or if immediate
laxation is needed, and notify Primary Team.
Post-Op/Phase II
Gastric (Single Response) [88021]
pantoprazole (PROTONIX) injection [800119] 40 mg, Intravenous, 1 X DAILY
Pharmacy to order oral pantoprazole (PROTONIX) EC
tab 40 mg orally once a day when patient tolerating
oral intake
Post-Op/Phase II
Potassium Supplementation (Single Response) [87702]
potassium chloride 10 mEq/100 mL bag [46253] 10 mEq, Intravenous, PRN, potassium
supplementation - See Administration Instructions
Order for patients WITHOUT renal impairment (CrCl
greater than 30 mL/min)
For potassium level between 3.8 - 4.0 mmol/L give 10
mEq x2
For potassium level between 3.5 - 3.7 mmol/L give 10
mEq x4
For potassium level between 3.2 - 3.4 mmol/L give 10
mEq x6
Order for patients with renal impairment (CrCl less
than 30 mL/min)
For potassium level between 3.5 - 3.7 mmol/L give 10
mEq x1
For potassium level between 3.2 - 3.4 mmol/L give 10
mEq x2
for 60 Minutes, Post-Op/Phase II
Magnesium Supplementation (Single Response) [87703]
Magnesium Supplemental Scale [950039] PRN - NOTIFY PHARMACY WHEN NEEDED, PRN
comment: magnesium supplementation - See
Administration Instructions
For serum magnesium 1.6-1.8 mg/dL give 0.05 g/kg IV
For serum magnesium 1.0-1.5 mg/dL give 0.1 g/kg IV
For serum magnesium less than 1 mg/dL give 0.15
g/kg IV
Administer each bag (2 gram or 1 gram) over 3 hours
at a frequency of one bag every 4 hours.
Post-Op/Phase II
Page 13 of 25
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Magnesium Supplemental Scale - NOTE: Order in
patients with RENAL impairment (CrCl <30
mL/min) [950039]
PRN - NOTIFY PHARMACY WHEN NEEDED, PRN
comment: magnesium supplementation - See
Administration Instructions
For serum magnesium 1.6-1.8 mg/dL give 0.025 g/kg
IV
For serum magnesium 1.0-1.5 mg/dL give 0.05 g/kg IV
For serum magnesium less than 1 mg/dL give 0.075
g/kg IV
Administer each bag (2 gram or 1 gram) over 3 hours
at a frequency of one bag every 4 hours.
NOTE: Order in patients with RENAL impairment
(CrCl < 30 mL/min)
Post-Op/Phase II
Non-categorized [88025]
mannitol 25% vial [39352] 12.5 g, Intravenous, EVERY 8 HOURS For 3 Doses
**Examine for Crystals** Administer with 0.2 or 0.22
micron filter
Post-Op/Phase II
sodium chloride flush 0.9% 10 mL injection
[785055]
Flush, PRN, flush/line care, Flush per guideline
Flushing/Locking of Venous Access Devices, Post-
Op/Phase II
naloxone (NARCAN) injection [800199] 0.1 mg, Intravenous, PRN, opioid overdose
Administer every 3 minutes times 4 doses as needed
for respiratory rate less than 8 breaths/minute or
sedation score of 5 or greater. Notify MD if naloxone
administered.
Post-Op/Phase II
Vasoactive Agents [88027]
DOPamine (INTROPIN) 800 mg in dextrose 5%
250 mL infusion [50506]
2 mcg/kg/min, Intravenous, CONTINUOUS, Post-
Op/Phase II
norepinephrine (LEVOPHED) infusion [700247] Intravenous, CONTINUOUS
Titrate by 0.01 mcg/kg/min every 3 minutes to
maintain mean arterial pressure greater than ***
mmHg or systolic blood pressure greater than ***
mmHg (Maximum 0.99 mcg/kg/min)
Post-Op/Phase II
vasopressin (PITRESSIN) 20 units in dextrose 5
% 100 mL infusion (SEPTIC SHOCK) [700977]
Intravenous, CONTINUOUS
Titrate by 0.01 unit/minute every *** minutes to
maintain mean arterial presure greater than *** mmHg
or systolic pressure greater than *** mmHg (Maximum
0.06 units/min)
epINEPHrine infusion [700197] Intravenous, CONTINUOUS
Titrate by 0.01 mcg/kg/min every 3 minutes to
maintain mean arterial pressure greater than ***
mmHg or systolic blood pressure greater than ***
mmHg (Maximum 0.1 mcg/kg/min)
Post-Op/Phase II
milrinone (PRIMACOR) 20 mg in dextrose 5%
100 mL infusion [175995]
Intravenous, CONTINUOUS
Titrate by *** mcg/kg/min every 6 hours to keep
cardiac index greater than 2 L/min/m2 or systolic
blood pressure greater than *** mmHg (Maximum 0.75
mcg/kg/min)
Post-Op/Phase II
Page 14 of 25
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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DOBUTamine (DOBUTREX) 1000mg in dextrose
5% 250 mL infusion [51747]
Intravenous, CONTINUOUS
Titrate by 1 mcg/kg/min every 6 hours to keep cardiac
index greater than 2 L/min/m2 or systolic blood
pressure greater than *** mmHg (Maximum 20
mcg/kg/min)
Post-Op/Phase II
Medications - Immunosuppressants
Calcineurin Inhibitors (Single Response) [88029]
tacrolimus susp [780140] 1 mg, Oral, EVERY 12 HOURS, Post-Op/Phase II
tacrolimus (GENERIC) cap [61281] Sublingual, EVERY 12 HOURS, Post-Op/Phase II
tacrolimus (GENERIC) cap - NOTE: For patients
with cystic fibrosis [61281]
Sublingual, EVERY 12 HOURS
NOTE: For patients with cystic fibrosis
Post-Op/Phase II
Purine Synthesis Inhibitors [88030]
mycophenolate (CELLCEPT) intraVENOUS
[800198]
1,000 mg, Intravenous, 2 X DAILY (AT MEALTIME)
Pharmacy to order mycophenolate sodium
(MYFORTIC) EC tab 720 mg oral 2x daily on POD # 5
if patient is tolerating oral intake.
Post-Op/Phase II
Interleukin-2 Inhibitor [88031]
basiliximab (SIMULECT) 20 mg in sodium
chloride 0.9 % 50 mL bag [700156]
20 mg, Intravenous, ONCE Starting 9/30/17 For 1
Doses, Post-Op/Phase II
Steroids [88032]
Lung Transplant - Steriod Taper [222785] "Followed by" Linked Panel
methylprednisolone sodium succ. (SOLU-
MEDROL) intraVENOUS [800058]
125 mg, Intravenous, EVERY 8 HOURS For 3
Doses
Round dose to the nearest 5 mg
Post-Op/Phase II
methylprednisolone sodium succ. (SOLU-
MEDROL) intraVENOUS [800058]
0.5 mg/kg, Intravenous, EVERY 12 HOURS For 6
Doses
Round up dose to the nearest 5 mg
Post-Op/Phase II
methylprednisolone sodium succ. (SOLU-
MEDROL) intraVENOUS [800058]
0.25 mg/kg, Intravenous, EVERY 12 HOURS For 8
Doses
Round up dose to the nearest 5 mg
Post-Op/Phase II
prednisone (DELTASONE) tab [41277] 0.2 mg/kg, Oral, 2 X DAILY (AT MEALTIME) For 44
Doses
Round up dose to the nearest 5 mg
Post-Op/Phase II
prednisone (DELTASONE) tab [41277] 0.1 mg/kg, Oral, 2 X DAILY (AT MEALTIME) For 58
Doses
Round up dose to the nearest 5 mg
Post-Op/Phase II
prednisone (DELTASONE) tab [41277] 0.1 mg/kg, Oral, 1 X DAILY For 58 Doses
Round up dose to the nearest 5 mg
Post-Op/Phase II
Note: May give intravenous methylprednisonlone
in equivalent dose if patient unable to tolerate oral
intake (methylprednisolone to prednisone
conversion of 4 mg to 5 mg) [950018]
ONCE For 1 Doses
Note: May give intravenous methylprednisonlone in
equivalent dose if patient unable to tolerate oral intake
(methylprednisolone to prednisone conversion of 4 mg
to 5 mg)
Post-Op/Phase II
Medications - For Cystic Fibrosis/Bronchiectasis Patients
Non-categorized [88034]
Page 15 of 25
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sorbitol 70% soln [132049] 30 mL, Oral, 3 X DAILY, Post-Op/Phase II
sodium chloride-sodium bicarbonate (SINU-
CLEANSE) nasal Kit [114345]
Nasal, 1 X DAILY, Post-Op/Phase II
multivitamin cystic fibrosis cap [800234] Oral, Post-Op/Phase II
Pancreatic Enzymes [88035]
Note: Self Administered Medication Program
Documentation [950000]
ONCE For 1 Doses
Patient may self-administer pancreatic enzymes
Post-Op/Phase II
Note: Patient may use home supply of pancreatic
enzymes if available [950018]
ONCE For 1 Doses
Patient may use home supply of pancreatic enzymes if
available
Post-Op/Phase II
pancrelipase (CREON) 12000 units delayed
release cap [136488]
Oral, 3 X DAILY (AT MEALTIME)
With meals
Post-Op/Phase II
pancrelipase (CREON) 12000 units delayed
release cap [136488]
Oral, PRN, snacks, Post-Op/Phase II
pancrelipase (CREON) 12000 units delayed
release cap [136488]
1 cap, Oral, EVERY 12 HOURS, Post-Op/Phase II
pancrelipase (ZENPEP) 5000 units delayed
release cap [138296]
Oral, 3 X DAILY (AT MEALTIME)
With meals
Post-Op/Phase II
pancrelipase (ZENPEP) 5000 units delayed
release cap [138296]
Oral, PRN, Post-Op/Phase II
pancrelipase (ZENPEP) 5000 units delayed
release cap [138296]
1 cap, Oral, EVERY 12 HOURS, Post-Op/Phase II
pancrelipase (ZENPEP) 10000 units delayed
release cap [138297]
Oral, 3 X DAILY (AT MEALTIME)
With meals
Post-Op/Phase II
pancrelipase (ZENPEP) 10000 units delayed
release cap [138297]
Oral, PRN, snacks, Post-Op/Phase II
pancrelipase (ZENPEP) 10000 units delayed
release cap [138297]
1 cap, Oral, EVERY 12 HOURS, Post-Op/Phase II
pancrelipase (ZENPEP) 15000 units delayed
release cap [138298]
Oral, 3 X DAILY (AT MEALTIME)
With meals
Post-Op/Phase II
pancrelipase (ZENPEP) 15000 units delayed
release cap [138298]
Oral, PRN, snacks, Post-Op/Phase II
pancrelipase (ZENPEP) 15000 units delayed
release cap [138298]
1 cap, Oral, EVERY 12 HOURS, Post-Op/Phase II
pancrelipase (ZENPEP) 20000 units delayed
release cap [138299]
Oral, 3 X DAILY (AT MEALTIME)
With meals
Post-Op/Phase II
pancrelipase (ZENPEP) 20000 units delayed
release cap [138299]
Oral, PRN, snacks, Post-Op/Phase II
pancrelipase (ZENPEP) 20000 units delayed
release cap [138299]
1 cap, Oral, EVERY 12 HOURS, Post-Op/Phase II
Beta-lactams (Single Response) [88037]
cefepime (MAXIPIME) intraVENOUS [231260]
cefepime (MAXIPIME) 2 g vial + minibag [52163] 2 g, Intravenous, ONCE For 1 Doses, for .5 Hours
cefepime (MAXIPIME) 2 g vial + minibag [52163] 2 g, Intravenous
Start 6 hours after initial one-time order
for 4 Hours
Note: Run cefepime (MAXIPIME) over 4 hours
[950056]
EVERY 12 HOURS, Post-Op/Phase II
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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meropenem (MERREM) intraVENOUS - Note:
For patients 50 kg or less [800055]
40 mg/kg, Intravenous, EVERY 8 HOURS For 365
Days, Post-Op/Phase II
meropenem (MERREM) intraVENOUS - Note:
For patients greater than 50 kg [800055]
2,000 mg, Intravenous, EVERY 8 HOURS For 365
Days, Post-Op/Phase II
Piperacillin-Tazobactam 4.5 grams [227885]
piperacillin-tazobactam (ZOSYN) 4.5 g vial +
minibag [54251]
4.5 g, Intravenous, EVERY 8 HOURS
Start 6 hours after initial one-time order
for 4 Hours
Note: Run piperacillin-tazobactam (ZOSYN) over
4 hours [950048]
EVERY 8 HOURS
Fluoroquinolones [88036]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, EVERY 8 HOURS, Post-
Op/Phase II
Aminoglycosides (Single Response) [88038]
tobramycin (NEBCIN) neb soln [800220] 80 mg, Nebulization, EVERY 12 HOURS, Post-
Op/Phase II
tobramycin (NEBCIN) intraVENOUS [800081] 10 mg/kg, Intravenous, EVERY 24 HOURS, Post-
Op/Phase II
tobramycin (NEBCIN) intraVENOUS [800081] 5 mg/kg, Intravenous, EVERY 12 HOURS, Post-
Op/Phase II
Laboratory
Immediately Postoperative [103170]
BLOOD GASES AND O2 SATURATION
[HCBGASOS]
STAT, Starting today For 1 Occurrences, Routine
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Immediately postoperative, Post-Op/Phase II
CALCIUM [CA] STAT, 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?
Immediately postoperative, Post-Op/Phase II
ELECTROLYTES [LYTE] STAT, 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?
Immediately postoperative, Post-Op/Phase II
GLUCOSE [GLU] STAT, 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?
Immediately postoperative, Post-Op/Phase II
HEMATOCRIT [HCT] STAT, 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?
Immediately postoperative, Post-Op/Phase II
MAGNESIUM [MAG] STAT, 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?
Immediately postoperative, Post-Op/Phase II
Page 17 of 25
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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PHOSPHATE [PHOS] STAT, 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?
Immediately postoperative, Post-Op/Phase II
PLATELET COUNT [PLT] STAT, 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?
Immediately postoperative, Post-Op/Phase II
PROTHROMBIN TIME/INR [PT] STAT, 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?
Immediately postoperative, Post-Op/Phase II
In AM Postoperative Day 1 [88042]
ALBUMIN [ALB] 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?
Post-Op/Phase II
ALKALINE PHOSPHATASE [ALKP] 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?
Post-Op/Phase II
ALT/SGPT [ALT] 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?
Post-Op/Phase II
BILIRUBIN, TOTAL [TBIL] 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?
Post-Op/Phase II
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?
Post-Op/Phase II
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?
Post-Op/Phase II
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GGT [GGT] 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?
Post-Op/Phase II
LD, TOTAL [LDH] 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?
Post-Op/Phase II
TACROLIMUS [HCTAC] 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?
Post-Op/Phase II
Daily - Beginning Postoperative Day 2 [95483]
TACROLIMUS [HCTAC] NEXT AM, Starting 9/28/17 at 7:00 AM For 6 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
CREATININE [CRET] NEXT AM, Starting 9/28/17 at 7:00 AM For 4 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
BUN [BUN] NEXT AM, Starting 9/28/17 For 4 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
ELECTROLYTES [LYTE] NEXT AM, Starting 9/28/17 at 7:00 AM For 4 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
CBC WITHOUT DIFFERENTIAL [HEMO] NEXT AM, Starting 9/28/17 at 7:00 AM For 4 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
Conditional Labs [88044]
HEMATOCRIT [HCT] CONDITIONAL For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? 1 hour after packed
red blood cell infusion
Post-Op/Phase II
Page 19 of 25
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PROTHROMBIN TIME/INR [PT] CONDITIONAL For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? 1 hour after plasma
infusion
Post-Op/Phase II
BLOOD GASES AND O2 SATURATION
[HCBGASOS]
CONDITIONAL, Starting today For 2 Days, STAT
If source is OTHER, indicate here:
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Every 1 hour PRN with
vent changes
Post-Op/Phase II
POTASSIUM [K] CONDITIONAL, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw 1 hour after IV
potassium replacement and 4 hours after oral
potassium replacement
Post-Op/Phase II
MAGNESIUM [MAG] CONDITIONAL For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw AM following
completion of magnesium infusion
Post-Op/Phase II
Conditional Cultures [88047]
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL For 4 Days, Routine, For optimum
diagnosis of sepsis, sample 3-4 sites only on the first
day of a septic episode. Cultures on subsequent days
are of minimal diagnostic value. Culture detects
bacteria, Candida and Cryptococcus. If filamentous
fungi are suspected see Culture, Blood, Filamentous
Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, every 24 hours,
as needed for temperature greater than 38.3 degrees
Celsius
Post-Op/Phase II
Page 20 of 25
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL, Starting today For 4 Days, Routine,
For optimum diagnosis of sepsis, sample 3-4 sites
only on the first day of a septic episode. Cultures on
subsequent days are of minimal diagnostic value.
Culture detects bacteria, Candida and Cryptococcus.
If filamentous fungi are suspected see Culture, Blood,
Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition? Once, every 24 hours,
as needed for temperature greater than 38.3 degrees
Celsius
Post-Op/Phase II
CULTURE, SPUTUM WITH GRAM STAIN
[HCSPUCS]
CONDITIONAL For 4 Days, Routine, For patients with
an ET tube or tracheostomy, quantitative mini-BAL by
RT or bronchoscopic BAL are the preferred methods
of specimen collection.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, every 24 hours,
as needed for temperature greater than 38.3 degrees
Celsius
Post-Op/Phase II
CULTURE, URINE [URC] CONDITIONAL For 4 Days, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, every 24 hours,
as needed for temperature greater than 38.3 degrees
Celsius
Post-Op/Phase II
Diagnostic Tests and Imaging
Imaging [88055]
X-RAY CHEST AP VIEW - Immediately
Postoperative [R71010]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, STAT
Current signs and symptoms? Status post lung
transplant
What specific question(s) would you like answered by
this exam? status post lung transplant
Relevant recent/past history? Status post lung
transplant
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
Immediately postoperative, Post-Op/Phase II
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

X-RAY CHEST AP VIEW - Postoperative Day 1
[R71010]
ONCE-RAD NEXT AVAILABLE, Starting tomorrow at
6:00 AM For 1 Occurrences, Routine
Current signs and symptoms? Status post Lung
Transplant
What specific question(s) would you like answered by
this exam? Status post Lung Transplant
Relevant recent/past history? Status post Lung
Transplant
Is patient pregnant?
If being performed remotely, where? Bedside
Transport Method: Floor Determined/Entered
Post-Op/Phase II
X-RAY CHEST AP VIEW - Postoperative Day 1
[R71010]
ONCE-RAD NEXT AVAILABLE, Starting tomorrow at
3:00 PM For 1 Occurrences, Routine
Current signs and symptoms? Status post Lung
Transplant
What specific question(s) would you like answered by
this exam? Status post Lung Transplant
Relevant recent/past history? Status post Lung
Transplant
Is patient pregnant?
If being performed remotely, where? Bedside
Transport Method: Floor Determined/Entered
Post-Op/Phase II
X-RAY CHEST AP VIEW - Postoperative Day 2
[R71010]
ONCE-RAD NEXT AVAILABLE, Starting 9/28/17 For 1
Occurrences, Routine
Current signs and symptoms? Status post Lung
Transplant
What specific question(s) would you like answered by
this exam? Status post Lung Transplant
Relevant recent/past history? Status post Lung
Transplant
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Post-Op/Phase II
X-RAY ABDOMEN AP VIEW (KUB) -
Postoperative Day 3 [R74000]
ONCE-RAD NEXT AVAILABLE, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? S/P Lung Transplant
What specific question(s) would you like answered by
this exam? Evaluate for ileus or bowel distension
Relevant recent/past history? S/P Lung Transplant
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Post-Op/Phase II
Consults
Consults [88057]
Diabetes Consult Order Panel (Adult) [188497]
Page 22 of 25
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Diabetes Management Service : Will provide management or treatment recommendations for
patients with hyperglycemia and/or those who report outpatient use of insulin or other diabetes
medications. Patients should be expected to remain inpatient > 24 hrs from time of consult.
Consult is required for patients with insulin pumps or who use U-500 insulin. Consult Endocrine
for any non-diabetes-related endocrine questions.
Learning Center - Diabetes Education (Adult): Diabetes Education (Adult): Diabetes education
(meter/insulin skills/other diabetes survival skills) for patients/families with knowledge deficits
and/or need for diabetes knowledge assessment. Recommended for all new diagnoses or
patients with A1C > 9.
Diabetes Education – Nutrition: Diabetes nutrition therapy including nutrition assessment,
carbohydrate education (consistent carbohydrate meals, use of insulin-to-carbohydrate ratio),
and/or individualized, nutritious meal planning for carbohydrates, portions, or considering other
comorbidities. Recommended for all new diagnoses or patients with A1C > 9
Consult Diabetes Management Service (DMS)
(Inpatient) [CON0022]
ONCE
Can this consult be done via video?
Call back number:
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Post-Op/Phase II
Consult Learning Center - Diabetes Education
(Adult) [CON0021]
ONCE, Routine, - If patient is newly diagnosed or is
new to insulin, provide 24 hours notice to allow
adequate time for education,
- Indicate diabetes medication/treatment plan if
known.
- Consults requested after 1600 on Fridays may not
be seen until following Monday. Learning Center
available Mon-Sat 0800-1630 (only 1 RN available
on Saturday for CSC and AFCH).
- Staff may be contacted by Pager 7927 on
weekdays and Pager 3276 on weekends.
- Learning Center staff are not available on holidays.
Type of Education: Diabetes Self-Management
Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Post-Op/Phase II
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Consult Diabetes Education - Nutrition (Inpatient)
[CON0126]
ONCE, Routine, · If your patient is newly diagnosed
and/or is new to insulin therapy, provide 24 hours
notice to allow adequate time for nutrition education.
· Indicate diabetes medication/treatment plan if
known.
· Consults requested after 1300 on Friday may not
be completed until the following Monday.
· If you are placing a consult on a weekend day for a
patient who will be discharging that weekend, please
have the Paging Center contact the on-call dietitian
to help you facilitate the diabetes nutrition education
session prior to the patient's discharge.
Type of Education: Diabetes Self-Management
Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Post-Op/Phase II
Consult Infectious Disease (Inpatient) [CON0037] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Antibiotics
recommentation for Cystic Fibrosis/Bronchiectasis
patient, status post lung transplant.
Post-Op/Phase II
Consult Nutrition (Inpatient) [CON0043] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Delegate to Initiate and Manage Tube Feeding:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
Can this consult be done via video?
Post-Op/Phase II
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult: Mobility
Training
Post-Op/Phase II
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Occupational Therapy Consult: ADL
Training
Post-Op/Phase II
Consult Cardiac Rehab/Preventive Cardiology
(Inpatient) [CON0010]
ONCE, Starting today For 1 Occurrences, Routine
Reason for consult: Exercise prescription,Initiate bike
protocol POD 2,Other (Comment),(Strength &
conditioning)
Post-Op/Phase II
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: DISCHARGE PLANNING
Post-Op/Phase II
Consult Pulmonary Medicine (Inpatient)
[CON0065]
ONCE
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Immunosuppressive
management, status post lung transplant
Consult Advanced Pulmonary, Post-Op/Phase II
Page 24 of 25
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Consult Allergy (Inpatient) [CON0002] ONCE
Intent: Consult and Recommend (No Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Sulfa desensitization
Can this consult be done via video?
Call back number:
Post-Op/Phase II
BestPractice
No Hospital Problems have yet been identified [107363]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing., Post-Op/Phase II
Page 25 of 25
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org