/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/urology/,

/clinical/cckm-tools/content/order-sets/inpatient/urology/name-118664-en.cckm

201710296

page

100

UWHC,UWMF,

Tools,

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

IP - Cystectomy with Urinary Diversion - Adult - Postoperative [6502]

IP - Cystectomy with Urinary Diversion - Adult - Postoperative [6502] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Urology


IP - Cystectomy with Urinary Diversion - Adult Postoperative [6502]
for Adult Patients OnlyIntended
Admission Status
Level of Care (Single Response) [187485]
*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:
Post-Op/Phase II
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admission Status [112875]
Page 1 of 16
Printed by WILLIAMS, HEATHER R [HRS0] at 10/23/2017 8:32:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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:
Post-Op/Phase II
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admission Status [84059]
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:
Post-Op/Phase II
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
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]
Page 2 of 16
Printed by WILLIAMS, HEATHER R [HRS0] at 10/23/2017 8:32:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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
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
Page 3 of 16
Printed by WILLIAMS, HEATHER R [HRS0] at 10/23/2017 8:32:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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 [90721]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every hour times 2, then every two hours times 2, then
every four hours times 4 and then every eight hours.,
Post-Op/Phase II
Activity [90722]
Bed Rest Day of Surgery [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:
Post-Op/Phase II
Chair [NURACT0008] CONTINUOUS, Starting tomorrow, 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:
Post-Op/Phase II
Page 4 of 16
Printed by WILLIAMS, HEATHER R [HRS0] at 10/23/2017 8:32:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Activity [NURACT0008] CONTINUOUS, Starting tomorrow, Routine
AD LIB:
AMBULATE: 3x 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:
Post-Op/Phase II
May Shower on Post Operative Day 3
[NURACT0011]
CONTINUOUS, Post-Op/Phase II
Nutrition [90723]
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
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:
Post-Op/Phase II
Respiratory [90724]
Oxygen Therapy [RT0032] CONTINUOUS, Starting tomorrow For Until specified,
Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 92
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Discontinue if saturation is equal to or greater than
92% on room air starting postoperative day 1., Post-
Op/Phase II
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today For 24 Hours, Routine,
Post-Op/Phase II
Pulse Oximetry [NURMON0009] SEE COMMENTS, Starting tomorrow, Routine, Every
*** hours starting postoperative hour 24., Post-
Op/Phase II
Incentive Spirometry [NURTRT0018] EVERY 1 HOUR, Starting today, Routine, While
Awake, Post-Op/Phase II
Cough And Deep Breathe [NURTRT0019] EVERY 1 HOUR, Starting today, Routine, While
Awake, Post-Op/Phase II
Respiratory Therapy per Protocol [RT0035] Routine
Protocol Type:
Post-Op/Phase II
Intake and Output [90726]
Measure Intake And Output [NURMON0005] SEE COMMENTS, Starting today, Routine, Every 4
hours times 3, then every 8 hours., Post-Op/Phase II
Non-Categorized Patient Care Orders [90727]
Page 5 of 16
Printed by WILLIAMS, HEATHER R [HRS0] at 10/23/2017 8:32:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Insert and Maintain Nasogastric Tube
[NURTAD0014]
CONTINUOUS, Routine
Options: Low, Intermittent Suction
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.
Nothing Per Rectum [NURCOM0022] CONTINUOUS, Starting today, Post-Op/Phase II
Contingency Parameters [90728]
Notify [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 180
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg): 110
If diastolic blood pressure < (mmHg): 60
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 110
If heart rate < (bpm): 50
If respiratory rate >: 20
If respiratory rate <: 10
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 89
If urine output < (mL): 30 mL/hour
Other:
Post-Op/Phase II
Cystectomy Urinary Diversion - Procedure Specific Orders
Cystectomy Urinary Diversion - Procedure Specific Orders [225105]
Illeal Loop [225106]
Consult Ostomy Care Service (Inpatient)
[CON0052]
ONCE, Routine
Reason for Consult:
Can this consult be done via video?
Post-Op/Phase II
Wound Care - Closed Incision (Adult)
[NURWND0055]
CONTINUOUS, Routine
Wound Site:
Wound Location:
Assess Frequency: EVERY 8 HOURS
Incision Closed With: Staples
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): Open to air
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
Page 6 of 16
Printed by WILLIAMS, HEATHER R [HRS0] at 10/23/2017 8:32:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Maintain Drain [NURTAD0003] CONTINUOUS, Routine
Type: Closed Suction (Jackson-Pratt)
Site: Abdomen
Location:
Drainage Options: Bulb
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip: 2 X DAILY
Strip For:
Dressing Change Frequency: 2X DAILY
Dressing Type:
Post-Op/Phase II
Maintain Urethral Drain (Foley) to Dependent
Drainage [NURWND0018]
CONTINUOUS, Post-Op/Phase II
Indiana Pouch [225273]
Maintain Urethral Drain (Foley) to Dependent
Drainage [NURWND0018]
CONTINUOUS, Post-Op/Phase II
Stomal Catheter Capped [NURWND0018] ONCE, Post-Op/Phase II
Wound Care - Closed Incision (Adult)
[NURWND0055]
CONTINUOUS, Routine
Wound Site:
Wound Location:
Assess Frequency: EVERY 8 HOURS
Incision Closed With: Staples
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): Open to air
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
Maintain Drain - Suprapubic Catheter
[NURTAD0003]
CONTINUOUS, Routine
Type: Other (Comment Required) (Malecot)
Site: Abdomen
Location:
Drainage Options: Dependent Drainage
Irrigate Frequency: EVERY 8 HOURS
Irrigate With: Normal Saline
Irrigant Volume (mL): 30-50 mL
Strip:
Strip For:
Dressing Change Frequency:
Dressing Type:
Assess drain every 8 hours to make sure it is
properly secured to the patient, resecure as needed.
On Postoperative day 2, RN to irrigate suprapubic
catheter every 8 hours and PRN., Post-Op/Phase II
Page 7 of 16
Printed by WILLIAMS, HEATHER R [HRS0] at 10/23/2017 8:32:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Maintain Drain - Stent (#1) [NURTAD0003] CONTINUOUS, Routine
Type: Stent
Site: Abdomen
Location: Anterior
Drainage Options: Dependent Drainage
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For:
Dressing Change Frequency:
Dressing Type:
Assess drain every 8 hours to make sure it is
properly secured to the patient, resecure as needed.,
Post-Op/Phase II
Maintain Drain - Stent (#2) [NURTAD0003] CONTINUOUS, Routine
Type: Stent
Site: Abdomen
Location: Anterior
Drainage Options: Dependent Drainage
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For:
Dressing Change Frequency:
Dressing Type:
Assess drain every 8 hours to make sure it is
properly secured to the patient, resecure as needed.,
Post-Op/Phase II
Maintain Drain - Jackson-Pratt [NURTAD0003] CONTINUOUS, Routine
Type: Closed Suction (Jackson-Pratt)
Site: Abdomen
Location:
Drainage Options: Bulb
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip: EVERY 6 HOURS
Strip For:
Dressing Change Frequency:
Dressing Type:
Assess drain every 8 hours to make sure it is
properly secured to the patient, resecure as needed.,
Post-Op/Phase II
Neobladdder [225275]
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?
Post-Op/Phase II
Page 8 of 16
Printed by WILLIAMS, HEATHER R [HRS0] at 10/23/2017 8:32:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Wound Care - Closed Incision (Adult)
[NURWND0055]
CONTINUOUS, Routine
Wound Site:
Wound Location:
Assess Frequency: EVERY 8 HOURS
Incision Closed With: Staples
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): Open to air
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
Maintain Drain - Suprapubic Catheter
[NURTAD0003]
CONTINUOUS, Routine
Type: Other (Comment Required) (Malecot)
Site: Abdomen
Location:
Drainage Options: Dependent Drainage
Irrigate Frequency: EVERY 8 HOURS
Irrigate With: Normal Saline
Irrigant Volume (mL): 30-50 mL
Strip:
Strip For:
Dressing Change Frequency:
Dressing Type:
Assess drain every 8 hours to make sure it is
properly secured to the patient, resecure as needed.
On Postoperative day 2, RN to irrigate suprapubic
catheter every 8 hours and PRN., Post-Op/Phase II
Maintain Drain - Stent (#1) [NURTAD0003] CONTINUOUS, Routine
Type: Stent
Site: Abdomen
Location: Anterior
Drainage Options: Dependent Drainage
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For:
Dressing Change Frequency:
Dressing Type:
Assess drain every 8 hours to make sure it is
properly secured to the patient, resecure as needed.,
Post-Op/Phase II
Page 9 of 16
Printed by WILLIAMS, HEATHER R [HRS0] at 10/23/2017 8:32:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Maintain Drain - Stent (#2) [NURTAD0003] CONTINUOUS, Routine
Type: Stent
Site: Abdomen
Location: Anterior
Drainage Options: Dependent Drainage
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For:
Dressing Change Frequency:
Dressing Type:
Assess drain every 8 hours to make sure it is
properly secured to the patient, resecure as needed.,
Post-Op/Phase II
Maintain Drain - Jackson-Pratt [NURTAD0003] CONTINUOUS, Routine
Type: Closed Suction (Jackson-Pratt)
Site: Abdomen
Location:
Drainage Options: Bulb
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip: EVERY 6 HOURS
Strip For:
Dressing Change Frequency:
Dressing Type:
Assess drain every 8 hours to make sure it is
properly secured to the patient, resecure as needed.,
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 16
Printed by WILLIAMS, HEATHER R [HRS0] at 10/23/2017 8:32:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@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 Therapy [148833]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Post-Op/Phase II
sodium chloride flush 0.9% 10 mL injection
[785055]
Flush, PRN, flush/line care, Flush per VAD guidelines,
Post-Op/Phase II
IV Fluids (Single Response) [146975]
sodium chloride 0.9% infusion [64367] at 125 mL/hr, Intravenous, CONTINUOUS, Post-
Op/Phase II
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L
infusion [44910]
at 125 mL/hr, Intravenous, CONTINUOUS, Post-
Op/Phase II
sodium chloride 0.45% with KCl 20mEq/L infusion
[73035]
at 125 mL/hr, Intravenous, CONTINUOUS, Post-
Op/Phase II
sodium chloride 0.9% with KCl 20 mEq/L infusion
[46261]
at 125 mL/hr, Intravenous, CONTINUOUS, Post-
Op/Phase II
sodium chloride 0.45% infusion [42187] at 125 mL/hr, Intravenous, CONTINUOUS, Post-
Op/Phase II
Surgical Prophylaxis
First Line (Single Response) [148719]
cefuroxime (ZINACEF) intraVENOUS - NOTE:
Patients who are 40-160 kg - if not entering the GI
tract [800030]
1.5 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
cefuroxime (ZINACEF) intraVENOUS - NOTE:
Patients who are 160 kg and greater - If not
entering the GI tract [800030]
3 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
cefoxitin (MEFOXIN) intraVENOUS - NOTE:
Patients who are 40 - 120 kg - If entering the GI
tract [800022]
2 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
cefoxitin (MEFOXIN) intraVENOUS - NOTE:
Patients who are 121 kg and greater - If entering
the GI tract [800022]
3 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
MRSA/Documented MRSA History (Single Response) [148809]
Patients who are 40 - 160 kg - If not entering the
GI tract [231425]
Page 11 of 16
Printed by WILLIAMS, HEATHER R [HRS0] at 10/23/2017 8:32:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

cefuroxime (ZINACEF) intraVENOUS [800030] 1.5 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS -
NOTE: Maximum dose 2000 mg [800084]
20 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Patients who are 160 kg and greater - If not
entering the GI tract [231428]
cefuroxime (ZINACEF) intraVENOUS [800030] 3 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS -
NOTE: Maximum dose 2000 mg [800084]
20 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Patients who are 40 - 120 kg - If entering the GI
tract [231431]
cefoxitin (MEFOXIN) intraVENOUS [800022] 2 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Patients who are 121 kg and greater - If entering
the GI tract [231434]
cefoxitin (MEFOXIN) intraVENOUS [800022] 3 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single Response) [148818]
Patient who are 40 - 120 kg - If not entereing the
GI tract [231714]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS
(Maxium dose = 2000 mg) [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patient who are 121 - 160 kg - If not entereing
the GI tract [231717]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS
(Maximum dose = 2000 mg) [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patient who are greater than 161 kg - If not
entereing the GI tract [231720]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patient who are 40 - 120 kg - If entereing the GI
tract [231723]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS
(Maximum dose = 2000 mg) [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patient who are 121 - 160 kg - If entereing the GI
tract [231726]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS
(Maximum dose = 2000 mg) [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Page 12 of 16
Printed by WILLIAMS, HEATHER R [HRS0] at 10/23/2017 8:32:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Patient who are greater than 161 kg - If entereing
the GI tract [231729]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL Starting today For 1
Doses with First Dose Include Now, IntraOp
vancomycin (VANCOCIN) intraVENOUS
(Maximun dose = 2000 mg) [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Anti-infectives - For patients with Enterococcus [148825]
ampicillin (OMNIPEN) intraVENOUS [800009] 1 g, Intravenous, Post-Op/Phase II
Medications - General
Analgesics - Aceaminophen - PRN [90732]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain,
Administer for mild to moderate pain, multimodl
therapy, or fever (39 degress C, Post-Op/Phase II
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Nasogastric Tube, EVERY 4 HOURS PRN,
pain/fever, Administer for mild to moderate pain,
multimodl therapy, or fever (39 degress C, Post-
Op/Phase II
Analgesics - NSAIDS - Scheduled [225381]
ketOROLAC (TORADOL) injection - NOTE: Do
NOT order ketorolac if patient 65 years or older,
50 kg or less, or serum creatinine 1.2 mg/dL or
more [800050]
15 mg, Intravenous, EVERY 6 HOURS For 48 Hours,
Post-Op/Phase II
Analgesics - Opioids - Intravenous - PRN (Single Response) [90733]
-Controlled Analgesia (PCA) patient controlled analgesia (PCA) refer to "Intravenous Patient For
Set" Supplemental Order -Adult
MORPHine PF injection RANGE [750057] 1-2 mg, Intravenous, EVERY 1 HOUR PRN, pain,
severe pain, for 4 Minutes, Post-Op/Phase II
HYDROmorphone PF (DILAUDID) injection
RANGE [750050]
0.2-0.6 mg, Intravenous, EVERY 2 HOURS PRN,
severe pain, for 3 Minutes, Post-Op/Phase II
GI Promotility - Opioid Antagonist [236758]
alvimopan (ENTEREG) cap [130251] 12 mg, Oral, 2 X DAILY For 15 Doses, Post-Op/Phase
II
Anti-emetics [90734]
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 12 HOURS PRN,
nausea/vomiting
Administer first line when unable to tolerate oral
Post-Op/Phase II
ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
4 mg, Oral, EVERY 12 HOURS PRN, nausea/vomiting
Administer first line
Post-Op/Phase II
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Administer second line when there is no response to
first line antiemetic within 30 minutes and patient
unable to toleral oral administraton
If ordered IV, push slowly, max rate 5 mg/minute
Post-Op/Phase II
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN, nausea/vomiting
Administer second line when there is no response to
first line antiemetic within 30 minutes
Post-Op/Phase II
Bowel Management [90735]
senna-docusate (SENOKOT-S) 8.6-50 mg per tab
[60530]
2 tab, Oral, 2 X DAILY PRN, constipation, Post-
Op/Phase II
Page 13 of 16
Printed by WILLIAMS, HEATHER R [HRS0] at 10/23/2017 8:32:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 1 X DAILY PRN, constipation
Administer as first line therapy for constipation
Dissolve in 240 mL of liquid
Post-Op/Phase II
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, Oral, 1 X DAILY PRN, constipation
Administer as second line therapy for constipation if
no response to first line therapy within 24 hours
May dilute with a small amount of water prior to
administration. Follow administration with a full glass
of water.
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal, 1 X DAILY PRN, constipation
Administer as third line therapy for constipation.
Administer if no response to first or second line
therapy within 24 hours or when there is need for
immediate laxation
Hypnotics [111640]
traZODONE (DESYREL) tab [720150] 25 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see IPOC supplemental Sleep/Rest
Disturbance Adult)
Post-Op/Phase II
Non-Categorized [225382]
naloxone (NARCAN) injection [800199] 0.1 mg, Intravenous, PRN, opioid overdose
Laboratory
Draw Stat in PACU [112876]
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?
PACU
BUN [BUN] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PACU
CALCIUM [CA] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PACU
CREATININE [CRET] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PACU
ELECTROLYTES [LYTE] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PACU
GLUCOSE [GLU] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PACU
Page 14 of 16
Printed by WILLIAMS, HEATHER R [HRS0] at 10/23/2017 8:32:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

MAGNESIUM [MAG] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PACU
PHOSPHATE [PHOS] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PACU
Draw Postoperative Day 1 [114161]
CBC WITHOUT DIFFERENTIAL [HEMO] NEXT AM, Starting today For 5 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
ELECTROLYTES [LYTE] NEXT AM, Starting today For 5 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 today For 5 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 today For 5 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
GLUCOSE [GLU] NEXT AM, Starting today For 5 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
CALCIUM [CA] NEXT AM, Starting today For 5 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
MAGNESIUM [MAG] NEXT AM, Starting today For 5 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
PHOSPHATE [PHOS] NEXT AM, Starting today For 5 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
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging in PACU [112883]
Page 15 of 16
Printed by WILLIAMS, HEATHER R [HRS0] at 10/23/2017 8:32:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

X-RAY ABDOMEN AP VIEW (KUB) [R74000] ONCE-RAD NEXT AVAILABLE, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? IP PACU
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Done in PACU, PACU
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? IP PACU
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Done in PACU, PACU
Consults
Consults [90741]
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult:
Post-Op/Phase II
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Occupational Therapy Consult:
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 16 of 16
Printed by WILLIAMS, HEATHER R [HRS0] at 10/23/2017 8:32:35 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org