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/clinical/cckm-tools/content/order-sets/inpatient/urology/name-99552-en.cckm

201704104

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

IP - Urology - General - Pediatric - Postoperative [2492]

IP - Urology - General - Pediatric - Postoperative [2492] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Urology


IP - Urology - General - Pediatric - Postoperative [2492]
Urology Procedure Type
Procedure Type Specific Orders (Single Response) [145503]
Ureteral Reimplantation Specific Orders [145497]
Measure Urine Output From Ureteral Stent
[NURMON0012]
EVERY 2 HOURS, Routine, Post-Op/Phase II
Measure Urine Output From Ureteral Stent
[NURMON0012]
EVERY 2 HOURS, Routine, Post-Op/Phase II
Maintain Drain [NURTAD0003] CONTINUOUS, Routine
Type: Ureteral Stent
Site:
Location:
Drainage Options:
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For:
Dressing Change Frequency:
Dressing Type:
Post-Op/Phase II
Maintain Drain [NURTAD0003] CONTINUOUS, Routine
Type: Ureteral Stent
Site:
Location:
Drainage Options:
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For:
Dressing Change Frequency:
Dressing Type:
Post-Op/Phase II
Pyeloplasty Specific Orders [145496]
Maintain Drain [NURTAD0003] CONTINUOUS, Routine
Type: Soft Open Tube (Penrose)
Site:
Location:
Drainage Options:
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For:
Dressing Change Frequency: PRN
Dressing Type: Gauze
Save all dressings for MD rounds. Save in plastic
container or bag after weighing and record dressing
weights in Input/Output, Post-Op/Phase II
Nephrectomy Specific Orders [147645]
Page 1 of 17
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Maintain Drain [NURTAD0003] CONTINUOUS, Routine
Type: Soft Open Tube (Penrose)
Site:
Location:
Drainage Options:
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For:
Dressing Change Frequency:
Dressing Type:
Hypospadias Specific Orders [147828]
bacitracin ointment [49271] Topical, 3 X DAILY
Apply to tip of penis and dressing until dressing
falls off.
Double Diapering [NURWND0018] ONCE
Restraints: Nonviolent and/or Non Self-
Destructive [RST0001]
1 CALENDAR DAY, Starting today For 1 Days,
Routine, For behavior that could be classified as
irrational or uncooperative, such as attempting to
seriously interfere with a physical treatment or
device, such as an IV line, other indwelling lines,
respirator, or a dressing. Patients experiencing
cognitive impairment typically fit into this category,
including the patient in alcohol withdrawal.
Restraint orders have a one calendar day limit. A
new order should be placed, preferably by noon, for
every calendar day the patient remains in
restraints.
Restraint Type:
Reason for Restraint:
Strict Bedrest [NURACT0008] CONTINUOUS, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: strict bedrest
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Head of Bed no greater than 30 degrees
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.
Page 2 of 17
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

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 (Single Response) [99220]
Admit To Inpatient Status [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 Status [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Page 3 of 17
Printed by WILLIAMS, HEATHER R S [HRS0] at 4/12/2017 4:02:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

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
Patient Care Orders
Vital Signs [80982]
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 4, then every 2 hours times 4, then
every 4 hours., Post-Op/Phase II
Patient Monitoring [145396]
Page 4 of 17
Printed by WILLIAMS, HEATHER R S [HRS0] at 4/12/2017 4:02:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Insert and 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:
Details: To Dependent Drainage
Does this need to be inserted/placed? Yes
Normal urine output for patients ages 0-12 months is
2 ml/kg/hr. For patients greater than 12 months,
normal urine output is 0.5-1 ml/kg/hr. If urine output
is less than normal, irrigate foley and perform bladder
scan. Notify MD as directed., Post-Op/Phase II
Do Not Perform Urinary Catheter Care
[NURELM0061]
ONCE, Post-Op/Phase II
Continuous Bladder Irrigation [NURELM0071] CONTINUOUS, Routine
Irrigate With: Normal Saline
Post-Op/Phase II
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:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Normal urine output for patients ages 0-12 months is
2 ml/kg/hr. For patients greater than 12 months,
normal urine outpu is 0.5-1 ml/kg/hr. If urine output is
less than normal, irrigate foley and perform bladder
scan. Notify MD as directed., Post-Op/Phase II
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:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Normal urine output for patients ages 0-12 months is
2 ml/kg/hr. For patients greater than 12 months,
normal urine outpu is 0.5-1 ml/kg/hr. If urine output is
less than normal, irrigate foley and perform bladder
scan. Notify MD as directed., Post-Op/Phase II
Activity [80983]
Page 5 of 17
Printed by WILLIAMS, HEATHER R S [HRS0] at 4/12/2017 4:02:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Chair Day of Surgery [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR: other (comment)
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
Ambulate 3 Times Daily [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:
Starting postoperative day 1., Post-Op/Phase II
Nutrition [99219]
Strict NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: NPO
NPO Diet: Strict NPO
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
Clear Liquid Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: Diet Modifications
Diet Modifications: Liquid
Liquid: Clear Liquid
No Red or Purple Dye:
Liquid Thickness: Thin
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
Ketogenic Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: Diet Modifications
Diet Modifications: Metabolic
Metabolic: Ketogenic
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
Page 6 of 17
Printed by WILLIAMS, HEATHER R S [HRS0] at 4/12/2017 4:02:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Breast Feeding Mom [DIE0008] Please Provide Tray for Breast Feeding Mom: Yes
Routine, CONTINUOUS, Starting today, Post-
Op/Phase II
Respiratory [80984]
Cardio-Respiratory Monitor - Pediatric - Without
Rhythm [139420]
Cardio-Respiratory Monitor - Pediatric - Without
Rhythm [NURMON0074]
ONCE, Routine, Please complete the Notify
Provider order below, including specification for
apnea > *** seconds. If indicated, order pulse
oximetry separately.
Device Present:
Device Mode:
Device Low Rate Limit (BPM):
Notify Provider:
Post-Op/Phase II
Notify [NURCOM0001] CONTINUOUS
Provider to Notify: Provider
Notify based on:
Notify provider for apnea > 20 seconds, Post-
Op/Phase II
Blow Bubbles [NURTRT0047] 4X DAILY, Routine, Post-Op/Phase II
Oxygen Therapy [RT0032] CONTINUOUS, Starting today, 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 oxygen by weaning to room air while
maintaining a saturation equal to or greater than
92%., Post-Op/Phase II
Pulse Oximetry [NURMON0009] EVERY 4 HOURS, Starting today, Routine, 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
Wound/Procedure Site Care [80985]
Maintain Nephrostomy Tube [NURTAD0025] CONTINUOUS, Starting today, Routine
Location:
Drainage Options:
Flush With(Must also enter seperate medication order
to obtain drug):
Site Assessment Frequency:
Care Frequency:
Wash With:
Primary Dressing:
Secondary Dressing:
Post-Op/Phase II
Page 7 of 17
Printed by WILLIAMS, HEATHER R S [HRS0] at 4/12/2017 4:02:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Maintain Nephrostomy Tube [NURTAD0025] CONTINUOUS, Starting today, Routine
Location:
Drainage Options:
Flush With(Must also enter seperate medication order
to obtain drug):
Site Assessment Frequency:
Care Frequency:
Wash With:
Primary Dressing:
Secondary Dressing:
Post-Op/Phase II
Maintain Drain [NURTAD0003] CONTINUOUS, Starting today, Routine
Type:
Site:
Location:
Drainage Options:
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For:
Dressing Change Frequency:
Dressing Type:
Post-Op/Phase II
Maintain Drain [NURTAD0003] CONTINUOUS, Starting today, Routine
Type:
Site:
Location:
Drainage Options:
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For:
Dressing Change Frequency:
Dressing Type:
Post-Op/Phase II
Wound Care [NURWND0015] CONTINUOUS, Starting today, Routine
Wound Type: Closed - Incision
Wound Site: Abdomen
Wound Location:
Assess Frequency: 2X DAILY
Care Frequency: 2X DAILY
Wash With:
Irrigate/Rinse With: sodium chloride 0.9%
Apply (Must also enter separate medication order to
obtain drug):
Primary Dressing:
Secondary Dressing:
Post-Op/Phase II
Intake and Output [80986]
Measure Intake And Output [NURMON0005] EVERY 4 HOURS, Starting today, Routine, Post-
Op/Phase II
Non-Categorized Patient Care Orders [99218]
Strain all Urine, Save Fragments [NURELM0061] CONTINUOUS, Starting today, Post-Op/Phase II
Page 8 of 17
Printed by WILLIAMS, HEATHER R S [HRS0] at 4/12/2017 4:02:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Post Void Residual [GU0032] ONCE, Starting today, Routine
Reason for Exam:
Post-Op/Phase II
NG Tube Placement - Pediatric [121658]
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:
Recommendations for flush quantity:
For patients < 30 kg, use 1mL of fluid per 1 kg.
For patients >30 kg, 30 mLs of fluid should be
sufficient.
In general, consider the amount of fluid needed to
clear the tube and patient’s fluid status before
determining flush quantity., Post-Op/Phase II
lidocaine-oxymetazoline 3%-0.01% (PEDS) nasal
spray [785104]
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.
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?
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
Post-Op/Phase II
Contingency Parameters < 6 Months of Age [99217]
Page 9 of 17
Printed by WILLIAMS, HEATHER R S [HRS0] at 4/12/2017 4:02:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] CONTINUOUS
Provider to Notify: Provider
If systolic blood pressure > (mmHg): 100
If systolic blood pressure < (mmHg): 65
If diastolic blood pressure > (mmHg): 65
If diastolic blood pressure < (mmHg): 45
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 180
If heart rate < (bpm): 90
If respiratory rate >: 50
If respiratory rate <: 25
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 95
If urine output < (mL):
Other:
Nausea/vomiting not relieved by prescribed
medications. Pain not controlled by prescribed
medications. Normal urine output for patients ages
0-12 months is 2 ml/kg/hr. For patients greater than
12 months, normal urine outpu is 0.5-1 ml/kg/hr. If
urine output is less than normal, irrigate foley and
perform bladder scan. Notify MD as directed., Post-
Op/Phase II
Contingency Parameters - 6 Months to 2 Years Old [99216]
Notify Provider [NURCOM0001] CONTINUOUS
Provider to Notify: Provider
If systolic blood pressure > (mmHg): 118
If systolic blood pressure < (mmHg): 85
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 160
If heart rate < (bpm): 80
If respiratory rate >: 40
If respiratory rate <: 20
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other:
Nausea/vomiting not relieved by prescribed
medications. Pain not controlled by prescribed
medications. Normal urine output for patients ages
0-12 months is 2 ml/kg/hr. For patients greater than
12 months, normal urine outpu is 0.5-1 ml/kg/hr. If
urine output is less than normal, irrigate foley and
perform bladder scan. Notify MD as directed., Post-
Op/Phase II
Contingency Parameters - 3 to 6 Years of Age [99215]
Page 10 of 17
Printed by WILLIAMS, HEATHER R S [HRS0] at 4/12/2017 4:02:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] CONTINUOUS
Provider to Notify: Provider
If systolic blood pressure > (mmHg): 118
If systolic blood pressure < (mmHg): 87
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 140
If heart rate < (bpm): 75
If respiratory rate >: 30
If respiratory rate <: 18
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other:
Nausea/vomiting not relieved by prescribed
medications. Pain not controlled by prescribed
medications. Normal urine output for patients ages
0-12 months is 2 ml/kg/hr. For patients greater than
12 months, normal urine outpu is 0.5-1 ml/kg/hr. If
urine output is less than normal, irrigate foley and
perform bladder scan. Notify MD as directed., Post-
Op/Phase II
Contingency Parameters - 7 to 10 Years of Age [99214]
Notify Provider [NURCOM0001] CONTINUOUS
Provider to Notify: Provider
If systolic blood pressure > (mmHg): 125
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 70
If respiratory rate >: 24
If respiratory rate <: 14
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other:
Nausea/vomiting not relieved by prescribed
medications. Pain not controlled by prescribed
medications. Normal urine output for patients ages
0-12 months is 2 ml/kg/hr. For patients greater than
12 months, normal urine outpu is 0.5-1 ml/kg/hr. If
urine output is less than normal, irrigate foley and
perform bladder scan. Notify MD as directed., Post-
Op/Phase II
Contingency Parameters - 11 Years and Older [99213]
Page 11 of 17
Printed by WILLIAMS, HEATHER R S [HRS0] at 4/12/2017 4:02:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] CONTINUOUS
Provider to Notify: Provider
If systolic blood pressure > (mmHg): 140
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 110
If heart rate < (bpm): 60
If respiratory rate >: 22
If respiratory rate <: 12
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other:
Nausea/vomiting not relieved by prescribed
medications. Pain not controlled by prescribed
medications. Normal urine output for patients ages
0-12 months is 2 ml/kg/hr. For patients greater than
12 months, normal urine outpu is 0.5-1 ml/kg/hr. If
urine output is less than normal, irrigate foley and
perform bladder scan. Notify MD as directed., Post-
Op/Phase II
Intravenous Therapy
IV Fluids [98956]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Do not cap IV or change IV fluid rates until directed to
do so by provider. This will be addressed in twice
daily rounds ., Post-Op/Phase II
Cap Peripheral IV Catheter. [NURVAD0053] ONCE, Post-Op/Phase II
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS, Post-Op/Phase II
dextrose 5%-NaCl 0.2% infusion [51615] Intravenous, CONTINUOUS, Post-Op/Phase II
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L
infusion [44910]
Intravenous, CONTINUOUS, Post-Op/Phase II
dextrose 5%-NaCl 0.2% with KCl 20 mEq/L
infusion [44909]
Intravenous, CONTINUOUS, Post-Op/Phase II
sodium chloride flush 0.9% 10 mL injection
[785055]
Flush, Post-Op/Phase II
Premedication for Needle Insertion [84317]
Lidocaine [152737]
Page 12 of 17
Printed by WILLIAMS, HEATHER R S [HRS0] at 4/12/2017 4:02:06 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, prior to needle
sticks to reduce pain. See "LMX Use Instructions"
order in Active Orders report or the Admin
Instructions for application details
FOR PATIENTS 5 Kg OR LESS: Do NOT apply to
area greater than 100 square centimeters.
(maximum 1 g/site; maximum 1 site per hour, 6
times per day).
FOR PATIENTS 5.1-10 Kg: Do NOT apply to area
greater than 100 square centimeters. (maximum 1
g/site; maximum 2 sites per hour, 6 times per day).
FOR PATIENTS GREATER THAN 10 Kg: Do NOT
apply to area greater than 200 square centimeters.
(maximum 2.5 g/site; maximum 4 sites per hour, 6
times per day).
For patients less than 1 year old do NOT leave on
longer than 1 hour. For patients 1 year or older do
NOT leave on longer than 2 hours
Post-Op/Phase II
LMX Use Instructions for Premedication Prior to
Needle Insertion [NURCOM0095]
Post-Op/Phase II
Medications
Analgesics - Acetaminophen - Scheduled (Single Response) [219501]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 10 mg/kg
(Maximum 650 mg/dose) [800005]
10 mg/kg, Oral, EVERY 6 HOURS For 72 Hours
Administer for mild pain Maximum 5 doses/day No
more than 4 grams acetaminophen per 24 hours for
adults or 15mg/kg per dose for peds <40kg.
Post-Op/Phase II
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 15 mg/kg
(Maximum 650 mg/dose) [800005]
15 mg/kg, Oral, EVERY 6 HOURS For 72 Hours
Administer for mild pain Maximum 5 doses/day No
more than 4 grams acetaminophen per 24 hours for
adults or 15mg/kg per dose for peds <40kg.
Post-Op/Phase II
acetaMINOPHEN (TYLENOL) suppository -
NOTE: Suggested dose 20 mg/kg. Must order in
whole suppository size (Maximum 650 mg/dose)
[43994]
Rectal, EVERY 6 HOURS For 72 Hours
Administer for mild pain Maximum 5 doses/day No
more than 4 grams acetaminophen per 24 hours for
adults or 15mg/kg per dose for peds <40kg
Post-Op/Phase II
acetaMINOPHEN (TYLENOL) tab - Maximum
650 mg/dose [34149]
Oral, EVERY 6 HOURS For 72 Hours
Administer for mild pain Maximum 5 doses/day
(Maximum 650 mg/dose) No more than 4 grams
acetaminophen per 24 hours for adults or 15mg/kg
per dose for peds <40kg
Post-Op/Phase II
Analgesics - Acetaminophen - PRN (Single Response) [219502]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 10 mg/kg
(Maximum 650 mg/dose) [800005]
10 mg/kg, Oral, EVERY 4 HOURS PRN, pain
Administer for mild pain Maximum 5 doses/day No
more than 4 grams acetaminophen per 24 hours for
adults or 15mg/kg per dose for peds <40kg.
Post-Op/Phase II
Page 13 of 17
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acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 15 mg/kg
(Maximum 650 mg/dose) [800005]
15 mg/kg, Oral, EVERY 4 HOURS PRN, pain
Administer for mild pain Maximum 5 doses/day No
more than 4 grams acetaminophen per 24 hours for
adults or 15mg/kg per dose for peds <40kg.
Post-Op/Phase II
acetaMINOPHEN (TYLENOL) suppository -
NOTE: Suggested dose 20 mg/kg. Must order in
whole suppository size (Maximum 650 mg/dose)
[43994]
Rectal, EVERY 4 HOURS PRN, pain
Administer for mild pain Maximum 5 doses/day No
more than 4 grams acetaminophen per 24 hours for
adults or 15mg/kg per dose for peds <40kg
Post-Op/Phase II
acetaMINOPHEN (TYLENOL) tab - Maximum
650 mg/dose [34149]
Oral, EVERY 4 HOURS PRN, pain
Administer for mild pain Maximum 5 doses/day
(Maximum 650 mg/dose) No more than 4 grams
acetaminophen per 24 hours for adults or 15mg/kg
per dose for peds <40kg
Post-Op/Phase II
Analgesics - NSAIDS - Scheduled [219503]
ketOROLAC (TORODOL) injection - NOTE:
Suggested dose 0.5 mg/kg (Maximum 15
mg/dose) [800050]
0.5 mg/kg, Intravenous, EVERY 6 HOURS For 72
Hours
Administer for mild to moderate pain
Post-Op/Phase II
ibuprofen (MOTRIN) susp - NOTE: Suggested
dose 10 mg/kg (Maximum 600 mg/dose) [45376]
10 mg/kg, Oral, EVERY 6 HOURS For 72 Hours
Administer for mild to moderate pain
Post-Op/Phase II
Analgesics - NSAIDS - PRN (Single Response) [219504]
ketOROLAC (TORODOL) injection - NOTE:
Suggested dose 0.5 mg/kg (Maximum 15
mg/dose) [800050]
0.5 mg/kg, Intravenous, EVERY 6 HOURS PRN For 5
Days, Administer for mild to moderate pain, Post-
Op/Phase II
ibuprofen (MOTRIN) tab - NOTE: Suggested
dose 10 mg/kg (Maximum 600 mg/dose) [38353]
Oral, EVERY 6 HOURS PRN, pain
Administer for mild to moderate pain
Post-Op/Phase II
ibuprofen (MOTRIN) susp - NOTE: Suggested
dose 10 mg/kg (Maximum 600 mg/dose) [45376]
10 mg/kg, Oral, EVERY 6 HOURS PRN, pain,
Administer for mild to moderate pain or multimodal
therapy, Post-Op/Phase II
Analgesics - Opiods - Oral - PRN (Single Response) [219505]
oxycodone soln RANGE - (Maximum 10
mg/dose) [750031]
0.05-0.1 mg/kg, Oral, EVERY 4 HOURS PRN, pain,
Administer for severe pain
Administer for severe pain
Post-Op/Phase II
oxycodone tab RANGE - NOTE: Suggested dose
0.05 - 0.1 mg/kg (Maximum 10 mg/dose)
[750032]
Oral, EVERY 4 HOURS PRN, pain, Administer for
severe pain
Administer for severe pain
Post-Op/Phase II
Analgesics - Opiods - Intavenous - PRN (Single Response) [219506]
MORPHine PF injection - NOTE: suggested dose
0.05 - 0.1 mg/kg (Maximum 2 mg/dose) [750057]
0.05-0.1 mg/kg, Intravenous, EVERY 2 HOURS PRN,
pain, Administer if unable to take PO. Administer for
severe pain., for 4 Minutes, Post-Op/Phase II
HYDROmorphone PF (DILAUDID) injection -
NOTE: suggested dose 0.01 - 0.02 mg/kg
(Maximum 0.4 mg/dose) [750050]
0.01-0.02 mg/kg, Intravenous, EVERY 2 HOURS
PRN, Administer if unable to take PO. Administer for
severe pain.
Administer if unable to take PO.
for 3 Minutes, Post-Op/Phase II
Anti-emetics [91631]
Page 14 of 17
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ondansetron (ZOFRAN) injection - NOTE:
Suggested dose 0.1 mg/kg (Maximum 4
mg/dose) [800202]
0.1 mg/kg, Intravenous, EVERY 8 HOURS PRN,
nausea/vomiting
NOTE: Suggested dose 0.1 mg/kg (Maximum 4
mg/dose)
Post-Op/Phase II
prochlorperazine (COMPAZINE) injection
RANGE - NOTE: Suggested dose 0.1-0.15
mg/kg (Maximum 10 mg/dose) [750059]
0.1-0.15 mg/kg, Intravenous, EVERY 8 HOURS PRN,
nausea/vomiting
Use as a second line agent.
Use only if unable to take orally.
NOTE: Suggested dose 0.1-0.15 mg/kg (Maximum 10
mg/dose)
If ordered IV: push slowly, max rate 5 mg/minute.
Post-Op/Phase II
prochlorperazine (COMPAZINE) tab RANGE -
NOTE: Suggested dose 0.1-0.15 mg/kg
(Maximum 10 mg/dose) [750035]
Oral, EVERY 8 HOURS PRN, nausea/vomiting
Use as a second line agent. If unable to tolerate PO
NOTE: Suggested dose 0.1-0.15 mg/kg (Maximum 10
mg/dose)
Post-Op/Phase II
Bowel Management - Scheduled [98951]
polyethylene glycol (MIRALAX) oral packet
[61829]
Oral
Dissolve in *** ounces of liquid. Hold for loose stools
Post-Op/Phase II
Bowel Management - As Needed - First Line [98952]
senna-docusate (SENOKOT-S) 8.6-50 mg per
tab [60530]
Oral, Post-Op/Phase II
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal
Administer if oral agents fail
Post-Op/Phase II
Bowel Management - As Needed - Second Line [98953]
magnesium hydroxide (MILK OF MAGNESIA)
susp - NOTE: Suggested dose 0.5 mL/kg
(Maximum dose 30 mL) [65443]
0.5 mL/kg, Oral, 1 X DAILY PRN, constipation
glycerin (PEDIATRIC) rectal suppository
[153728]
1 suppository, Rectal, 1 X DAILY PRN, constipation
Administer if first line agent fails.
Post-Op/Phase II
phosphate (FLEET PEDIATRIC) enema [37522] 1 enema, Rectal, 1 X DAILY PRN, constipation
Administer if first line agent fails
Post-Op/Phase II
phosphate (FLEET) enema [37517] 1 enema, Rectal, 1 X DAILY PRN, constipation
Administer if first line agent fails
Post-Op/Phase II
Antispasmodics [98954]
oxybutynin (DITROPAN) 5 MG/5ML syrup -
NOTE: Suggested dose 0.1 mg/kg (Maximum 5
mg/dose) [45972]
0.1 mg/kg, Oral, EVERY 8 HOURS
NOTE: Suggested dose 0.1 mg/kg (Maximum 5
mg/dose)
Post-Op/Phase II
oxybutynin (DITROPAN) 5 MG/5ML syrup -
NOTE: Suggested dose 0.1 mg/kg (Maximum 5
mg/dose) [45972]
0.1 mg/kg, Oral, EVERY 6 HOURS
NOTE: Suggested dose 0.1 mg/kg (Maximum 5
mg/dose)
Post-Op/Phase II
Sucrose for Oral Analgesia [110668]
sucrose (SWEET-EASE) 24% buccal soln
[794009]
Oral, PRN, pain, mild pain or potentially painful
procedures. See Admin Instructions, Post-Op/Phase
II
Ureteral Colic - For Patients 12 Years or Older [98955]
Page 15 of 17
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tamsulosin (FLOMAX) cap - NOTE: Order for
patients 12 years or older WITH ureteral colic
[140027]
0.4 mg, Oral, 1 X DAILY (HS)
NOTE: Order for patients 12 years or older WITH
ureteral colic
Post-Op/Phase II
Surgical Prophylaxis
First Line [80703]
cefazolin (ANCEF) intraVENOUS - NOTE:
Suggested dose 30 mg/kg (Maximum 2 g/dose)
[800000]
30 mg/kg, Intravenous, EVERY 8 HOURS For 2
Doses
NOTE: Suggested dose 30 mg/kg (Maximum 2
g/dose)
Post-Op/Phase II
cefazolin (ANCEF) intraVENOUS : NOTE: For
surgical flap, complex hypspadias repair or penile
repair (Maximum 2000 mg/dose) [800000]
40 mg/kg, Intravenous, EVERY 8 HOURS, Post-
Op/Phase II
MRSA/Documented MRSA History [145777]
Cefaxolin (Maximum 2 g/dose) and Vancomycin
(Maximum 2000 mg/dose) [219512]
cefazolin (ANCEF) intraVENOUS [800000] 30 mg/kg, Intravenous, EVERY 8 HOURS For 2
Doses, 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 [145780]
vancomycin (VANCOCIN) intraVENOUS -
Maximum 2000 mg/dose [800084]
15 mg/kg, Intravenous, EVERY 6 HOURS For 3
Doses, Post-Op/Phase II
UTI Prophlyaxis [80704]
sulfamethoxazole-trimethoprim 200-40 mg/5 mL
(BACTRIM) susp CUSTOM - NOTE: Suggested
dose 2 mg/kg of trimethoprim (Maximum 800/160
mg/dose) [58784]
2 mg/kg, Oral, 1 X DAILY
NOTE: Suggested dose 2 mg/kg of trimethoprim
(Maximum 800/160 mg/dose)
Post-Op/Phase II
Laboratory
Draw in Recovery Room [80988]
HEMOGLOBIN [HGB] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Draw Postoperative Hour 4 [80989]
HEMATOCRIT [HCT] CONDITIONAL - RN COLLECT, Starting today For 1
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw postoperative
hour 4
Post-Op/Phase II
ELECTROLYTES [LYTE] CONDITIONAL - RN COLLECT, Starting today For 1
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw postoperative
hour 4
Post-Op/Phase II
Page 16 of 17
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GLUCOSE [GLU] CONDITIONAL - RN COLLECT For 1 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw postoperative
hour 4
Post-Op/Phase II
Draw Postoperative Day 1 [80990]
CBC WITHOUT DIFFERENTIAL [HEMO] NEXT AM 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
MAGNESIUM [MAG] NEXT AM 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
PHOSPHATE [PHOS] NEXT AM 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
ELECTROLYTES [LYTE] NEXT AM 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 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
GLUCOSE [GLU] NEXT AM 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
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 17 of 17
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