/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/vascular-surgery/,

/clinical/cckm-tools/content/order-sets/inpatient/vascular-surgery/name-97872-en.cckm

201712341

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Vascular Surgery

IP – Abdominal Aortic Aneurysm Repair – Open – Adult –Postoperative [2747]

IP – Abdominal Aortic Aneurysm Repair – Open – Adult –Postoperative [2747] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Vascular Surgery


IP - Abdominal Aortic Aneurysm Repair - Open - Adult - Postoperative [2747]
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 [84057]
Page 1 of 25
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12/2017CCKM@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 25
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@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 subcutaneous injection [800290] 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 subcutaneous injection [800290] 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 subcutaneous injection [800290] 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 subcutaneous injection [800290] 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 25
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:43:58 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@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
PACU Normoglycemia Management
Normoglycemia Management (Single Response) [217140]
Patients withOUT Diabetes and NOT on Insulin
Infusion [228192]
Glucose, POC [IPGLUCOSE] ONCE For 1 Occurrences, Routine, Glucose, POC
should always be ordered in conjunction with orders
for hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
PACU
If Glucose POC 200 mg/dL or Greater Initiate
Perioperative Normoglycemia for Surgical
Patients Adult Delegation Protocol
[NURMON0167]
CONTINUOUS For 24 Hours, Routine, Use order set
Perioperative Normoglycemia for Surgical Patients
Delegation Protocol order set [6133] to place orders,
PACU
Patients WITH Diabetes and NOT on Insulin
Infusion [228194]
Glucose, POC [IPGLUCOSE] ONCE For 1 Occurrences, Routine, Glucose, POC
should always be ordered in conjunction with orders
for hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
PACU
If Glucose POC is 180 mg/dL or Greater Initiate
Perioperative Normoglycemia for Surgical
Patients Adult Delegation Protocol
[NURMON0167]
ONCE For 1 Occurrences, Routine, Use order set
Perioperative Normoglycemia for Surgical Patients
Delegation Protocol order set [6133] to place orders,
PACU
Patient ON Insulin Infusion [217180]
insulin infusionSupplemental order set [1345] to order -Adult -Insulin Infusion -IP Use
Confirm Time and Value of Last Glucose POC
and Insulin Infusion Column [NURCOM0022]
ONCE, PACU
Hypoglycemia Management [216855]
URL:
Hypoglycemia Management (Adult) [191576]
Page 4 of 25
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting today For Until specified,
Routine, Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition?
PACU
Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA
TREATMENT, Starting today For Until specified,
Routine, Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition?
Per hypoglycemia treatment algorithm Recheck
glucose 15 minutes after providing treatment until
glucose is greater than or equal to 70 mg/dL. If
patient has been critically low (i.e., glucose less than
40 mg/dL), recheck glucose after 1 hour to ensure
glucose remains greater than or equal to 70mg/dL.
After resolution of mild hypoglycemia (i.e., glucose
40-69 mg/dL), consider rechecking after 1 hour if
patient has signs/symptoms of hypoglycemia or is at
risk for a subsequent hypoglycemic event (e.g.,
previously administered insulin still active, altered
renal status, altered mental status, NPO or
interrupted nutrition, or any other condition that
increases hypoglycemia risk), PACU
Notify Provider [NURCOM0001] Provider to Notify: Provider
Notify based on: Blood Glucose,Other
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
Other: Nutritional status changes
PACU
Hypoglycemia Treatment for blood glucose less
than 40 mg/dL and patient able to eat/swallow
safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If blood glucose less
than 40mg/dL and patient able to eat/swallow safely.
Give 30 grams of carbohydrate (8 oz. of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater., PACU
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If glucose is 40-69
mg/dL and patient able to eat/swallow safely
Give 15 grams of carbohydrate (4 oz of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater., PACU
glucose-vitamin C chew tab [50690] 16 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose 40-
69 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
PACU
Page 5 of 25
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:43:58 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

glucose-vitamin C chew tab [50690] 32 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose
less than 40 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
PACU
glucagon injection kit [107799] 1 mg, Subcutaneous, PRN, For blood glucose less
than 69 mg/dL and patient unable to eat/swallow
safely AND has NO IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
PACU
dextrose injection [800233] 12.5 g, Intravenous, PRN, For blood glucose 40-69
mg/dL and patient unable to eat/swallow safely AND
has IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
PACU
dextrose injection [800233] 25 g, Intravenous, PRN, For blood glucose less than
40 mg/dL and patient unable to eat/swallow safely
AND has IV access.
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
PACU
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
PACU
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting 12/15/17 For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
PACU
Post-OP Normoglycemia Management
Normoglycemia Management (Single Response) [216839]
Patients withOUT Diabetes and NOT on Insulin
Infusion [228199]
Glucose, POC [IPGLUCOSE] CONDITIONAL For 8 Hours, Routine, Glucose, POC
should always be ordered in conjunction with orders
for hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
Check once on arrival if PACU Glucose POC is >/=
180 mg/dL
Recheck in 4 hours if initial floor Glucose POC is
180-199 mg/dL, Post-Op/Phase II
Page 6 of 25
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:43:58 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Glucose Monitoring and Response
[NURCOM0022]
ONCE For 1 Occurrences, If Glucose POC obtained
on arrival is:
< 180 mg/dL - no further action needed.
180-199 mg/dL - recheck and contact provider to
order the following: if patient is NPO, provider to
order glucose POC every 6 hours; if eating glucose
POC before meals and at bedtime. Provider should
order an A1c if not performed in the last 90 days.
200 mg/dL or greater - initiate Perioperative
Normoglycemia Delegation Protocol, Post-Op/Phase
II
If Glucose POC is 200 mg/dL or Greater Initiate
Perioperative Normoglycemia for Surgical
Patients Adult Delegation Protocol
[NURMON0167]
CONTINUOUS For 24 Hours, Routine, Use order set
Perioperative Normoglycemia for Surgical Patients
Delegation Protocol order set [6133] to place orders,
Post-Op/Phase II
Patients WITH Diabetes and NOT on Insulin
Infusion [228200]
Glucose, POC [IPGLUCOSE] ONCE For 1 Occurrences, Routine, Glucose, POC
should always be ordered in conjunction with orders
for hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
Post-Op/Phase II
Glucose Monitoring and Response
[NURCOM0022]
ONCE For 1 Occurrences, If Glucose POC obtained
on arrival is:
<180 mg/dL - contact provider to order the following:
if patient is NPO, provider to order glucose POC
every 6 hours; if eating glucose POC before meals
and at bedtime. Provider should order an A1c if not
performed in the last 90 days.
180 mg/dL or greater - initiate Perioperative
Normoglycemia Delegation Protocol, Post-Op/Phase
II
If Glucose POC 180 mg/dL or Greater Initiate
Perioperative Normoglycemia for Surgical
Patients Adult Delegation Protocol
[NURMON0167]
CONTINUOUS, Routine, Use order set Perioperative
Normoglycemia for Surgical Patients Delegation
Protocol order set [6133] to place orders, Post-
Op/Phase II
Patient ON Insulin Infusion [217180]
insulin infusionSupplemental order set [1345] to order -Adult -Insulin Infusion -IP Use
Confirm Time and Value of Last Glucose POC
and Insulin Infusion Column [NURCOM0022]
ONCE, Post-Op/Phase II
Hypoglycemia Management [217170]
Hypoglycemia Management (Adult) [191576]
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting today For Until specified,
Routine, Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition?
Post-Op/Phase II
Page 7 of 25
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:43:58 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA
TREATMENT, Starting today For Until specified,
Routine, Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition?
Per hypoglycemia treatment algorithm Recheck
glucose 15 minutes after providing treatment until
glucose is greater than or equal to 70 mg/dL. If
patient has been critically low (i.e., glucose less than
40 mg/dL), recheck glucose after 1 hour to ensure
glucose remains greater than or equal to 70mg/dL.
After resolution of mild hypoglycemia (i.e., glucose
40-69 mg/dL), consider rechecking after 1 hour if
patient has signs/symptoms of hypoglycemia or is at
risk for a subsequent hypoglycemic event (e.g.,
previously administered insulin still active, altered
renal status, altered mental status, NPO or
interrupted nutrition, or any other condition that
increases hypoglycemia risk), Post-Op/Phase II
Notify Provider [NURCOM0001] Provider to Notify: Provider
Notify based on: Blood Glucose,Other
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
Other: Nutritional status changes
Post-Op/Phase II
Hypoglycemia Treatment for blood glucose less
than 40 mg/dL and patient able to eat/swallow
safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If blood glucose less
than 40mg/dL and patient able to eat/swallow safely.
Give 30 grams of carbohydrate (8 oz. of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater., Post-Op/Phase II
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If glucose is 40-69
mg/dL and patient able to eat/swallow safely
Give 15 grams of carbohydrate (4 oz of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater., Post-Op/Phase II
glucose-vitamin C chew tab [50690] 16 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose 40-
69 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
Post-Op/Phase II
glucose-vitamin C chew tab [50690] 32 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose
less than 40 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
Post-Op/Phase II
Page 8 of 25
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:43:58 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

glucagon injection kit [107799] 1 mg, Subcutaneous, PRN, For blood glucose less
than 69 mg/dL and patient unable to eat/swallow
safely AND has NO IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
Post-Op/Phase II
dextrose injection [800233] 12.5 g, Intravenous, PRN, For blood glucose 40-69
mg/dL and patient unable to eat/swallow safely AND
has IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
Post-Op/Phase II
dextrose injection [800233] 25 g, Intravenous, PRN, For blood glucose less than
40 mg/dL and patient unable to eat/swallow safely
AND has IV access.
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
Post-Op/Phase II
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
Post-Op/Phase II
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting 12/15/17 For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
Post-Op/Phase II
Patient Care Orders
Vital Signs [86014]
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., Post-
Op/Phase II
Assess Bilateral Dorsalis Pedis and Posterior
Tibial Pulses [NURMON0008]
SEE COMMENTS, Starting today, Routine
Method:
Pulse Side: Bilateral
Pulse Location: Pedal,Posterial Tibial
Every hour times 4, then every 2 hours., Post-
Op/Phase II
Activity [86015]
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:
 
12/2017CCKM@uwhealth.org

Bed Rest [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
Dangle [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE: other (comment)
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
Chair [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
Nutrition [86016]
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 [86017]
Mechanical Ventilation - Adult [117146]
Provide Manual Resuscitator at Bedside
[RT0039]
CONTINUOUS, Routine, 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:
 
12/2017CCKM@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):
Post-Op/Phase II
chlorhexidine (PERIDEX) 0.12 % soln
MULTIDOSE [792004]
15 mL, Other, 2 X DAILY Starting today
Use to swab oral cavity. D/C when patient no longer
on ventilation.
Post-Op/Phase II
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today, Routine, Post-
Op/Phase II
Wean From Vent [RT0052] CONTINUOUS, Starting today, Routine
Wean: As Tolerated per RT
Options: Continuous
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:
Attempt to Wean Off Oxygen? Yes
Post-Op/Phase II
Cough And Deep Breathe [NURTRT0019] EVERY 2 HOURS, Starting today, Routine, While
awake., Post-Op/Phase II
Incentive Spirometry [NURTRT0018] EVERY 2 HOURS, Starting today, Routine, While
awake., Post-Op/Phase II
Respiratory Therapy per Protocol [RT0035] Routine
Protocol Type:
Post-Op/Phase II
Wound/Procedure Site Care [86018]
Page 11 of 25
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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): Dry Gauze
Incision Care (after 48 hours): Cleanse daily with CHG
If dressing becomes saturated in 48 hours, sterile
dressing change? No - Notify provider
Wound location: Abdomen & Leg, 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): Mepilex with Border
Incision Care (after 48 hours): Other (Comment)
(Every 48 hours)
If dressing becomes saturated in 48 hours, sterile
dressing change? No - Notify provider
Wound Location: Groin, Post-Op/Phase II
Intake and Output [86019]
Measure Intake And Output [NURMON0005] SEE COMMENTS, Starting today, Routine, Every
hour times 4, then every 2 hours., Post-Op/Phase II
Non-Categorized Patient Care Orders [86020]
order Point of Care Gluocse and sliding scale insulin, please refer To
-Adult -Diabetes Management without Pump -order set IP to
[3140] Supplemental
Page 12 of 25
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12/2017CCKM@uwhealth.org

Measure Hemodynamic Parameters
[NURMON0023]
CONTINUOUS, Starting today, Routine
Pulmonary Artery Systolic Pressure (mmHg):
Pulmonary Artery Diastolic Pressure (mmHg):
Pulmonary Artery Mean Pressure (mmHg):
Pulmonary Artery Wedge Pressure (mmHg):
Central Venous Pressure (mmHg):
Central Venous Pressure (mmH2O):
Cardiac Output:
Cardiac Output Method:
Cardiac Index:
Systemic Vascular Resistance:
Pulmonary Vascular Resistance:
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
Post-Op/Phase II
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:
Indication for Placement: Postoperative Requirements
of Specific Procedure
Initiate Urinary Catheter Removal Protocol? (NP/PA
Must Select "No"): Yes
Details: To Dependent Drainage
Does this need to be inserted/placed?
Post-Op/Phase II
NG Tube Placement - Adult [120994]
Insert and Maintain Nasogastric Tube
[NURTAD0014]
CONTINUOUS, Routine
Options: Low, Continuous 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., Post-Op/Phase II
Page 13 of 25
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12/2017CCKM@uwhealth.org

lidocaine-oxymetazoline 4%-0.05% (ADULT)
nasal spray [785081]
2 spray, Nasal, ONCE For 1 Doses
For numbing prior to feeding tube insertion.
Slowly spray the chosen nostril once, if required may
repeat x1 in opposite nostril. Angle toward back of
throat spraying the anterior nostril and wait 30-60
seconds before introducing more local
anesthetic into the nostril. Caution: Entire bottle
should not be used for insertion of tube. Discard
excess solution when procedure completed.
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
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With?
Weigh when?
Post-Op/Phase II
OCCULT BLOOD, STOOL, POC
[HCOCCULTPOC]
CONDITIONAL, Starting today For 1 Days, Routine
If Conditional, What Condition? Obtain after each
bowel movement for 24 hours.
Post-Op/Phase II
Have Patient Lift Legs off Bed [NURCOM0022] SEE COMMENTS, Starting today, Every hour for 24
hours., Post-Op/Phase II
Check for Vigorous Ankle and Leg Movement
Between Leg Lifts [NURCOM0022]
SEE COMMENTS, Starting today, Every hour for 24
hours., Post-Op/Phase II
Maintain Arterial Line [NURVAD0001] CONTINUOUS, Starting today For Until specified,
Routine
Device Status:
Flush Solution:
Site:
Post-Op/Phase II
Page 14 of 25
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Maintain Drain [NURTAD0003] CONTINUOUS, Starting today For Until specified,
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 Non-Tunneled Central Catheter
[NURVAD0017]
CONTINUOUS, Starting today For Until specified,
Routine
Device Status:
Site:
Post-Op/Phase II
Measure Ankle/Brachial Index - PACU
[NURMON0017]
ONCE, Starting today For 1 Occurrences, Routine,
Perform in PACU, PACU
Measure Ankle/Brachial Index - Postoperative
Day 1 [NURMON0017]
ONCE, Starting tomorrow For 1 Occurrences, Routine,
To be done by nursing in the morning on
postoperative day 1. No need for formal studies
unless this is abnormal., Post-Op/Phase II
Contingency Parameters [86021]
Notify [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 155
If systolic blood pressure < (mmHg): 120
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 100
If heart rate < (bpm): 50
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL): 75 mL/hour for first 24 hours
postoperative. Then if urine output less than 50 mL/
hour.
Other: Potassium less than 4.0 or greater than 5.0
mmol/Liter,Hematocrit less than 30%,Pulmonary
capillary wedge pressure greater than *** or less than
*** mmHg,Central venous pressure greater than *** or
less than *** mmHg,Leg weakness,Positive occult
blood,Maximum dose of esmolol reached,Maximum
dose of nitroglycerin reached,If Ankle/Brachial Index
decreases by 0.15 or greater
Post-Op/Phase II
Intravenous Therapy
Premedications for Needle Insertion [106327]
Page 15 of 25
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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 immediate.
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
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.
Post-Op/Phase II
IV Fluids [86335]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today For Until specified,
Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Post-Op/Phase II
sodium chloride 0.9% infusion [64367] at 125 mL/hr, Intravenous, CONTINUOUS, Post-
Op/Phase II
dextrose 5%-NaCl 0.45% infusion [51613] 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
lactated ringers infusion [38890] at 125 mL/hr, Intravenous, CONTINUOUS, Post-
Op/Phase II
Medications - Anti-infectives
First Line (Single Response) [144498]
cefuroxime (ZINACEF) intraVENOUS - Note:
Patients who are 40-120 kg [800030]
1.5 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
cefuroxime (ZINACEF) intraVENOUS - NOTE:
Patients who are 121 kg and greater [800030]
3 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
MRSA/Documented History of MRSA OR High Risk for MRSA (Implanted Devices) (Single Response)
[144499]
Patients who are 40-120 kg [228688]
cefuroxime (ZINACEF) intraVENOUS [800030] 1.5 g, 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
Patients who are 121 kg and greater [228689]
cefuroxime (ZINACEF) intraVENOUS [800030] 3 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
Page 16 of 25
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vancomycin (VANCOCIN) intraVENOUS
[800084]
15 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Patients with Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies [144507]
vancomycin (VANCOCIN) intraVENOUS [800084] 15 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Medications - General
Analgesics [86025]
-Adult -(PCA) Patient Controlled Analgesia (PCA) refer to "Patient Controlled Analgesia For
Supplemental" Order Set
acetaMINOPHEN (TYLENOL) suppository
[34153]
650 mg, Rectal, EVERY 4 HOURS PRN, pain/fever,
For pain or temperature greater than 38.5 degress
Celsius See pain management algorithm for the
selection of as-needed analgesics
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg. Use
when unable to tolerate oral medications.
Post-Op/Phase II
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Nasogastric Tube, EVERY 4 HOURS PRN,
pain/fever, For pain or temperature greater than 38.5
degress Celsius. See pain management algorithm for
the selection of as-needed analgesics
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg
Post-Op/Phase II
Analgesics - Severe Pain (Single Response) [146267]
-Adult -(PCA) Patient Controlled Analgesia (PCA) refer to "Patient Controlled Analgesia For
Supplemental" Order Set
HYDROmorphone PF (DILAUDID) injection
[750050]
0.2-0.5 mg, Intravenous, EVERY 1 HOUR PRN, pain,
See pain management algorithm for the selection of
as-needed analgesics, for 3 Minutes, Post-Op/Phase
II
Bowel Management [122993]
Adult - Bowel Management - Scheduled
[241890]
senna-docusate (SENOKOT S) 8.6-50 MG per
tab [60530]
2 tab, Oral, 2 X DAILY Starting tomorrow, Post-
Op/Phase II
Adult - Bowel Management - As Needed
[241564]
polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 1 X DAILY PRN Starting tomorrow,
constipation
First Line Therapy
Post-Op/Phase II
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, Oral, 1 X DAILY PRN Starting tomorrow,
constipation
Second line therapy, if no response to first line
therapy within 12 hours
Post-Op/Phase II
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal, 1 X DAILY PRN Starting tomorrow,
constipation
If unable to take medications by mouth or enteral
tube OR if need immediate laxation OR if failure of
second line agent after 6 hours
Post-Op/Phase II
Anti-emetics [12859]
ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
4 mg, Oral, EVERY 24 HOURS PRN,
nausea/vomiting, Post-Op/Phase II
Page 17 of 25
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ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 24 HOURS PRN,
nausea/vomiting, When unable to tolerate oral., Post-
Op/Phase II
Antihypertensives - NOTE: Order both nitroglycerine and esmolol drips for systolic blood pressure
greater than 160 mmHg [86027]
esmolol (BREVIBLOC) 2.5 g in sodium chloride
0.9% 250 mL infusion [66486]
50-300 mcg/kg/min, Intravenous, CONTINUOUS
Give esmolol bolus 500 mcg/kg IV as initial bolus now
and prior to each dose increase. Titrate per ADULT
protocol. Initiate at 25 mcg/kg/min or current rate and
titrate to maintain heart rate less than 70 beats per
minute and SBP between 120 to 155 mmHg.
Post-Op/Phase II
nitroglycerin 50 mg in dextrose 5% 250 mL
infusion [51611]
0.3-3 mcg/kg/min, Intravenous, CONTINUOUS
Titrate per ADULT protocol. Initiate at 0.3 mcg/kg/min
or current rate and titrate to maintain SBP 120 to 155
mmHg.
Beta-Blockers [86028]
labetalol (NORMODYNE;TRANDATE) injection
[750053]
10-20 mg, Intravenous, EVERY 1 HOUR PRN, SBP
greater than 160 mmHg. Hold for heart rate less than
50 beats/minute., for 2 Minutes, Post-Op/Phase II
metoprolol (LOPRESSOR) injection [800274] 5 mg, Intravenous, EVERY 6 HOURS
Hold for heart rate less than 50 beats/minute or SBP
less than 90 mmHg
Post-Op/Phase II
Gastric [86030]
pantoprazole (PROTONIX) injection [800119] 40 mg, Intravenous, 1 X DAILY, Post-Op/Phase II
Potassium Chloride Supplementation (Single Response) [108685]
potassium chloride 10 mEq/100 mL bag [46253] 10 mEq, Intravenous, PRN - NOTIFY PHARMACY
WHEN NEEDED, potassium supplementation - See
Admin Instruction
For serum K between 3.6 - 3.9 mmol/L give 10 mEq
x2;
For serum K between 3.1 - 3.5 mmol/L give 10 mEq
x4;
For serum K between 2.5 - 3.0 mmol/L give 10 mEq
x6;
For serum K less than 2.5 mmol/L give 10 mEq x8
for 60 Minutes
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
for 60 Minutes, Post-Op/Phase II
potassium chloride 20 mEq/ 50 mL bag
CENTRAL LINE ONLY [46256]
20 mEq, Intravenous, PRN, potassium
supplementation - See Admin Instruction
For serum K between 3.6 - 3.9 mmol/L give 20 mEq
x1;
For serum K between 3.1 - 3.5 mmol/L give 20 mEq
x2;
For serum K between 2.5 - 3.0 mmol/L give 20 mEq
x3;
For serum K less than 2.5 mmol/L give 20 mEq x4 for
60 Minutes
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
for 60 Minutes, Post-Op/Phase II
Page 18 of 25
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potassium chloride 10 mEq/100 mL bag - NOTE:
Order in patients with RENAL impairment (CrCl <
30 mL/min) [46253]
10 mEq, Intravenous, PRN - NOTIFY PHARMACY
WHEN NEEDED, potassium supplementation - See
Admin Instruction
For serum K between 3.6 - 3.9 mmol/L give 10 mEq
x1;
For serum K between 3.1 - 3.5 mmol/L give 10 mEq
x2;
For serum K between 2.5 - 3.0 mmol/L give 10 mEq
x3;
For serum K less than 2.5 mmol/L give 10 mEq x4.
Use only if patient is unable to tolerate enteral
administration
for 60 Minutes
NOTE: Order in patients with RENAL impairment
(CrCl < 30 mL/min)
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
Non-cardiac patients: For serum magnesium 1.6-1.8
mg/dL - do not replace
Cardiac patients: For serum magnesium 1.6-1.8
mg/dL give 0.05 g/kg IV x1
For serum magnesium 1.0-1.5 mg/dL give 0.1 g/kg IV
x1
For serum magnesium less than 1 mg/dL give 0.15
g/kg IV x1
Administer each 2 gram bag over 3 hours at a
frequency of one bag every 4 hours.
Maximum 6 grams per replacement dose
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
Post-Op/Phase II
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
Non-cardiac patients: For serum magnesium 1.6-1.8
mg/dL - do not replace
Cardiac patients: For serum magnesium 1.6-1.8
mg/dL give 0.025 g/kg IV x1
For serum magnesium 1.0-1.5 mg/dL give 0.05 g/kg IV
x1
For serum magnesium less than 1 mg/dL give 0.075
g/kg IV x1
Administer each 2 gram bag over 3 hours at a
frequency of one bag every 4 hours.
Maximum 6 grams per replacement dose
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
NOTE: Order in patients with RENAL impairment
(CrCl < 30 mL/min)
Post-Op/Phase II
Non-categorized [86031]
Page 19 of 25
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metoclopramide (REGLAN) injection [800059] 10 mg, Intravenous, EVERY 6 HOURS PRN Starting
today, Delayed gastric emptying, Post-Op/Phase II
Laboratory
Draw in PACU [86033]
BLOOD GASES [HCBGAS] NEXT DRAW, 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?
Draw in PACU, PACU
MAGNESIUM [MAG] NEXT DRAW, 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?
Draw in PACU, PACU
PHOSPHATE [PHOS] NEXT DRAW, 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?
Draw in PACU, PACU
ELECTROLYTES [LYTE] NEXT DRAW, 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?
Draw in PACU, PACU
GLUCOSE [GLU] NEXT DRAW, 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?
Draw in PACU, PACU
BUN [BUN] NEXT DRAW, 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?
Draw in PACU, PACU
CREATININE [CRET] NEXT DRAW, 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?
Draw in PACU, PACU
CALCIUM [CA] NEXT DRAW, 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?
Draw in PACU, PACU
Page 20 of 25
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CBC WITHOUT DIFFERENTIAL [HEMO] NEXT DRAW, 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?
Draw in PACU, PACU
PROTHROMBIN TIME/INR [PT] NEXT DRAW, 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?
Draw in PACU, PACU
Draw Every 6 Hours Times 3 [103819]
HEMOGLOBIN [HGB] EVERY 6 HOURS For 3 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
PLATELET COUNT [PLT] EVERY 6 HOURS For 3 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
POTASSIUM [K] EVERY 6 HOURS, Starting today For 3 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
Draw Postoperative Day 1 [86035]
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?
Draw Postoperative Day 1, 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?
Draw Postoperative Day 1, 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?
Draw Postoperative Day 1, 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?
Draw Postoperative Day 1, 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?
Draw Postoperative Day 1, Post-Op/Phase II
Page 21 of 25
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:43:58 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

BUN [BUN] 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?
Draw Postoperative Day 1, 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?
Draw Postoperative Day 1, Post-Op/Phase II
CALCIUM [CA] 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?
Draw Postoperative Day 1, Post-Op/Phase II
PROTHROMBIN TIME/INR [PT] 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?
Draw Postoperative Day 1, Post-Op/Phase II
BLOOD GASES [HCBGAS] NEXT AM 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?
Draw Postoperative Day 1, Post-Op/Phase II
LACTATE [GM2255] 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?
Draw Postoperative Day 1, Post-Op/Phase II
BILIRUBIN, TOTAL [TBIL] 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?
Draw Postoperative Day 1, Post-Op/Phase II
Conditional Labs [86034]
POTASSIUM [K] 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 1 hour after IV
replacement or 4 hours after oral 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 infusion.
Post-Op/Phase II
Draw for Ruptured Aortic Aneurysm Repair Patients [86036]
AMYLASE [AMYL] NEXT DRAW, 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?
Post-Op/Phase II
Draw for Amylase Levels Greater than 100 units/Liter [86037]
Page 22 of 25
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:43:58 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

LIPASE [LIPS] CONDITIONAL, Starting today For 4 Days, Routine
If Conditional, What Condition? Draw if patient's
amylase level is greater than 100 unit/Liter
If add on test, what should lab do if unable to add test
to previous specimen?
Post-Op/Phase II
Diagnostic Tests and Imaging
Obtain Now [86039]
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, 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?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Post-Op/Phase II
Obtain Postoperative Day 1 [86040]
X-RAY CHEST AP VIEW [R71010] ONCE-ON SPECIFIC DATE, Starting tomorrow For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam? Evaluation of endotracheal tube placement
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Post-Op/Phase II
Consults
Consults [86042]
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
Diabetes Consult Order Panel (Adult) [188497]
Page 23 of 25
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:43:58 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@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
Page 24 of 25
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:43:58 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@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 Critical Care (Inpatient) [CON0018] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
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
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:43:58 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org