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/clinical/cckm-tools/content/order-sets/inpatient/vascular-surgery/name-97878-en.cckm

201712341

page

100

UWHC,UWMF,

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

IP - Thoracoabdominal Aneurysm Repair - Adult - Postoperative [2757]

IP - Thoracoabdominal Aneurysm Repair - Adult - Postoperative [2757] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Vascular Surgery


IP - Thoracoabdominal Aneurysm Repair - Adult - Postoperative [2757]
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]
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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) [209942]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Moderate VTE Risk with High Bleed Risk
[211704]
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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) [210846]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Moderate VTE Risk [211681]
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 [86325]
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
Neurovascular Checks [NURMON0045] SEE COMMENTS, Starting today, Routine
Location:
Every hour times 4, then every 2 hours., Post-
Op/Phase II
Activity [86326]
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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
Keep Head of Bed Flat [NURACT0011] CONTINUOUS, Starting today For 24 Hours, Post-
Op/Phase II
Nutrition [86327]
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 [86328]
Mechanical Ventilation - Adult [117146]
Provide Manual Resuscitator at Bedside
[RT0039]
CONTINUOUS, Routine, Post-Op/Phase II
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. Discontinue when patient no
longer on ventilation.
Post-Op/Phase II
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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
Wean From Ventilator [RT0052] CONTINUOUS, Starting today, Routine
Wean: As Tolerated per RT
Options:
Post-Op/Phase II
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today, Routine, 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
Wound/Procedure Site Care [86329]
Wound Care - Closed Incision (Adult)
[NURWND0055]
CONTINUOUS, Starting tomorrow, 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
Post-Op/Phase II
Intake and Output [86330]
Measure Intake And Output [NURMON0005] SEE COMMENTS, Starting today, Routine, Every
hour times 4, then every 2 hours., Post-Op/Phase II
Spinal Drain Orders [86331]
Connect Spinal Drain to Ventriculostomy
Transducer [NURTAD0046]
CONTINUOUS, Starting today, Post-Op/Phase II
Monitor Spinal Fluid Pressure [NURTAD0046] SEE COMMENTS, Starting today, Every hour times 4,
then every 2 hours., Post-Op/Phase II
Drain Spinal Fluid [NURTAD0046] CONTINUOUS, Starting today, In 5 mL increments as
needed to keep spinal fluid pressure less than ***
mmHg until patient is awake and responding to
commands., Post-Op/Phase II
Non-Categorized Patient Care Orders [86332]
order Point of Care Gluocse and sliding scale insulin, please To
Adult -Diabetes Management without Pump -order set IP refer to
[3140] Supplemental -
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Measure Hemodynamic Parameters by
Pulmonary Artery Catheter (SWAN-GANZ)
[NURMON0023]
SEE COMMENTS, 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
Every hour times 4, then every 2 hours., Post-
Op/Phase II
Have Patient Lift Legs Off Bed [NURACT0011] SEE COMMENTS, Starting today, Every hour. For a
decrease in leg strength, send the following text page
to #9291: "Patient name/MRN with postop TAA leg
weakness - report to room XX/XXX - Your name &
number." ALSO notify the cardiac anesthesia faculty
on call. To obtain the pager number for the cardiac
anesthesia faculty on call, call the operating room at
263-8595., 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:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Post-Op/Phase II
NG Tube Placement - Adult [120994]
Page 6 of 18
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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
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
Maintain Chest Tube [NURTAD0001] CONTINUOUS, Starting today, Routine
Location:
Position: N/A - Single Location
Drainage Options: -20 cm wall suction
Site Assessment Frequency:
Care Frequency:
Wash With:
Primary Dressing:
Secondary Dressing:
Post-Op/Phase II
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Maintain Drain [NURTAD0003] CONTINUOUS, Starting today, Routine
Type: Other (Comment) (Peritoneal drain)
Site:
Location:
Drainage Options: Balloon
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For:
Dressing Change Frequency:
Dressing Type:
Post-Op/Phase II
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With?
Weigh when?
Post-Op/Phase II
No Forced Air Patient Warming (BAIR HUGGER)
[NURTRT0048]
CONTINUOUS, Starting today, Post-Op/Phase II
Maintain Arterial Line [NURVAD0001] CONTINUOUS, Starting today For Until specified,
Routine
Device Status:
Flush Solution:
Site:
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 [86333]
Page 8 of 18
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Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 155
If systolic blood pressure < (mmHg): 120
If diastolic blood pressure > (mmHg): 100
If diastolic blood pressure < (mmHg): 60
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): 400
If blood glucose < (mg/dL): 40
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL): 75 mL/hour for first 24 hours
postoperative, then if urine output is less than 50
mL/hour
Other: Potassium less than 4 or greater than 5
mmol/liter,Hematocrit less than 30%,Platelet count
less than 50,000/microliter,INR greater than
1.5,Pulmonary capillary wedge pressure less than ***
or greater than *** mmHg,Central venous pressure
less than *** or greater than *** mmHg,Change in leg
strength,Blood in spinal fluid,Pain not controlled with
ordered analgesics or ordered interventions,If
Ankle/Brachial Index decreases by 0.15 or
greater,Hemogloblin less than 10 g/dL
Notify Provider [NURCOM0001] Provider to Notify: Provider
Notify based on: Other
Other: Blood in spinal fluid
For blood in the spinal fluid, notify Vascular Surgery
attending on call and the Cardiac Anesthesia faculty
on call. To obtain the pager number for the cardiac
anesthesia faculty on call, call the operating room at
263-8595., Post-Op/Phase II
Intravenous Therapy
Premedications for Needle Insertion [242194]
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.
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 9 of 18
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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) [145946]
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 MRSA History OR High Risk for MRSA (Implanted Device) (Single Response)
[145951]
Patients who are 40-120 kg [228653]
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 [228654]
cefuroxime (ZINACEF) intraVENOUS [800030] 3 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 with Immediate/Severe Reaction to Penicillin or Known Cephalosporin Allergies (Single
Response) [145947]
vancomycin (VANCOCIN) intraVENOUS [800084] 15 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Medications - General
Analgesics [86337]
FENTanyl PF injection [800187] 25 mcg, Intravenous, EVERY 1 HOUR PRN For 24
Hours, pain
See Pain Management Algorithm for the Selection of
As-needed Analgesics
Post-Op/Phase II
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acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Nasogastric Tube, EVERY 4 HOURS PRN,
pain/fever
Temperature greater than 38.5 degrees Celsius or
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
acetaMINOPHEN (TYLENOL) suppository
[34153]
650 mg, Rectal, EVERY 4 HOURS PRN, pain/fever
Temperature greater than 38.5 degrees Celsius or
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.
If unable to take oral medications
Post-Op/Phase II
Note: No MORPHine or HYDROmorphone
[950018]
EVERY 8 HOURS
No MORPHine or HYDROmorphone
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
Antihypertensives - NOTE: Order both nitroglycerin and esmolol drips for SBP greater than 160 mmHg
[131757]
esmolol (BREVIBLOC) 2.5 g in sodium chloride
0.9% 250 mL infusion [66486]
50-300 mcg/kg/min, Intravenous, CONTINUOUS
Give esmolol bolus 0.5 mg/kg IV as initial bolus now
and prior to each dose increase. Titrate by 50
mcg/kg/min every 5 minutes as needed to maintain
systolic blood pressure between 120 and 155 mmHg
(maximum 300 mcg/kg/min)
Post-Op/Phase II
nitroglycerin 50 mg in dextrose 5% 250 mL
infusion [51611]
0.3-3 mcg/kg/min, Intravenous, CONTINUOUS
Titrate by 0.3 mcg/kg/min every 5 minutes as needed
to maintain systolic blood pressure between 120 and
155 mmHg and heart rate less than 70 beats/minute
(maximum 3 mcg/kg/min)
Post-Op/Phase II
Page 11 of 18
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Note: No hydrALAZINE or nitroprusside [950018] EVERY 8 HOURS
No hydrALAZINE or nitroprusside
Post-Op/Phase II
Gastric [86339]
mag-al-simeth (MYLANTA ES) 400-400-40
MG/5ML susp [44073]
15 mL, Nasogastric Tube, EVERY 8 HOURS
Alternate with aluminum hydroxide suspension
Post-Op/Phase II
pantoprazole (PROTONIX) injection 40 mg
[800119]
40 mg, Intravenous, 1 X DAILY, Post-Op/Phase II
Sedation [141864]
propofol (DIPRIVAN) 10 mg/mL infusion [800260] Intravenous, CONTINUOUS
Initiate at 5 mcg/kg/min or current rate.Titrate by 5-10
mcg/kg/min every 5 minutes to maintain sedation
score of 0.
Post-Op/Phase II
Note: No Benzodiazepines [950009] 4 X DAILY (NOTE ACKNOWLEDGE), 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 12 of 18
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12/2017CCKM@uwhealth.org

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 [86341]
Page 13 of 18
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12/2017CCKM@uwhealth.org

naloxone (NARCAN) 2.5 mg in sodium chloride
0.9% 250 mL infusion [700242]
1 mcg/kg/hr, Intravenous, CONTINUOUS For 48
Hours, Post-Op/Phase II
Laboratory
Draw in PACU [86346]
ELECTROLYTES, WHOLE BLOOD
[HCWBLYTS]
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
BLOOD GASES AND O2 SATURATION
[HCBGASOS]
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
Page 14 of 18
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12/2017CCKM@uwhealth.org

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
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
Draw Every 6 Hours Times 8 [103821]
HEMOGLOBIN [HGB] EVERY 6 HOURS For 8 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 8 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 8 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 in AM [86677]
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
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
Page 15 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

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
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 AND O2 SATURATION
[HCBGASOS]
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
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
Diagnostic Tests and Imaging
Obtain Now [86356]
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? Chest tube placed, evaluate for
pneumothorax
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Post-Op/Phase II
Obtain Postoperative Day 1 [86357]
Page 16 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, 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 [86359]
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]
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
Page 17 of 18
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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
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 Nephrology (Inpatient) [CON0083] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): End stage renal
disease
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 18 of 18
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:45:31 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org