Post Op Non ICU Admit Plan Begin Immediately/PACU PHYSICIAN S Weight Allergies Admit/Discharge/Transfer Request Patient Bed Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights) Patient Condition Acuity Level Floor Status Acuity Level Intermediate Communication Code Status Code Status: Full Code Code Status: DNR Do Not Resuscitate Code Status: DNI Do Not Intubate Code Status: Partial Resuscitative Effort Notify Provider/Primary Team of Pt Admit In AM Upon Arrival to Unit Now Notify Provider (Misc) Notify Dr. Jaime Villareal, Reason: For any Pain related issues., Pager 806 721 2429 Notify Dr. Jason Felton, Reason: For any Pain related issues., Pager 806 721 1938 Notify Joey Stone NP, Reason: For any Pain related issues., Pager 806 721 8899 Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. methocarbamol 750 mg, IVPB, ivpb, ONE TIME, Infuse over 30 min ***Administer within 1 hour of arriving to PACU*** ***Pt in PACU*** meperidine 12.5 mg, IVPush, inj, q15min, PRN, x 2 dose HYDROmorphone 0.5 mg, IVPush, inj, q5min, PRN pain, Do not exceed 2 mg. ***Do Not exceed 2 mg*** 0.5 mg, IVPush, inj, q10min, PRN pain, Do not exceed 2 mg. ***Do Not exceed 2 mg*** promethazine 6.25 mg, IVPush, inj, q15min, PRN nausea/vomiting, x 2 dose ***VESICANT*** Dilute with 10 ml NS & IVP over 2 3 min through a running IV line with large bore access. ondansetron 4 mg, IVPush, soln, ONE TIME, PRN nausea/vomiting PCA ***CAUTION*** Ordering a continuous rate (Basal Dose), should be reserved for opioid tolerant patients who require high dose therapy. Page: 1 Post Op Non ICU Admit Version: Plan 2 Effective on: 03/19/14
Post Op Non ICU Admit Plan Begin Immediately/PACU PHYSICIAN S ***DOSING NOTES*** Initial doses are for opioid naive patients. Chronic pain patients may require higher doses. Decrease initial starting dose by 25 30% in patients > 65 yrs, or patients with renal, hepatic, or pulmonary impairment. morphine (morphine 30 mg/30 ml PCA) Dose (mg) = 1, Lock out Interval (min) = 10, 4 hour Limit (mg) = 20, Start date/time T;N Dose (mg) = 1, Lock out Interval (min) = 8, 4 hour Limit (mg) = 20, Start date/time T;N Dose (mg) = 2, Lock out Interval (min) = 10, 4 hour Limit (mg) = 40, Start date/time T;N Start date/time T;N NS (Normal Saline) IV, 100 ml/hr IV, 75 ml/hr IV, 125 ml/hr IV, 150 ml/hr ACUTE MANAGEMENT OF RESPIRATORY DEPRESSION: If respiratory rate is less than 10/min or patient is unresponsive 1. Stop PCA Pump 2. Dilute naloxone (Narcan) 0.4mg / 1mL in 9mL NS and administer 0.1 mg (2.5mL) by IVP every 2 3 minutes until respiratory rate is greater than 10 3. Notify Physician naloxone (naloxone 0.4 mg/ml injectable solution) 0.1 mg, IVPush, inj, q2h, PRN bradypnea, Dilute in 9mL NS and Administer every 2 3 minutes until respiratory rate is greater than 10. Continuous Pulse Oximetry While on PCA Page: 2 Post Op Non ICU Admit Version: Plan 2 Effective on: 03/19/14
Arrives to Room PHYSICIAN S Patient Care Vital Signs Per Unit Standards q4h q4h q1h q2h Perform Neurological Checks q4h q2h q1h Daily Weight Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest Bedrest Bathroom Privileges Out of Bed Up in Chair Bedrest STRICT, Bed Position: HOB Flat, Can sit up for meals and to use restroom. Telemetry Monitoring Insert Urinary Catheter Foley, To: Dependent Drainage Bag Urinary Catheter Care Strict Intake and Output Wound Care by Nursing Accucheck q6h, DC if glucose is < 150 for 24hrs. Communication Notify Provider of VS Parameters Temp > 101.5, RR > 24, RR < 10, SpO2 < 92, HR > 120, HR < 60 Notify Provider (Misc) Reason: Urine output less than 30 ml/hr averaged over 4 hours. Notify Nurse (DO NOT USE FOR MEDS) For Temp > 101.4 obtain UA, UA C&S, Sputum C&S, and Blood Cultures X 2. Notify Provider (Misc) Notify Dr. Jaime Villareal, Reason: For any Pain related issues., Pager 806 721 2429 Notify Dr. Jason Felton, Reason: For any Pain related issues., Pager 806 721 1938 Notify Joey Stone NP, Reason: For any Pain related issues., Pager 806 721 8899 Dietary Clear Liquid Diet Advance Diet as Tolerated Advance Diet To: Regular Diet IV Solutions Page: 3 Post Op Non ICU Admit Version: Plan 2 Effective on: 03/19/14
Arrives to Room PHYSICIAN S D5 1/2 NS IV, 100 ml/hr IV, 75 ml/hr IV, 125 ml/hr IV, 150 ml/hr D5 1/2 NS + 20 meq KCl/L IV, 100 ml/hr IV, 75 ml/hr IV, 125 ml/hr IV, 150 ml/hr NS + 20 meq KCl/L IV, 100 ml/hr IV, 125 ml/hr IV, 75 ml/hr IV, 150 ml/hr Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. methocarbamol 750 mg, IVPB, ivpb, q6h, x 72 hr, Infuse over 30 min ***Start 6 hours after first dose given in PACU***.Medication Management Start date T;N Schedule methocarbamol to start 6 hours after first dose given in PACU. Pain Study Analgesics investigational drug (acetaminophen or placebo 1000 mg IVPB) 1,000 mg, IVPB, ivpb, q6h, x 4 dose ***Start 6 hrs after initial dose*** Do not exceed 4000 mg of acetaminophen per day from all sources..medication Management Start date T;N Start IV Acetaminophen or Placebo 6 hours after initial dose given in OR. GI Prophylaxis esomeprazole 40 mg, IVPush, inj, q24h 40 mg, IVPush, inj, q12h famotidine 20 mg, IVPush, inj, Daily Dilute to 2 mg/ml with NS. IV push over 2 min. 20 mg, IVPush, inj, BID Dilute to 2 mg/ml with NS. IV push over 2 min. Antiemetics ondansetron 4 mg, IVPush, soln, q6h, PRN nausea/vomiting promethazine 25 mg, IVPush, inj, q6h, PRN nausea/vomiting ***VESICANT*** Dilute with 10 ml NS & IVP over 2 3 min through a running IV line with large bore access. Gastrointestinal Agents Page: 4 Post Op Non ICU Admit Version: Plan 2 Effective on: 03/19/14
Arrives to Room PHYSICIAN S docusate 100 mg, PO, cap, Nightly, PRN constipation *****IF docusate is contraindicated or ineffective after 12 hours, USE bisacodyl***** bisacodyl 10 mg, rectally, supp, Daily, PRN constipation *****IF bisacodyl is contraindicated or ineffective after 6 hours, USE Fleet Enema***** senna 8.6 mg, PO, tab, Nightly, PRN constipation Antibiotics cefazolin 1 g, IVPB, ivpb, q6h, Infuse over 30 min vancomycin 1000 mg, IVPB, ivpb, q12h, Infuse over 90 min 1000 mg, IVPB, ivpb, q24h, Infuse over 90 min clindamycin 900 mg, IVPB, ivpb, q8h, Infuse over 30 min 600 mg, IVPB, ivpb, q8h, Infuse over 30 min Antacids Al hydroxide Mg hydroxide simethicone (Mylanta) 30 ml, PO, susp, q4h, PRN indigestion Administer 1 hour before meals and nightly. Respiratory Incentive Spirometry 10 times each hour while awake....additional Orders Page: 5 Post Op Non ICU Admit Version: Plan 2 Effective on: 03/19/14
Arrives to Room Sliding Scale Insulin Protocol Plan PHYSICIAN S Patient Care Accucheck Per Sliding Scale Insulin Frequency AC & HS AC & HS 3 days TID BID q12h q6h q6h 24 hr q4h q2h Sliding Scale Insulin Protocol Follow SSI Reference Text Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. insulin regular (Low Dose Insulin Sliding Scale) 0 10 units, subcut, inj, AC & nightly, PRN glucose levels see parameters Low Dose Insulin Sliding Scale Blood glucose <70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician 111 150 0 units; 151 200 2 units subq; 201 250 3 units subq; 251 300 4 units subq; 301 350 6 units subq; 351 400 8 units subq; >400 10 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG <300, then resume normal accucheck and sliding scale routine. Call physician. 0 10 units, subcut, inj, q6h, PRN glucose levels see parameters Low Dose Insulin Sliding Scale Blood glucose <70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician 111 150 0 units; 151 200 2 units subq; 201 250 3 units subq; 251 300 4 units subq; 301 350 6 units subq; 351 400 8 units subq; >400 10 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG <300, then resume normal accucheck and sliding scale routine. Call physician. 0 10 units, subcut, inj, q4h, PRN glucose levels see parameters Low Dose Insulin Sliding Scale Blood glucose <70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician 111 150 0 units; 151 200 2 units subq; 201 250 3 units subq; 251 300 4 units subq; 301 350 6 units subq; 351 400 8 units subq; >400 10 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG <300, then resume normal accucheck and sliding scale routine. Call physician. Continued on next page... Page: 6 Post Op Non ICU Admit Version: Plan 2 Effective on: 03/19/14
Arrives to Room Sliding Scale Insulin Protocol Plan PHYSICIAN S 0 10 units, subcut, inj, q2h, PRN glucose levels see parameters Low Dose Insulin Sliding Scale Blood glucose <70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician 111 150 0 units; 151 200 2 units subq; 201 250 3 units subq; 251 300 4 units subq; 301 350 6 units subq; 351 400 8 units subq; >400 10 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG <300, then resume normal accucheck and sliding scale routine. Call physician. 0 10 units, subcut, inj, TID, PRN glucose levels see parameters Low Dose Insulin Sliding Scale Blood glucose <70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician 111 150 0 units; 151 200 2 units subq; 201 250 3 units subq; 251 300 4 units subq; 301 350 6 units subq; 351 400 8 units subq; >400 10 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG <300, then resume normal accucheck and sliding scale routine. Call physician. 0 10 units, subcut, inj, BID, PRN glucose levels see parameters Low Dose Insulin Sliding Scale Blood glucose <70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician 111 150 0 units; 151 200 2 units subq; 201 250 3 units subq; 251 300 4 units subq; 301 350 6 units subq; 351 400 8 units subq; >400 10 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG <300, then resume normal accucheck and sliding scale routine. Call physician. Page: 7 Post Op Non ICU Admit Version: Plan 2 Effective on: 03/19/14
Arrives to Room Sliding Scale Insulin Protocol Plan PHYSICIAN S insulin regular (Moderate Dose Insulin Sliding Scale) 0 12 units, subcut, inj, AC & nightly, PRN glucose levels see parameters Moderate Dose Insulin Sliding Scale Blood glucose <70 if patient is symptomatic; Initiate hypoglycemic protocol and Call physician 111 150 2 units subq; 151 200 3 units subq; 201 250 4 units subq; 251 300 6 units subq; 301 350 8 units subq; 351 400 10 units subq; >400 12 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG <300; then resume normal accucheck and sliding scale routine. Call physician. 0 12 units, subcut, inj, q6h, PRN glucose levels see parameters Moderate Dose Insulin Sliding Scale Blood glucose <70 if patient is symptomatic; Initiate hypoglycemic protocol and Call physician 111 150 2 units subq; 151 200 3 units subq; 201 250 4 units subq; 251 300 6 units subq; 301 350 8 units subq; 351 400 10 units subq; >400 12 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG <300; then resume normal accucheck and sliding scale routine. Call physician. 0 12 units, subcut, inj, q4h, PRN glucose levels see parameters Moderate Dose Insulin Sliding Scale Blood glucose <70 if patient is symptomatic; Initiate hypoglycemic protocol and Call physician 111 150 2 units subq; 151 200 3 units subq; 201 250 4 units subq; 251 300 6 units subq; 301 350 8 units subq; 351 400 10 units subq; >400 12 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG <300; then resume normal accucheck and sliding scale routine. Call physician. 0 12 units, subcut, inj, q2h, PRN glucose levels see parameters Moderate Dose Insulin Sliding Scale Blood glucose <70 if patient is symptomatic; Initiate hypoglycemic protocol and Call physician 111 150 2 units subq; 151 200 3 units subq; 201 250 4 units subq; 251 300 6 units subq; 301 350 8 units subq; 351 400 10 units subq; >400 12 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG <300; then resume normal accucheck and sliding scale routine. Call physician. Continued on next page... Page: 8 Post Op Non ICU Admit Version: Plan 2 Effective on: 03/19/14
Arrives to Room Sliding Scale Insulin Protocol Plan PHYSICIAN S 0 12 units, subcut, inj, TID, PRN glucose levels see parameters Moderate Dose Insulin Sliding Scale Blood glucose <70 if patient is symptomatic; Initiate hypoglycemic protocol and Call physician 111 150 2 units subq; 151 200 3 units subq; 201 250 4 units subq; 251 300 6 units subq; 301 350 8 units subq; 351 400 10 units subq; >400 12 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG <300; then resume normal accucheck and sliding scale routine. Call physician. 0 12 units, subcut, inj, BID, PRN glucose levels see parameters Moderate Dose Insulin Sliding Scale Blood glucose <70 if patient is symptomatic; Initiate hypoglycemic protocol and Call physician 111 150 2 units subq; 151 200 3 units subq; 201 250 4 units subq; 251 300 6 units subq; 301 350 8 units subq; 351 400 10 units subq; >400 12 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG <300; then resume normal accucheck and sliding scale routine. Call physician. insulin regular (High Dose Insulin Sliding Scale) 0 14 units, subcut, inj, AC & nightly, PRN glucose levels see parameters High Dose Insulin Sliding Scale Blood glucose <70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician; 111 150 3 units subq; 151 200 4 units subq; 201 250 6 units subq; 251 300 8 units subq; 301 350 10 units subq; 351 400 12 units subq; >400 14 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG <300, then resume normal accucheck and sliding scale routine. Call physician 0 14 units, subcut, inj, q6h, PRN glucose levels see parameters High Dose Insulin Sliding Scale Blood glucose <70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician; 111 150 3 units subq; 151 200 4 units subq; 201 250 6 units subq; 251 300 8 units subq; 301 350 10 units subq; 351 400 12 units subq; >400 14 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG <300, then resume normal accucheck and sliding scale routine. Call physician Continued on next page... Page: 9 Post Op Non ICU Admit Version: Plan 2 Effective on: 03/19/14
Arrives to Room Sliding Scale Insulin Protocol Plan PHYSICIAN S 0 14 units, subcut, inj, q4h, PRN glucose levels see parameters High Dose Insulin Sliding Scale Blood glucose <70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician; 111 150 3 units subq; 151 200 4 units subq; 201 250 6 units subq; 251 300 8 units subq; 301 350 10 units subq; 351 400 12 units subq; >400 14 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG <300, then resume normal accucheck and sliding scale routine. Call physician 0 14 units, subcut, inj, q2h, PRN glucose levels see parameters High Dose Insulin Sliding Scale Blood glucose <70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician; 111 150 3 units subq; 151 200 4 units subq; 201 250 6 units subq; 251 300 8 units subq; 301 350 10 units subq; 351 400 12 units subq; >400 14 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG <300, then resume normal accucheck and sliding scale routine. Call physician 0 14 units, subcut, inj, TID, PRN glucose levels see parameters High Dose Insulin Sliding Scale Blood glucose <70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician; 111 150 3 units subq; 151 200 4 units subq; 201 250 6 units subq; 251 300 8 units subq; 301 350 10 units subq; 351 400 12 units subq; >400 14 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG <300, then resume normal accucheck and sliding scale routine. Call physician 0 14 units, subcut, inj, BID, PRN glucose levels see parameters High Dose Insulin Sliding Scale Blood glucose <70 and patient is symptomatic; Initiate hypoglycemic protocol and Call physician; 111 150 3 units subq; 151 200 4 units subq; 201 250 6 units subq; 251 300 8 units subq; 301 350 10 units subq; 351 400 12 units subq; >400 14 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG <300, then resume normal accucheck and sliding scale routine. Call physician Continued on next page... Page: 10 Post Op Non ICU Admit Version: Plan 2 Effective on: 03/19/14
Arrives to Room Sliding Scale Insulin Protocol Plan PHYSICIAN S insulin regular (Blank Insulin Sliding Scale) See Comments, subcut, inj, PRN glucose levels see parameters Blood glucose < ; Initiate hypoglycemic protocol and Call physician; 70 110 units; 111 150 units subq; 151 200 units subq; 201 250 units subq; 251 300 units subq; 301 350 units subq; 351 400 units subq; >400 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG <, then resume normal accucheck and sliding scale routine. Call physician HYPOglycemia Protocol HYPOglycemia Protocol If BS < 70 mg/dl, and patient SYMPTOMATIC, give 6 oz. of juice PO (if applicable) and/or follow HYPOglycemia Protocol meds. glucose (D50) 25 g, IVP, syringe, as needed, PRN glucose levels see parameters Patient unable to swallow / NPO WITH IV access. Dextrose 50% 50 ml IV. Recheck BG in 15 20 minutes. Repeat treatment until blood glucose > 100 mg/dl. If not NPO provide additional snack once able to swallow. glucose 15 g, PO, gel, as needed, PRN glucose levels see parameters glucagon 1 mg, IM, inj, as needed, PRN glucose levels see parameters Patient UNABLE to swallow / NPO WITHOUT IV access. Administer Glucagon 1 mg IM or SubQ. Contact physician for further orders. Establish IV access with saline lock. Recheck BG every 15 to 20 minutes. Use aspiration precautions as glucagon may cause nausea and vomiting. Page: 11 Post Op Non ICU Admit Version: Plan 2 Effective on: 03/19/14
Arrives to Room VTE Prophylaxis Plan PHYSICIAN S Patient Care VTE Guidelines See Reference Text for Guidelines ***If VTE Pharmacologic Prophylaxis not given, choose the Contraindications for VTE below and complete reason contraindi cated*** Contraindications VTE Patient low risk for VTE Patient is ambulatory Patient Refusal Family/Caregiver Refusal Cont IV heparin day of/after admission Anticoag therapy not warfarin for Afib Warfarin prior to admit; on hold r/t INR Risk of Bleeding Thrombocytopenia Active Bleeding Alteplase Administered w/in 24 hrs IV Heparin w/in 24 hrs of Surgery Apply Elastic Stockings Apply to: Bilateral Lower Extremities, Length: Knee High Apply to: Left Lower Extremity (LLE), Length: Knee High Apply to: Right Lower Extremity (RLE), Length: Knee High Apply to: Bilateral Lower Extremities, Length: Thigh High Apply to: Left Lower Extremity (LLE), Length: Thigh High Apply to: Right Lower Extremity (RLE), Length: Thigh High Apply Sequential Compression Device Apply to Bilateral Lower Extremities Apply to Left Lower Extremity (LLE) Apply to Right Lower Extremity (RLE) Apply Pedal Pump Apply to Bilateral Feet Apply to Left Foot Apply to Right Foot Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. ***Recommended Trauma Dose = 30 mg, subcut, q12h*** ***Recommended Dose for Morbidly Obese Patients = 40 mg, subcut, q12h*** enoxaparin 40 mg, subcut, syringe, q24h 30 mg, subcut, syringe, q24h 30 mg, subcut, syringe, q12h 40 mg, subcut, syringe, q12h heparin 5,000 units, subcut, inj, q12h 5,000 units, subcut, inj, q8h fondaparinux 2.5 mg, subcut, syringe, Daily ***If you order RIVAROXABAN for your patient, please indicate the reason below*** Page: 12 Post Op Non ICU Admit Version: Plan 2 Effective on: 03/19/14
Arrives to Room VTE Prophylaxis Plan PHYSICIAN S Reason for Oral Factor Xa Inhibitor Reason: Atrial fibrillation Reason: Persistent atrial fibrillation Reason: Paroxysmal atrial fibrillation Reason: Atrial flutter Reason: Hx Afib/flutter NA w/in 8wks post CABG Reason: Partial hip arthroplasty Reason: Total hip arthroplasty Reason: Total hip replacement Reason: Total knee arthroplasty Reason: Total knee replacement rivaroxaban 10 mg, PO, tab, Daily warfarin 5 mg, PO, tab, QPM aspirin 81 mg, PO, tab, Daily 325 mg, PO, tab, Daily Page: 13 Post Op Non ICU Admit Version: Plan 2 Effective on: 03/19/14