Bariatric Surgery Post Op Plan PACU Phase PHYSICIAN S Weight Allergies Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Code Status Code Status: Full Code Code Status: DNI Do Not Intubate Code Status: DNR Do Not Resuscitate Code Status: Partial Resuscitative Effort Admitting Diagnosis/Reason for Visit Bariatric Surgery Post Op Laboratory CBC STAT, Comment: Patient is in PACU Basic Metabolic Panel STAT, Comment: Patient is in PACU Comprehensive Metabolic Panel STAT, Comment: Patient is in PACU Order Taken by Signature: Page: 1 Bariatric Surgery Post Op Plan Version: 3 Effective on: 12/18/13 **
Arrives to Room PHYSICIAN S Patient Care Patient Activity Out of Bed Assist as Needed, Bed Position: HOB >/= 30 degrees, Pt MUST visit Bathroom. HOB elevated 30 degrees at all times. Post Op Day 1 MANDATORY Out of Bed q4hrs Apply Elastic Stockings Apply to: Bilateral Lower Extremities, Length: Knee High, IF appropriate size available Apply Pedal Pump Apply to Bilateral Feet, Remove after first visit to bathroom Insert Urinary Catheter (Insert Foley) Foley, Straight cath if no void by 8hr post op. Strict Intake and Output Per Unit Standards, Pt to void into commode chair in bathroom, not in bed. Notify Provider (Misc) Notify Dr. Syn Office:687 5670 Pager: 740 6545 Cell: 438 9415, Reason: If urine volume >300cc leave foley and call MD Dietary Dr. Syn s Post Gastric NO Carbonated beverages. NO sugar. NO Juice. Leave water at bedside and encourage 8 cups of water per day. ADA Diet Adult 1200 Calories, Low Fat, NO Carbonated beverages. NO sugar. NO Juice. Leave water at bedside and encourage 8 cups of water per day. IV Solutions LR IV, 125 ml/hr IV, 150 ml/hr Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. albuterol (albuterol 2.5 mg/3 ml (0.083%) inhalation solution) 2.5 mg, inhalation, soln, q6h heparin 5,000 units, subcut, inj, BID clindamycin 900 mg, IVPB, ivpb, q12h, x 2 dose, Infuse over 30 min Begin 12 hours after preoperative dose given. cyanocobalamin 1000 mcg, IM, inj, ONE TIME thiamine 100 mg, IVPB, ivpb, Daily, x 4 days ***Not to exceed 4 days*** Order Taken by Signature: Page: 2 Bariatric Surgery Post Op Plan Version: 3 Effective on: 12/18/13 **
Arrives to Room PHYSICIAN S insulin aspart units, subcut, inj ketorolac 30 mg, IVPush, inj, Daily, x 3 dose To be given at 6:00 AM (0600) post op day 1 HYDROcodone acetaminophen (HYDROcodone acetaminophen 5 mg 325 mg oral tablet) 2 tab, PO, tab, q4h, PRN pain Do Not Substitute ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** 1 tab, PO, tab, q4h, PRN pain Do Not Substitute ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** ondansetron 4 mg, IVPush, inj, q4h, PRN nausea If no refief may give Phenergan (promethazine) promethazine 12.5 mg, IVPush, inj, q6h, PRN nausea If no relief from Zofran (ondansetron) ***VESICANT*** Dilute with 10 ml NS & IVP over 2 3 min through a running IV line with large bore access. zolpidem 5 mg, PO, tab, Nightly, PRN insomnia scopolamine (scopolamine 1.5 mg transdermal film, extended release) 1.5 mg, transdermal, adh patch, Every 3 days Place behind ear and change every three days acetaminophen 1,000 mg, PO, tab, q4h, PRN fever, Temp >101 ***DO NOT administer until POD 1*** Do not exceed 4000 mg of acetaminophen per day from all sources. 500 mg, PO, tab, q4h, PRN fever, Temp >101 ***DO NOT administer until POD 1*** Do not exceed 4000 mg of acetaminophen per day from all sources. Order Taken by Signature: Page: 3 Bariatric Surgery Post Op Plan Version: 3 Effective on: 12/18/13 **
Arrives to Room PHYSICIAN S tramadol 50 mg, PO, tab, TID 50 mg, PO, tab, q12h, PRN pain 50 mg, PO, tab, q6h, PRN pain 100 mg, PO, tab, q6h, PRN pain 100 mg, PO, tab, q4h, PRN pain piperacillin tazobactam 3.375 g, IVPB, ivpb, q6h, x 2 dose Begin 6 hours after post op dose. 2.25 g, IVPB, ivpb, q6h, x 2 dose Begin 6 hours after post op dose. Laboratory CBC Next Day in AM, T+1;0300 Next Day in AM, T+1;0300, Every AM for 2 days CBC with Differential Next Day in AM, T+1;0300 Next Day in AM, T+1;0300, Every AM for 2 days Basic Metabolic Panel Next Day in AM, T+1;0300 Next Day in AM, T+1;0300, Every AM for 2 days Comprehensive Metabolic Panel Next Day in AM, T+1;0300 Next Day in AM, T+1;0300, Every AM for 2 days Diagnostic Tests DX UGI (w/o Barium, Air) T+1;0500, Other (specify below), Use Gastgrograffin. Assess for leak at Gastro jejunostomy site. Respiratory Chest Physiotherapy Target Lung Area(s): All lung areas, q6h, While Awake. With Postural Drainage. Oxygen Therapy 2 6 L/min, Keep sats greater than %: 92, PRN IS Instruct 10x/day, 10 times every hour while awake. Physical Medicine and Rehab Consult PT Mobility for Eval & Treat Consults/Referrals Consult Dietician...Additional Orders Order Taken by Signature: Page: 4 Bariatric Surgery Post Op Plan Version: 3 Effective on: 12/18/13 **
Arrives to Room Sliding Scale Insulin Aspart 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 aspart (Low Dose Insulin Aspart Sliding Scale) 0 10 units, subcut, inj, AC & nightly, PRN glucose levels see parameters 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 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 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. Order Taken by Signature: Page: 5 Bariatric Surgery Post Op Plan Version: 3 Effective on: 12/18/13 **
Arrives to Room Sliding Scale Insulin Aspart Protocol Plan PHYSICIAN S 0 10 units, subcut, inj, q2h, PRN glucose levels see parameters 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 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 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. Order Taken by Signature: Page: 6 Bariatric Surgery Post Op Plan Version: 3 Effective on: 12/18/13 **
Arrives to Room Sliding Scale Insulin Aspart Protocol Plan PHYSICIAN S insulin aspart (Moderate Dose Insulin Aspart Sliding Scale) 0 12 units, subcut, inj, AC & nightly, PRN glucose levels see parameters 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 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 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 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. Order Taken by Signature: Page: 7 Bariatric Surgery Post Op Plan Version: 3 Effective on: 12/18/13 **
Arrives to Room Sliding Scale Insulin Aspart Protocol Plan PHYSICIAN S 0 12 units, subcut, inj, TID, PRN glucose levels see parameters 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 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 aspart (High Dose Insulin Aspart Sliding Scale) 0 14 units, subcut, inj, AC & nightly, PRN glucose levels see parameters 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 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 Order Taken by Signature: Page: 8 Bariatric Surgery Post Op Plan Version: 3 Effective on: 12/18/13 **
Arrives to Room Sliding Scale Insulin Aspart Protocol Plan PHYSICIAN S 0 14 units, subcut, inj, q4h, PRN glucose levels see parameters 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 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 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 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 insulin aspart (Blank Insulin Aspart Sliding Scale) Order Taken by Signature: Page: 9 Bariatric Surgery Post Op Plan Version: 3 Effective on: 12/18/13 **
Arrives to Room Sliding Scale Insulin Aspart Protocol Plan PHYSICIAN S 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. Order Taken by Signature: Page: 10 Bariatric Surgery Post Op Plan Version: 3 Effective on: 12/18/13 **
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*** Order Taken by Signature: Page: 11 Bariatric Surgery Post Op Plan Version: 3 Effective on: 12/18/13 **
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 Order Taken by Signature: Page: 12 Bariatric Surgery Post Op Plan Version: 3 Effective on: 12/18/13 **