- Phase:. PHYSICIAN S Diagnosis Weight Allergies DETAILS Patient Care Vital Signs Per Unit Standards, q15min x 4, q30min x 2, then q1h x 4 until sheath discontinued. Per Unit Standards Perform Neurovascular Checks To: Bilateral Upper Extremities Bilateral Lower Extremities, q1h, for 12hrs then q2h for 12hrs then Per Unit Standards. Notify Nurse (DO NOT USE FOR MEDS) PA Catheter: Assess PAP, PCWP, CVP, SVR, PVR, CO, and CL q1h x 4 then q4h. Flush q24h with saline. Strict Intake and Output Per Unit Standards Patient Activity Bedrest Insert Urinary Catheter Criticore Foley Urinary Catheter Care Per Unit Standards Core Body Temperature Monitoring with Criticore Notify Nurse (DO NOT USE FOR MEDS) Assess groin incision and sheath site for hematoma q2h x 4 then qshift Warming Measures Treat hypothermia with warming blanket to keep Temp greater than 96.8 degrees F (36 C) Wound Care by Nursing Place Device at Bedside Femstop to bedside Maintain Gastric Tube Maintain Nasogastric - NG, Low Intermittent Suction Maintain Orogastric - OG, Low Intermittent Suction Maintain Chest Tube Notify Nurse (DO NOT USE FOR MEDS) If chest tube output is greater than ml/hr, order H&H, PT, PTT, and platelet count. Bedside Pacemaker Settings Communication Notify Provider of VS Parameters Temp Greater Than 101.5, RR Greater Than 28, RR Less Than 8, SpO2 Less Than 92, SBP Greater Than 180, SBP Less Than 100, HR Greater Than 120, HR Less Than 50 Order Taken by Signature: 1 of 14
- Phase:. PHYSICIAN S DETAILS Reason: Urine output less than 30 ml/hr. Reason: Blood Glucose greater than 180 or less than 60. Reason: Onset of Chest Pain or Dyspnea. Dietary NPO Diet NPO NPO, Except Meds NPO, Except Meds, Except Ice Chips Oral Diet Clear Liquid Diet, Advance as tolerated to AHA ADA Diet IV Solutions NS IV, 75 ml/hr IV, 125 ml/hr IV, 150 ml/hr IV, 200 ml/hr 1/2 NS IV, 75 ml/hr IV, 125 ml/hr IV, 150 ml/hr IV, 200 ml/hr Volume Replacement LR (LR bolus) 1,000 ml, IV, iv soln, ONE TIME, PRN hypotension, Infuse over 1 hr Administer for systolic blood pressure less than 90mmHg or MAP less than 60mmHg. albumin human (albumin human 5% bolus) 12.5 g, IVPB, ivpb, ONE TIME, PRN hypotension, Infuse over 1 hr Administer for systolic blood pressure less than 90mmHg or MAP less than 60mmHg. May give up to 1,000 ml. Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. Antibiotics cefuroxime 1.5 g, IVPB, ivpb, q8h, x 2 dose Start 8 hours after the pre-op dose was administered. vancomycin 1,000 mg, IVPB, ivpb, q12h, x 1 dose Start 12 hours after the pre-op dose was administered. Vasodilators nitroglycerin (nitroglycerin sublingual) 0.4 mg, SL, tab, q5minx3, PRN chest pain ***If chest pain continues, obtain STAT EKG and notify physician STAT*** Order Taken by Signature: 2 of 14
- Phase:. PHYSICIAN S DETAILS Anti Platelets Loading Dose ticagrelor 180 mg, PO, tab, ONE TIME prasugrel 60 mg, PO, tab, ONE TIME clopidogrel 300 mg, PO, tab, ONE TIME 600 mg, PO, tab, ONE TIME Maintenance Dose ticagrelor 90 mg, PO, tab, BID Begin 12 hours after loading dose. prasugrel 10 mg, PO, tab, Daily 5 mg, PO, tab, Daily clopidogrel 75 mg, PO, tab, Daily Begin 24 hours after loading dose. aspirin 81 mg, PO, tab ec, Daily 325 mg, PO, tab, Daily Hemodynamics DOBUTamine 250 mg/250 ml D5W - Titratabl (DOBUTamine 250 mg/250 ml D5W - Titratable) IV, Max dose: 20 mcg/kg/min Final concentration = 1 mg/ml (1,000 mcg/ml). Start at rate: mcg/kg/min milrinone 20 mg/100 ml D5W - Titratable Start at rate: mcg/kg/min IV, Max dose: 1 mcg/kg/min norepinephrine 4 mg/250 ml NS - Titratab (norepinephrine 4 mg/250 ml NS - Titratable) Start at rate: mcg/min IV, Max dose: 60 mcg/min EPINEPHrine 4 mg/250 ml NS - Titratable IV, Max dose: 20 mcg/min Final concentration = 0.016 mg/ml (16 mcg/ml). Start at rate: mcg/min amiodarone 150 mg, IVPB, ivpb, ONE TIME, Infuse over 10 min amiodarone 900 mg/500 ml D5W IV Final concentration = 1.8 mg/ml. Usual maintenance dose is 33.3 ml/hr (1 mg/min) x 6 hr, then 16.7 ml/hr (0.5 mg/min) thereafter. If systolic blood pressure is less than 90 or heart rate is less than 60, hold infusion and notify physician. Continued on next page... Order Taken by Signature: 3 of 14
- Phase:. PHYSICIAN S DETAILS Start at rate: mg/min Other Medications famotidine 20 mg, PO, tab, BID pantoprazole 40 mg, PO, tab ec, Daily Do not crush or chew. Laboratory POC Blood Sugar Check Hemoglobin and Hematocrit STAT CBC PTT Prothrombin Time with INR Comprehensive Metabolic Panel Basic Metabolic Panel Potassium Level STAT Magnesium Level Glucose Random D Dimer HS Diagnostic Tests EKG-12 Lead STAT, upon arrival to unit. EKG-12 Lead T+1;0500, In AM Notify Nurse (DO NOT USE FOR MEDS) EKG STAT PRN Chest Pain Echo Transthoracic (TTE) with contrast i (Echo Transthoracic (TTE) with contrast if needed) T+1;N, Routine DX Chest Portable Routine DX Chest Portable T+1;0500, Routine DX Chest PA & Lateral T+2;0500, Routine...Additional Orders Order Taken by Signature: 4 of 14
- Phase:. PHYSICIAN S DETAILS Order Taken by Signature: 5 of 14
- Phase: VTE PROPHYLAXIS PLAN PHYSICIAN S DETAILS 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 Active/high risk for bleeding Treatment not indicated Patient or caregiver refused Other anticoagulant ordered Anticipated procedure within 24 hours Intolerance to all VTE chemoprophylaxis 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, q12h 30 mg, subcut, syringe, q24h, For CrCl less than 30 ml/min 40 mg, subcut, syringe, q12h, For BMI greater than 39 heparin 5,000 units, subcut, inj, q12h 5,000 units, subcut, inj, q8h fondaparinux 2.5 mg, subcut, syringe, q24h rivaroxaban 10 mg, PO, tab, In PM 20 mg, PO, tab, In PM warfarin 5 mg, PO, tab, In PM aspirin 81 mg, PO, tab chew, Daily 325 mg, PO, tab, Daily Order Taken by Signature: 6 of 14
- Phase: DISCOMFORT MED PLAN PHYSICIAN S DETAILS Patient Care Perform Bladder Scan Scan PRN, If more than 250, Then: Call MD, Perform as needed for patients complaining of urinary discomfort and/or bladder distention present OR 6 hrs post Foley removal and patient has not voided. Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. benzocaine-menthol topical (Chloraseptic 6 mg-10 mg mucous membrane lozenge) 1 lozenge, mucous membrane, lozenge, q4h, PRN sore throat dextromethorphan-guaifenesin (dextromethorphan-guaifenesin 20 mg-200 mg/10 ml oral liquid) 10 ml, PO, liq, q4h, PRN cough dexamethasone-diphenhydramin-nystatin-ns (Fred s Brew) 15 ml, swish & spit, liq, q2h, PRN mucositis While awake Analgesics acetaminophen 500 mg, PO, tab, q6h, PRN pain-mild (scale 1-3) ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF acetaminophen ineffective/contraindicated, USE ibuprofen if ordered:***** 1,000 mg, PO, tab, q4h, PRN pain-mild (scale 1-3) ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF acetaminophen ineffective/contraindicated, USE ibuprofen if ordered:***** 650 mg, rectally, supp, q4h, PRN pain-mild (scale 1-3) ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF acetaminophen ineffective/contraindicated, USE ibuprofen if ordered:***** ibuprofen 400 mg, PO, tab, q6h, PRN pain-mild (scale 1-3) ***Do not exceed 3,200 mg of ibuprofen from all sources in 24 hours***. Give with food. Select either HYDROcodone-acetaminophen or acetaminophen-codeine #3, but not both HYDROcodone-acetaminophen (HYDROcodone-acetaminophen 5 mg-325 mg oral tablet) 1 tab, PO, tab, q4h, PRN pain-moderate (scale 4-7) Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours ****IF HYDROcodone-acetaminophen ineffective/contraindicated or the patient is NPO, USE ketorolac if ordered**** 2 tab, PO, tab, q4h, PRN pain-moderate (scale 4-7) Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours ****IF HYDROcodone-acetaminophen ineffective/contraindicated or the patient is NPO, USE ketorolac if ordered**** Continued on next page... Order Taken by Signature: 7 of 14
- Phase: DISCOMFORT MED PLAN PHYSICIAN S DETAILS acetaminophen-codeine (acetaminophen-codeine (Tylenol with Codeine) 300 mg-30 mg oral tablet) 1 tab, PO, tab, q4h, PRN pain-moderate (scale 4-7) Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours.***** If acetaminophen-codeine #3 ineffective/contraindicated or NPO, USE ketorolac if ordered.***** 2 tab, PO, tab, q4h, PRN pain-moderate (scale 4-7) Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours.***** If acetaminophen-codeine #3 ineffective/contraindicated or NPO, USE ketorolac if ordered.***** ketorolac 15 mg, IVPush, inj, q6h, PRN pain-moderate (scale 4-7), x 48 hr ***May give IM if no IV access*** 30 mg, IVPush, inj, q6h, PRN pain-moderate (scale 4-7), x 48 hr ***May give IM if no IV access*** morphine 2 mg, Slow IVPush, inj, q4h, PRN pain-severe (scale 8-10) *****IF morphine is ineffective/contraindicated, USE HYDROmorphone if ordered***** 4 mg, Slow IVPush, inj, q4h, PRN pain-severe (scale 8-10) *****IF morphine is ineffective/contraindicated, USE HYDROmorphone if ordered***** HYDROmorphone 0.2 mg, Slow IVPush, inj, q4h, PRN pain-severe (scale 8-10) 0.4 mg, Slow IVPush, inj, q4h, PRN pain-severe (scale 8-10) 0.6 mg, Slow IVPush, inj, q4h, PRN pain-severe (scale 8-10) Antiemetics promethazine 25 mg, PO, tab, q4h, PRN nausea/vomiting *****IF promethazine is ineffective/contraindicated or patient is NPO, USE ondansetron if ordered***** ondansetron 4 mg, IVPush, soln, q8h, PRN nausea/vomiting Gastrointestinal Agents docusate 100 mg, PO, cap, Nightly, PRN constipation *****IF docusate is contraindicated or ineffective after 12 hours, USE bisacodyl if ordered***** bisacodyl 10 mg, rectally, supp, Daily, PRN constipation *****IF bisacodyl is contraindicated or ineffective after 6 hours, USE Fleet Enema if ordered***** sodium biphosphate-sodium phosphate (Fleet Enema) 1 ea, rectally, enema, Daily, PRN constipation loperamide 4 mg, PO, cap, ONE TIME, PRN diarrhea Initial dose after first loose stool 4 mg, PO, liq, ONE TIME, PRN diarrhea Initial dose after first loose stool Order Taken by Signature: 8 of 14
- Phase: DISCOMFORT MED PLAN PHYSICIAN S DETAILS loperamide 2 mg, PO, cap, as needed, PRN diarrhea 2 mg after each loose stool, up to 16 mg per day 2 mg, PO, liq, as needed, PRN diarrhea 2 mg after each loose stool, up to 16 mg per day Antacids Al hydroxide-mg hydroxide-simethicone (aluminum hydroxide-magnesium hydroxide-simethicone 200 mg-200 mg-20 mg/5 ml oral suspension) 30 ml, PO, susp, q4h, PRN indigestion Administer 1 hour before meals and nightly. simethicone 80 mg, PO, tab chew, q4h, PRN gas 160 mg, PO, tab chew, q4h, PRN gas Sedatives ALPRAZolam 0.25 mg, PO, tab, TID, PRN anxiety *****IF ALPRAZolam is ineffective/contraindicated or patient is NPO, USE LORazepam if ordered***** LORazepam 1 mg, IVPush, inj, q6h, PRN anxiety 0.5 mg, IVPush, inj, q6h, PRN anxiety zolpidem 5 mg, PO, tab, Nightly, PRN insomnia may repeat x1 in one hour if ineffective Antihistamines diphenhydramine 25 mg, PO, cap, q4h, PRN itching *****IF diphenhydramine PO is ineffective or patient is NPO, USE diphenhydramine inj if ordered***** diphenhydramine 25 mg, IVPush, inj, q4h, PRN itching Anti-pyretics acetaminophen 500 mg, PO, tab, q4h, PRN fever ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF acetaminophen is ineffective/contraindicated, USE ibuprofen if ordered***** 1,000 mg, PO, tab, q4h, PRN fever ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF acetaminophen is ineffective/contraindicated, USE ibuprofen if ordered***** Continued on next page... Order Taken by Signature: 9 of 14
- Phase: DISCOMFORT MED PLAN PHYSICIAN S DETAILS ibuprofen 200 mg, PO, tab, q4h, PRN fever Do not exceed 3,200 mg in 24 hours. Give with food. 400 mg, PO, tab, q4h, PRN fever Do not exceed 3,200 mg in 24 hours. Give with food. Anorectal Preparations witch hazel-glycerin topical (witch hazel-glycerin 50% topical pad) 1 app, topical, pad, as needed, PRN hemorrhoid care Wipe affected area *****IF witch hazel-glycerin ineffective/contraindicated, USE phenylephrine ointment if ordered***** phenylephrine topical (phenylephrine 0.25%-3% rectal ointment) 1 app, rectally, oint, q6h, PRN hemorrhoid care Apply to affected area *****IF phenylephrine ointment ineffective/contraindicated, USE hydrocortisone-pramoxine foam if ordered***** hydrocortisone-pramoxine topical (hydrocortisone-pramoxine 1%-1% rectal foam) 1 app, rectally, foam, q8h, PRN hemorrhoid care apply to affected area Order Taken by Signature: 10 of 14
- Phase: ELECTROLYTE MED PLAN PHYSICIAN S DETAILS Communication When placing the protocol order, do NOT order any meds unless you need IMMEDIATE electrolyte replacement therapy. Electrolyte Replacement Guideline ***See Reference Text*** Electrolyte Replacement Guideline (Aggressive Oral Potassium Replacement) Electrolyte Replacement Guideline (Oral Potassium Replacement) Electrolyte Replacement Guideline (Aggressive IV Potassium Replacement) Electrolyte Replacement Guideline (IV Potassium Replacement) Electrolyte Replacement Guideline (IV Potassium Phosphates Replacement) Electrolyte Replacement Guideline (IV Sodium Phosphates Replacement) Electrolyte Replacement Guideline (IV Magnesium Replacement) Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. Replacement orders should only be used in patients with a serum creatinine less than 2 mg/dl, BUN less than 30 mg/dl, and urinary output greater than 30 ml/hr Only the selected electrolytes will be replaced per protocol An infusion pump is required for all electrolyte infusions ORAL POTASSIUM REPLACEMENT: *****For asymptomatic patients able to take ORAL supplementation***** 20 meq, PO, tab sa, ONE TIME [Serum Potassium 3.6-3.9 mmol/l] **Aggressive Replacement ONLY** Repeat serum potassium with AM labs. Check magnesium levels if potassium does not respond after 2 doses. 20 meq, PO, tab sa, q2h, x 2 dose [Serum Potassium 3.1-3.5 mmol/l] Repeat serum potassium with AM labs. Check magnesium levels if potassium does not respond after 2 doses. Reason: [Serum Potassium LESS than 3.1 mmol/l] Notify provider for replacement orders as IV replacement may be necessary. IV POTASSIUM REPLACEMENT: *****Peripheral line administration***** Order Taken by Signature: 11 of 14
- Phase: ELECTROLYTE MED PLAN PHYSICIAN S DETAILS 20 meq, IVPB, ivpb, ONE TIME, Infuse over 2 hr PERIPHERAL LINE - [Serum Potassium 3.6-3.9 mmol/l] **Aggressive Replacement ONLY** Repeat serum potassium level 2 hours after total replacement is completed. Check magnesium levels if potassium does not respond after 2 doses. 40 meq, IVPB, ivpb, ONE TIME, Infuse over 4 hr PERIPHERAL LINE - [Serum Potassium 3.1-3.5 mmol/l] Repeat serum potassium level 2 hours after total replacement is completed. Check magnesium levels if potassium does not respond after 2 doses. 60 meq, IVPB, ivpb, ONE TIME, Infuse over 6 hr PERIPHERAL LINE - [Serum Potassium less than 3.1 mmol/l]. Give 60 meq IVPB ONE TIME and contact provider for further orders. Repeat serum potassium level 2 hours after total replacement is completed. Check magnesium levels if potassium does not respond after 2 doses. Reason: [Serum Potassium LESS than 3.1 mmol/l] Give 60 meq IVPB ONE TIME and contact provider for further orders. *****Central line administration***** 20 meq, IVPB, ivpb, ONE TIME, Infuse over 2 hr CENTRAL LINE - [Serum Potassium 3.6-3.9 mmol/l] Repeat serum potassium level 2 hours after total replacement is completed. Check magnesium levels if potassium does not respond after 2 doses. 40 meq, IVPB, ivpb, ONE TIME, Infuse over 4 hr CENTRAL LINE - [Serum Potassium 3.1-3.5 mmol/l] Repeat serum potassium level 2 hours after total replacement is completed. Check magnesium levels if potassium does not respond after 2 doses. Continued on next page... Order Taken by Signature: 12 of 14
- Phase: ELECTROLYTE MED PLAN PHYSICIAN S DETAILS 60 meq, IVPB, ivpb, ONE TIME, Infuse over 6 hr CENTRAL LINE - [Serum Potassium less than 3.1 mmol/l]. Give postassium chloride 60mEq IVPB ONE TIME and contact provider for further orders. Repeat serum potassium level 2 hours after total replacement is completed. Check magnesium levels if potassium does not respond after 2 doses. Reason: [Serum Potassium LESS than 3.1 mmol/l] Give 60 meq IVPB ONE TIME and contact provider for further orders. IV POTASSIUM PHOSPHATES REPLACEMENT: *****Use when phosphorus AND potassium need replacement***** potassium phosphate 15 mmol, IVPB, ivpb, ONE TIME, Infuse over 2 hr [serum phosphorus 2-2.5 mg/dl and serum potassium 3.6 3.9 mmol/l ] DO NOT USE if serum potassium is greater than 3.9 mmol/l. Repeat serum phosphorus and potassium levels 6 hours after infusion completed potassium phosphate 30 mmol, IVPB, ivpb, ONE TIME, Infuse over 4 hr [serum phosphorus 1-1.9 mg/dl and serum potassium 3.1 3.5 mmol/l] DO NOT USE if serum potassium is greater than 3.5 mmol/l. // /Repeat serum phosphorus and potassium levels 6 hours after infusion completed. potassium phosphate 45 mmol, IVPB, ivpb, ONE TIME, Infuse over 6 hr [serum phosphorus less than 1 mg/dl and serum potassium less than 3.1 mmol/l] DO NOT USE if serum potassium is greater than 3.5 mmol/l. Give potassium phosphate 45mMol IVPB ONE TIME and contact provider for further orders. Repeat serum phosphorus and potassium levels 6 hours after infusion completed Reason: [serum phosphorus less than 1 mg/dl and serum potassium less than 3.1 mmol/l] Give potassium phosphate 45mMol IVPB ONE TIME and contact provider for further orders. IV SODIUM PHOSPHATES REPLACEMENT: *****Use when only phosphorus needs replacement***** sodium phosphate 15 mmol, IVPB, ivpb, ONE TIME, Infuse over 2 hr [serum phosphorus 2-2.5 mg/dl and serum sodium less than 140 mmol/l] Repeat serum phosphorus level 6 hours after infusion completed. Continued on next page... Order Taken by Signature: 13 of 14
- Phase: ELECTROLYTE MED PLAN PHYSICIAN S DETAILS sodium phosphate 30 mmol, IVPB, ivpb, ONE TIME, Infuse over 4 hr [serum phosphorus 1-1.9 mg/dl and serum sodium less than 140 mmol/l] Repeat serum phosphorus level 6 hours after infusion completed. sodium phosphate 45 mmol, IVPB, ivpb, ONE TIME, Infuse over 6 hr [serum phosphorus less than 1 mg/dl and serum sodium less than 140 mmol/l] Give sodium phosphate 45 mmol IVPB ONE TIME and contact provider for further orders. Repeat serum phosphorus level 6 hours after infusion completed. Reason: [serum phosphorus less than 1 mg/dl] Give sodium phosphate 45 mmol IVPB ONE TIME and contact provider for further orders. IV MAGNESIUM REPLACEMENT: magnesium sulfate 2 g, IVPB, ivpb, ONE TIME, Infuse over 60 min [serum magnesium level less than 1.6 mg/dl] IF serum magnesium level is less than 1 mg/dl, give magnesium sulfate 2 grams IVPB ONE TIME and contact provider for further orders. Repeat serum magnesium level 2 hours after the infusion is completed. Reason: [serum magnesium level less than 1 mg/dl] Give magnesium sulfate 2 grams IVPB ONE TIME and contact provider for further orders. Laboratory Potassium Level Phosphorus Level Magnesium Level Order Taken by Signature: 14 of 14