Post Operative Above and Below Knee Amputation Admission [3041300028] Consider adding Insulin Adult -- Subcutaneous Insulin and Hypoglycemia Management [3041300000] General Admission (Single Response) ( ) Admit to Inpatient Details ( ) Place Patient in Observation Details ( ) Place outpatient in a bed Details ( ) Transfer patient Unit: Accommodation Code: Bed request comments: ( ) Return to unit with a Level of Care change [ ] Return to unit Routine, Once [ ] Level of Care Details ( ) Return to unit Routine, Once PACU (only) Admission (Single Response) ( ) Admit to Inpatient Details ( ) Place Patient in Observation Details ( ) Place outpatient in a bed Details ( ) Transfer patient Unit: Accommodation Code: Bed request comments: ( ) Return to unit with a Level of Care change [ ] Return to unit Routine, Once PACU (only) [ ] Level of Care Details ( ) Return to unit Routine, Once PACU (only) Code Status (Single Response) ( ) Full code Details ( ) Full code - unverified Details ( ) DNRCC Allow additional therapies? ( ) DNRCC-Arrest Detail: Code Status (Single Response) ( ) Full Code Details ( ) Full code - unverified Details ( ) DNRCC Allow additional therapies? Page 1 of 19
( ) DNRCC-Arrest Detail: Isolation (Single Response) ( ) Contact isolation Routine, Continuous For Until specified ( ) Contact plus isolation Routine, Continuous For Until specified ( ) Airborne isolation Routine, Continuous For Until specified ( ) Droplet isolation Routine, Continuous For Until specified ( ) Contact & airborne isolation status Routine, Continuous For Until specified ( ) Contact & droplet isolation status Routine, Continuous For Until specified ( ) Contact plus & airborne isolation Routine, Continuous For Until specified ( ) Contact plus & droplet isolation Routine, Continuous For Until specified Patient Care Nursing Orders Patient Care [ ] Vital signs Routine, Every 8 hours Every 2 hours x 12 hours, then every 4 hours x 24 hours, then every 8 hours, PACU to Post Procedure [ ] Nurse to assess for hypoglycemia, and follow guidelines as required [ ] Assess and manage hypoglycemia Routine, Until discontinued, Starting S Open Hypoglycemia Management Protocol orderset to place X1 orders for blood glucose less than 70 mg/dl. [ ] Notify physician Routine, Until discontinued, Starting S Other: Notify physician of all Blood Glucose less than 50 mg/dl Per Hypoglycemia Protocol Recheck blood glucose 15 minutes after intervention; if blood sugar remains less than 70 mg/dl, repeat intervention If repeat glucose remains less than 70 mg/dl, notify physician immediately [ ] Cardiac monitoring Routine, Until discontinued, Starting S, [ ] Intake and Output Routine, Every 8 hours For 72 Hours Notify physician if urine output less than 240 ml every 8 hours, Page 2 of 19
[ ] Notify physician Routine, Until discontinued, Starting S Temperature greater than: 101.5 Temperature less than: Systolic BP greater than: 180 Systolic BP less than: 90 Diastolic BP greater than: Diastolic BP less than: Heart rate greater than: 120 Heart rate less than: 60 Respiratory rate greater than: 24 Respiratory rate less than: 10 SpO2 less than: 90 Hemoglobin less than (g/dl) : 7 Other: Urine output less than 240 ml every 8 hours PACU to Post Procedure [ ] Cough and deep breathe Routine, Until discontinued, Starting S 10 times every hour while awake, [ ] Dressing change - physician only Routine, Until discontinued, Starting S, [ ] Elevate extremity Routine, Until discontinued, Starting S Other (comments) Operative extremity on pillow, [ ] Apply knee immobilizer Routine, Until discontinued, Starting S Extremity: At all times, [ ] Trapeze Routine, Until discontinued, Starting S, [ ] Patient education : teach patient / family self injections (if on lovenox) Foley Catheter Routine, Once For 1 Occurrences : teach patient / family self injections (if on lovenox) [ ] Unable to void - Bladder Scan and Catheter [ ] Bladder scan Routine, As needed On Post-Op Day (POD) #: 1 Every 8 hours for residual urine greater than 200 ml, starting on POD specified above, [ ] Straight cath Routine, As needed On Post-Op Day (POD) #: 1 Every 8 hours for residual urine greater than 200 ml, starting on POD specified above, [ ] Foley Catheter to straight drain - maintain then "And" Linked Panel discontinue POD#1 [ ] Foley catheter Routine, Continuous [ ] Discontinue foley catheter Routine, Once, Starting S+1 On Post-Op Day (POD) #: 1 [ ] Foley Catheter to straight drain - maintain then "And" Linked Panel discontinue POD#2 (prior to midnight) Page 3 of 19
[ ] Foley catheter Routine, Continuous [ ] Discontinue foley catheter Routine, Once, Starting S+2 On Post-Op Day (POD) #: 2 If foley is not to be discontinued by end of POD#2 notify physician to document reason and obtain order for continuation, [ ] Foley Catheter to straight drain - maintain and do not "And" Linked Panel remove while epidural in place [ ] Foley catheter Routine, Continuous [ ] Do not remove foley Routine, Until discontinued, Starting S Reason: Epidural catheter If foley is not to be discontinued by end of POD#2 due to epidural, notify physician to document reason and obtain order for continuation, [ ] Foley Catheter to straight drain - maintain and do not "And" Linked Panel remove (specify reason) [ ] Foley catheter Routine, Continuous To straight drain [ ] Do not remove foley Routine, Until discontinued, Starting S Reason: Dressing [ ] Wound V.A.C. and Consult to Enterostomal Therapy [ ] Wound V.A.C. Routine, Until discontinued, Starting S Negative pressure therapy type: Pressure setting (mmhg): VAC dressing: Change Monday, Wednesday and Friday [ ] Inpatient consult to Enterostomal Therapy Reason For Consult? Wound Care [ ] Remove dressing Routine, Once Site: surgical On Post-Op Day (POD) #: Page 4 of 19
[ ] Change dressing Routine, Daily Specify site: Dressing type: Product(s): Secure with: Cleanse site with: Irrigate wound/area with: Pack wound with: and as needed, [ ] Reinforce dressing as needed Routine, As needed [ ] Equipment / supplies to bedside - suture removal kit Routine, Once For 1 Occurrences Suture removal kit [ ] Nursing - dressing care per prosthetic vendor Routine, As needed - dressing care per prosthetic vendor Vendor: [ ] Do not remove dressing Routine, Until discontinued, Starting S Site: notify physician of excessive drainage, Drains [ ] Strip drain(s) tubing three times per day Routine, 3 times daily Type: Drain System/Suction: Location/Care (specify): strip drain(s) tubing three times per day [ ] Drain care, closed system w/ suction (bulb or other compressed) [ ] Drain care Routine, Once Type: Drain System/Suction: Location/Care (specify): [ ] Drain care Routine, Once Type: Drain System/Suction: Location/Care (specify): Routine, Every 8 hours Type: Drain System/Suction: Closed system w/ suction (bulb or other compressed) Location/Care (specify): empty and record output every 8hrs and PRN, Page 5 of 19
[ ] Drain care Routine, Once Type: Drain System/Suction: Location/Care (specify): [ ] Remove drain dressing Routine, Once Site: On Post-Op Day (POD) #: Nutrition Diet / Nutrition [ ] Diet NPO Diet effective now, Starting S Except: [ ] Diet NPO Except: SIPS WITH MEDS Diet effective now, Starting S Except: SIPS WITH MEDS [ ] Diet NPO Except: ICE CHIPS Diet effective now, Starting S Except: ICE CHIPS [ ] Diet; Special; Liquid; Clear Liquid Diet effective now, Starting S Regular or Special Diet?: Special Special Diet: Liquid Liquid Diet: Clear Liquid Optional Preferences / Modifiers: Fluid Restriction / 24h: [ ] Clear Liquid, Progress to Regular Diet "And" Linked Panel [ ] Diet; Special; Liquid; Clear Liquid Diet effective now, Starting S Regular or Special Diet?: Special Special Diet: Liquid Liquid Diet: Clear Liquid Fluid Restriction / 24h: Fluid Restriction total / 24h: Optional Preferences / Modifiers: Page 6 of 19
[ ] Progress to target diet Routine, Until discontinued, Starting S Regular or Special Diet?: Regular Fluid Restriction / 24h: Fluid Restriction total / 24h: Optional Preferences / Modifiers: Regular Diet: Regular Optional Preferences: Advance patient to the target diet when the following criteria are met: When patient tolerating clear liquids without signs of nausea or vomiting may advance to Full Liquid diet or Target diet depending on patient preference. If patient is on Full Liquid diet and tolerating without signs of nausea or vomiting, may advance to Target diet., [ ] Diet Special; Surgery; Low Fiber Diet effective now, Starting S Regular or Special Diet?: Special Special Diet: Surgery Surgery Diet: Low Fiber Optional Preferences / Modifiers: Fluid Restriction / 24h: [ ] Diet Special; Cardiac Diet effective now, Starting S Regular or Special Diet?: Special Special Diet: Cardiac Cardiac Diet: Optional Preferences / Modifiers: Fluid Restriction / 24h: [ ] Diet Regular; Regular Diet effective now, Starting S Regular or Special Diet?: Regular Regular Diet: Regular Optional Preferences: Fluid Restriction / 24h: [ ] Diet Special; Diabetic; Diabetic 1500-2000 kcal Diet effective now, Starting S Regular or Special Diet?: Special Special Diet: Diabetic Diabetic Diet: Diabetic 1500-2000 kcal Optional Preferences / Modifiers: Fluid Restriction / 24h: [ ] Diet Special; Renal Diet effective now, Starting S Regular or Special Diet?: Special Special Diet: Renal Renal Diet: Optional Preferences / Modifiers: Fluid Restriction / 24h: Activity Page 7 of 19
Activity [ ] Bedrest Routine, Until discontinued, Starting S, [ ] Turn patient Routine, Now then every 2 hours, [ ] Bathroom privileges Routine, Until discontinued, Starting S With Assistance: Yes [ ] Out of bed Routine, 2 times daily, Starting S+1 To chair, Consults Physician Consults [ ] Inpatient consult to Cardiology Reason for Consult? [ ] Inpatient consult to Endocrinology Reason for Consult? [ ] Inpatient consult to Family Medicine Reason for Consult? [ ] Inpatient consult to Gastroenterology Reason for Consult? [ ] Inpatient consult to Hospitalist Reason for Consult? [ ] Inpatient consult to Infectious Disease Reason for Consult? [ ] Inpatient consult to Internal Medicine Reason for Consult? [ ] Inpatient consult to Neurology Reason for Consult? [ ] Inpatient consult to Oncology Reason for Consult? Ancillary Consults Page 8 of 19
[ ] Inpatient consult to Physical Medicine Rehab Reason for Consult? [ ] Inpatient consult to Cardiac Rehab Reason For Consult? [ ] PT eval and treat and implement plan of care Routine, Once For 1 Occurrences Is the patient being discharged today? Reason for PT? [ ] OT eval and treat and implement plan of care Routine, Once For 1 Occurrences Is the patient being discharged today? Reason for OT? [ ] Inpatient consult to Dietitian Reason For Consult? [ ] Inpatient consult to Utilization Management & Care Coordination Laboratory Labs For: [ ] CBC Once For 1 Occurrences, PACU (only) [ ] CBC Daily, Starting S+1 For 2 Occurrences, [ ] Basic Metabolic Panel Once For 1 Occurrences, PACU (only) [ ] Basic Metabolic Panel Daily, Starting S+1 For 2 Occurrences, Radiology Radiology [ ] XR Femur Left 2 Views Routine, 1 time imaging, Starting S+1 at 6:00 AM For 1 Occurrences Portable? Reason for Exam: post-op knee amputation Is the patient pregnant? [ ] XR Femur Right 2 Views Routine, 1 time imaging, Starting S+1 at 6:00 AM For 1 Occurrences Portable? Reason for Exam: post-op knee amputation Is the patient pregnant? [ ] XR Tibia Fibula Left 2 Views Routine, 1 time imaging, Starting S+1 at 6:00 AM For 1 Occurrences Portable? Reason for Exam: post-op knee amputation Is the patient pregnant? Page 9 of 19
[ ] XR Tibia Fibula Right 2 Views Routine, 1 time imaging, Starting S+1 at 6:00 AM For 1 Occurrences Portable? Reason for Exam: post-op knee amputation Is the patient pregnant? Respiratory Therapy Respiratory Therapy [ ] Nasal cannula oxygen Routine, Continuous Liters per minute: 4 [ ] Oxygen titrate Routine, Until discontinued, Starting S to maintain SpO2 greater than or equal to: 92 If O2 saturation is equal to or greater than specified goal, wean O2 to off in (hours): 8 [ ] Pulse oximetry continuous Routine, Continuous Notify physician if SpO2 less than 90%, [ ] Incentive spirometry Routine, Every 1 hour (RT) 10 times every hour while awake, Respiratory Medications [ ] albuterol (PROVENTIL) nebulizer solution 2.5 mg, Inhalation, Every 8 hours (RT), For 48 Hours Continuous IV Therapy Saline Lock and Flush [ ] Saline Lock and Flush "And" Linked Panel [ ] Saline lock Routine, Continuous When patient tolerating PO, PACU to Post Procedure [ ] sodium chloride 0.9 % (NS) flush 5 ml, Intravenous, As needed, line care, PACU to Post Procedure [ ] sodium chloride 0.9 % (NS) flush 5 ml, Intravenous, Every 8 hours, PACU to Post Procedure Saline lock IV Fluids [ ] sodium chloride 0.45% (HALF SALINE) infusion 100 ml/hr, Intravenous, Continuous, [ ] sodium chloride 0.9% (NS) infusion Intravenous, Continuous, [ ] dextrose 5 % and sodium chloride 0.45 % infusion Intravenous, Continuous, [ ] dextrose 5 % and sodium chloride 0.45 % with KCl 20 Intravenous, Continuous, meq/l infusion [ ] dextrose 5 % and sodium chloride 0.45 % with KCl 40 Intravenous, Continuous, meq/l infusion [ ] dextrose 5 % and sodium chloride 0.9 % infusion Intravenous, Continuous, [ ] dextrose 5 % in lactated ringers infusion Intravenous, Continuous, Page 10 of 19
[ ] lactated ringers infusion Intravenous, Continuous, VTE Prophylaxis Patient ALREADY ON an anticoagulant- additional mechanical VTE prophylaxis optional (REQUIRED with dabigatran (PRADAXA) to meet guidelines) Patients already on dabigatran (PRADAXA): For all surgical patients, and non-surgical patients with moderate or high risk of VTE, mechanical prophylaxis with Intermittent Pneumatic Compression Devices MUST be ordered in addition to dabigatran (PRADAXA) to satisfy the VTE prophylaxis quality measure. Patients already on the following medications for approved indications do NOT require additional pharmacologic agents for VTE prophylaxis, but mechanical prophylaxis can be added, if desired: warfarin (COUMADIN), fondaparinux (ARIXTRA), apixaban (ELIQUIS), rivaroxaban (XARELTO), heparin, and enoxaparin (LOVENOX). [ ] Intermittent pneumatic compression device (REQUIRED to meet Quality Measure when dabigatran (PRADAXA) is ordered) Routine, Until discontinued, Starting S For Until specified Extremity: Bilat LE [ ] Antiembolism stockings Routine, Until discontinued, Starting S For Until specified Type: Thigh high Extremity: Bilat LE [ ] Foot pumps Routine, Until discontinued, Starting S For Until specified Extremity: Bilat LE [ ] Ambulate patient Routine, As needed For Until specified early and frequently (VTE/DVT prophylaxis) VTE Prophylaxis post-procedure for patients NOT already on anticoagulants For general surgery patients either one of the presented pharmacologic prophylaxis options -OR- Intermittent Pneumatic Compression Devices MUST be ordered, OR else documentation why these were not ordered MUST occur. Additional non-pharmacologic options can be added on, if desired. [ ] Pharmacological VTE Prophylaxis (If Anesthesia End Time between 0000-1059 (Single Response) ( ) heparin (porcine) injection 5,000 units every 8 hours 5,000 Units, Subcutaneous, Every 8 hours scheduled, ( ) enoxaparin (LOVENOX) injection 40 mg Daily (CrCl 30 40 mg, Subcutaneous, Daily, S at 8:00 PM, ml/min or greater) ( ) enoxaparin (LOVENOX) injection 40 mg every 12 hours 40 mg, Subcutaneous, Every 12 hours, Starting S, (BMI greater than 40 AND CrCl 30 ml/min or greater) ( ) enoxaparin (LOVENOX) injection 30 mg Daily (CrCl 10-29 ml/min) 30 mg, Subcutaneous, Daily, S at 8:00 PM, Page 11 of 19
( ) fondaparinux (ARIXTRA) injection 2.5 mg Daily (Option for patients with heparin allergy, AVOID if CrCl less than 30 ml/min or wt less than 50 kg) 2.5 mg, Subcutaneous, Daily, S at 8:00 PM, [ ] Pharmacological VTE Prophylaxis (If Anesthesia End Time between 1100-2259) (Single Response) ( ) heparin (porcine) injection 5,000 units every 8 hours 5,000 Units, Subcutaneous, Every 8 hours scheduled, ( ) enoxaparin (LOVENOX) injection 40 mg Daily (CrCl 30 40 mg, Subcutaneous, Daily, S+1 at 8:00 AM, ml/min or greater) ( ) enoxaparin (LOVENOX) injection 40 mg every 12 hours 40 mg, Subcutaneous, Every 12 hours, Starting S+1, (BMI greater than 40 AND CrCl 30 ml/min or greater) ( ) enoxaparin (LOVENOX) injection 30 mg Daily (CrCl 30 mg, Subcutaneous, Daily, S+1 at 8:00 AM, 10-29 ml/min) ( ) fondaparinux (ARIXTRA) injection 2.5 mg Daily (Option for patients with heparin allergy, AVOID if CrCl less than 30 ml/min or wt less than 50 kg) 2.5 mg, Subcutaneous, Daily, S+1 at 8:00 AM, [ ] Pharmacological VTE Prophylaxis (If Anesthesia End Time between 2300-2359) (Single Response) ( ) heparin (porcine) injection 5,000 units every 8 hours 5,000 Units, Subcutaneous, Every 8 hours scheduled, ( ) enoxaparin (LOVENOX) injection 40 mg Daily (CrCl 30 40 mg, Subcutaneous, Daily, S+1 at 8:00 PM, ml/min or greater) ( ) enoxaparin (LOVENOX) injection 40 mg every 12 hours 40 mg, Subcutaneous, Every 12 hours, Starting S+1, (BMI greater than 40 AND CrCl 30 ml/min or greater) ( ) enoxaparin (LOVENOX) injection 30 mg Daily (CrCl 30 mg, Subcutaneous, Daily, S+1 at 8:00 PM, 10-29 ml/min) ( ) fondaparinux (ARIXTRA) injection 2.5 mg Daily (Option for patients with heparin allergy, AVOID if CrCl less than 30 ml/min or wt less than 50 kg) 2.5 mg, Subcutaneous, Daily, S+1 at 8:00 PM, [ ] Mechanical VTE Prophylaxis [ ] Intermittent pneumatic compression device Routine, Until discontinued, Starting S For Until specified Extremity: Bilat LE [ ] Antiembolism stockings Routine, Until discontinued, Starting S For Until specified Type: Thigh high Extremity: Bilat LE [ ] Foot pumps Routine, Until discontinued, Starting S For Until specified Extremity: Bilat LE [ ] Ambulate patient Routine, As needed For Until specified early and frequently (VTE/DVT prophylaxis) [ ] VTE prophylaxis Contraindicated or Not Indicated (must "And" Linked Panel specify reason) Indicate a reason for both no pharmacological prophylaxis AND no mechanical prophylaxis. [ ] Reason for no VTE Prophylaxis - medications Reason(s) for no VTE prophylaxis - pharmacological: Page 12 of 19
[ ] Reason for no VTE Prophylaxis - mechanical Reason(s) for no VTE prophylaxis - mechanical: Medications Postop Antibiotics (Single Response) Vancomycin to be reserved for patients with known MRSA colonization or risk factors for MRSA (patients with recent hospitalization, nursing home residents, hemodialysis patients). ( ) Post-procedure PROPHYLACTIC Antibiotics (Single Response) Vancomycin to be reserved for patients with known MRSA colonization or risk factors for MRSA (patients with recent hospitalization, nursing?home residents, hemodialysis patients). ( ) cefazolin (ANCEF) IVPB x 1 dose post-procedure 2,000 mg, Intravenous, Once, For 1 Doses, Starting 8 hours after pre-procedure op dose x 1 dose. Indication (POST PROCEDURE): ( ) cefazolin (ANCEF) IVPB x 2 doses post-procedure 2,000 mg, Intravenous, Every 8 hours, For 2 Doses, Starting 8 hours after pre-procedure dose x 2 doses. Indication (POST PROCEDURE): ( ) If allergic to cephalosporins or penicillin: clindamycin (CLEOCIN) IVPB x 1 dose post-procedure ( ) If allergic to cephalosporins or penicillin: clindamycin (CLEOCIN) IVPB x 2 doses post-procedure 900 mg, Intravenous, Once, For 1 Doses, Starting 8 hours after pre-procedure dose x 1 dose. Indication (POST PROCEDURE): 900 mg, Intravenous, Every 8 hours, For 2 Doses, Starting 8 hours after pre-procedure dose x 2 doses. Indication (POST PROCEDURE): ( ) Pharmacy to dose vancomycin Routine, Until discontinued, Starting S For Until specified ( ) Post-procedure THERAPEUTIC Antibiotics (Single Response) ( ) piperacillin - tazobactam (ZOSYN) IVPB 4.5 g, Intravenous, Every 8 hours, Indication (POST PROCEDURE): Stress Ulcer Prophylaxis (Single Response) GI prophylaxis (Stress Ulcer Prophylaxis) is only indicated in critically ill patients with high risk of coagulopathy (e.g. mechanical ventilation greater than 48 hrs, low platelets, or elevated PT/INR). Unnecessary GI prophylaxis puts patients at increased risk of c.diff and HCAP. ( ) famotidine (PEPCID) tablet 20 mg, Oral, Every 12 hours scheduled, ( ) famotidine (PEPCID) injection 20 mg, Intravenous, Every 12 hours scheduled, ( ) famotidine (PEPCID) IV -or- Oral "Or" Linked Panel For patients with CrCl less than 50, reduce dose by 50% or increase dosing interval to 48 hours. Page 13 of 19
[ ] famotidine (PEPCID) injection 20 mg, Intravenous, Every 12 hours scheduled, Use oral route first, if tolerated. [ ] famotidine (PEPCID) tablet 20 mg, Oral, Every 12 hours scheduled, Use oral route first, if tolerated. ( ) pantoprazole (PROTONIX) EC tablet 40 mg, Oral, Daily, ( ) pantoprazole (PROTONIX) IV 40 mg, Intravenous, Daily, ( ) pantoprazole (PROTONIX) IV -or- Oral "Or" Linked Panel [ ] pantoprazole (PROTONIX) EC tablet 40 mg, Oral, Daily, Use oral route first, if tolerated. [ ] pantoprazole (PROTONIX) IV 40 mg, Intravenous, Daily, Use oral route first, if tolerated. Medications [ ] senna-docusate (SENNA-S) 8.6-50 mg per tablet (IF not 1 tablet, Oral, 2 times daily, ordered with Opioid Pain Management) Hold for loose stools [ ] aspirin EC tablet 81 mg, Oral, Daily, [ ] aspirin EC tablet 325 mg, Oral, Daily, [ ] metoprolol tartrate (LOPRESSOR) tablet 25 mg, Oral, 2 times daily, Hold if systolic blood pressure less than 120 or pulse less than 60. PRN Medications PRN Medications [ ] ondasetron (ZOFRAN) PO or IV "Or" Linked Panel [ ] ondansetron (ZOFRAN-ODT) disintegrating tablet 4 mg, Oral, Every 6 hours PRN, nausea, vomiting, [] Oral or IV - use oral route if tolerated. [ ] ondansetron (ZOFRAN) injection 4 mg, Intravenous, Every 6 hours PRN, nausea, vomiting, [] Oral or IV - use oral route if tolerated. [ ] trazodone (DESYREL) tablet 50 mg, Oral, Nightly PRN, sleep [] May repeat in 30 minutes if still awake. [ ] bisacodyl (DULCOLAX) suppository 10 mg, Rectal, Daily PRN, constipation, [ ] acetaminophen (TYLENOL) "Or" Linked Panel [ ] acetaminophen (TYLENOL) tablet 650 mg, Oral, Every 4 hours PRN, mild pain, fever 100.4 F or greater, Use oral or tube route first, as applicable. Use rectal route if oral/tube not tolerated. [ ] acetaminophen (TYLENOL) liquid Oral, Every 4 hours PRN, fever 100.4 F or greater, mild pain, Use oral or tube route first, as applicable. Use rectal route if oral/tube not tolerated. [ ] acetaminophen (TYLENOL) suppository 650 mg, Rectal, Every 4 hours PRN, fever 100.4 F or greater, mild pain, Use oral or tube route first, as applicable. Use rectal route if oral/tube not tolerated. Page 14 of 19
Opioid Pain Management OPIATE NAIVE/ HIGH RISK patient dosing regimens [ ] OPIATE NAIVE/ HIGH RISK patient ORAL ATC regimens (Ortho) (Single Response) ( ) oxycodone (ROXICODONE) immediate release tablet 5 mg, Oral, Every 4 hours, For 6 Doses, 5 mg [] Hold for sedation ( ) oxycodone (ROXICODONE) immediate release tablet 10 mg, Oral, Every 4 hours, For 6 Doses, 10 mg [] Hold for sedation. [ ] OPIATE NAIVE/ HIGH RISK patient ORAL PRN dosing regimens (Ortho) [ ] oxycodone (ROXICODONE) immediate release tablet 5-15 mg, Oral, Every 4 hours PRN, moderate to severe pain, [] Initiate with 10 mg oral every 4 hours prn moderate to severe pain. [] For unrelieved pain, may repeat 5 mg oral dose within 60 minutes of initial dose. [] If pain is RELIEVED after repeat dose, change to 15 mg oral every 4 hours prn moderate to severe pain. [] If pain is UNrelieved after repeat dose, or patient requires dose reduction, call physician. [] If multiple routes are ordered for pain meds, it is recommended that oral be the first choice, IV the second choice, rectal the third choice, and IM the fourth choice. [ ] OPIATE NAIVE/ HIGH RISK patient INTRAVENOUS PRN dosing regimens (Ortho) (Single Response) ( ) HYDROmorphone (DILAUDID) injection 0.25-0.5 mg 0.25-0.5 mg, Intravenous, Every 3 hours PRN, moderate to severe pain, [] Initiate with 0.25 mg IV every 3 hours prn moderate to severe pain. [] For unrelieved pain, may repeat 0.25 mg IV dose within 30 minutes of initial dose. [] If pain is RELIEVED after repeat dose, change to 0.5 mg IV every 3 hours prn moderate to severe pain. [] If pain is UNrelieved after repeat dose, or patient requires dose reduction, call physician. [] If multiple routes are ordered for pain meds, it is recommended that oral be the first choice, IV the second choice, rectal the third choice, and IM the fourth choice. Page 15 of 19
( ) HYDROmorphone (DILAUDID) injection 0.5-1 mg 0.5-1 mg, Intravenous, Every 3 hours PRN, moderate to severe pain, [] Initiate with 0.5 mg IV every 3 hours prn moderate to severe pain. [] For unrelieved pain, may repeat 0.5 mg IV dose within 30 minutes of initial dose. [] If pain is RELIEVED after repeat dose, change to 1 mg IV every 3 hours prn moderate to severe pain. [] If pain is UNrelieved after repeat dose, or patient requires dose reduction, call physician. [] If multiple routes are ordered for pain meds, it is recommended that oral be the first choice, IV the second choice, rectal the third choice, and IM the fourth choice. ( ) morphine injection 3-5 mg, Intravenous, Every 3 hours PRN, moderate to severe pain, [] Initiate with 3 mg IV every 3 hours prn moderate to severe pain. [] For unrelieved pain, may repeat 3 mg IV dose within 30 minutes of initial dose. [] If pain is RELIEVED after repeat dose, change to 5 mg IV every 3 hours prn moderate to severe pain. [] If pain is UNrelieved after repeat dose, or patient requires dose reduction, call physician. [] If multiple routes are ordered for pain meds, it is recommended that oral be the first choice, IV the second choice, rectal the third choice, and IM the fourth choice. OPIATE TOLERANT patient dosing regimens [ ] OPIATE TOLERANT patient ORAL ATC regimens (Ortho) (Single Response) ( ) oxycodone (OXYCONTIN) 12 hr tablet 20 mg, Oral, Every 12 hours scheduled, For 4 Doses, [] Hold for sedation. ( ) oxycodone (OXYCONTIN) 12 hr tablet 30 mg, Oral, Every 12 hours scheduled, For 4 Doses, [] Hold for sedation. [ ] OPIATE TOLERANT patient ORAL dosing regimens (Ortho) Page 16 of 19
[ ] oxycodone (ROXICODONE) immediate release tablet 10-30 mg, Oral, Every 4 hours PRN, moderate to severe pain, [] Initiate with 20 mg oral every 4 hours prn moderate to severe pain. [] For unrelieved pain, may repeat 10 mg oral dose within 60 minutes of initial dose. [] If pain is RELIEVED after repeat dose, change to 30 mg oral every 4 hours prn moderate to severe pain. [] If pain is UNrelieved after repeat dose, or patient requires dose reduction, call physician. [] If multiple routes are ordered for pain meds, it is recommended that oral be the first choice, IV the second choice, rectal the third choice, and IM the fourth choice. [ ] OPIATE TOLERANT patient INTRAVENOUS dosing regimens (Ortho) (Single Response) ( ) HYDROmorphone (DILAUDID) injection 0.5-1.5 mg, Intravenous, Every 3 hours PRN, moderate to severe pain, [] Initiate with 1 mg IV every 3 hours prn moderate to severe pain. [] For unrelieved pain, may repeat 0.5 mg IV dose within 30 minutes of initial dose. [] If pain is RELIEVED after repeat dose, change to 1.5 mg IV every 3 hours prn moderate to severe pain. [] If pain is UNrelieved after repeat dose, or patient requires dose reduction, call physician. [] If multiple routes are ordered for pain meds, it is recommended that oral be the first choice, IV the second choice, rectal the third choice, and IM the fourth choice. ( ) morphine injection 4-10 mg, Intravenous, Every 3 hours PRN, moderate to severe pain, [] Initiate with 8 mg IV every 3 hours prn moderate to severe pain. [] For unrelieved pain, may repeat 4 mg IV dose within 30 minutes of initial dose. [] If pain is RELIEVED after repeat dose, change to 10 mg IV every 3 hours prn moderate to severe pain. [] If pain is UNrelieved after repeat dose, or patient requires dose reduction, call physician. [] If multiple routes are ordered for pain meds, it is recommended that oral be the first choice, IV the second choice, rectal the third choice, and IM the fourth choice. Bowel regimen and Narcan orders for resp less than or equal to 8 per minute Senokot-S is NOT for abdominal surgery patients, [ ] senna-docusate (SENNA-S) 8.6-50 mg per tablet 1 tablet, Oral, 2 times daily, NOT for abdominal surgery patients. Hold for loose stools. [ ] Narcan orders for respiratory rate less than or equal to 8 "And" Linked Panel per minute Postop Page 17 of 19
[ ] naloxone (NARCAN) injection 0.1mg/2.5ml 0.1 mg, Intravenous, As needed, opioid reversal, Respiratory rate less than 8 per minute, [] Mix naloxone (NARCAN) 0.4 mg (1ml) with 9 ml of Normal Saline to total 10 ml. [] Administer 0.1 mg (2.5ml) IV Push every 2 minutes until respiratory rate is 10 or greater. [ ] Notify physician of respiratory rate less than or equal to 8 per minute STAT, Until discontinued, Starting S For Until specified Respiratory rate less than: 8 For respiratory rate less than or equal to 8 per minute, notify physician and/or appropriate staff for additional orders., [ ] naloxone (NARCAN) 0.4 mg/ml injection 0.4 mg, Intravenous, As needed, opioid reversal, patient is pulseless, breathless, and unresponsive, Call a code first, then administer naloxone dose undiluted IV Push over 30 seconds. Non-Opioid Analgesics (Ortho) (Single Response) Use NSAIDS with caution in patients with heart failure, renal dysfunction, or if receiving other nephrotoxic medications. Use ketorolac 15 mg max dose if: Age 65 years or greater OR weight less than 50 kg OR CrCl less than or equal to 50 ml/min. May use ketorolac 30 mg only if: Age under 65 years AND weight 50 kg or greater AND CrCl greater than 50 ml/min. Do NOT use ketorolac if CrCl less than 10 ml/min. Toradol has an automatic 48 hour stop date. ( ) acetaminophen (TYLENOL) tablet 650 mg, Oral, Every 4 hours while awake, ( ) ibuprofen (ADVIL,MOTRIN) tablet 600 mg, Oral, Every 6 hours while awake, [] Give with food. ( ) Non-opioid pain management with ketorolac 15mg IV "Followed by" Linked Panel around the clock x 48 hours, followed by ibuprofen every 6 hours while awake Toradol has an automatic 48 hour stop date. [ ] ketorolac (TORADOL) injection 15mg IV every 6 hours while awake x 48 hours [ ] ibuprofen (ADVIL,MOTRIN) tablet 600mg oral every 6 hours while awake ( ) Non-opioid pain management with ketorolac 30mg IV around the clock x 48 hours, followed by ibuprofen every 6 hours while awake 15 mg, Intravenous, Every 6 hours while awake, Starting S, For 48 Hours, [] For 48 hours. [] Toradol has an automatic 48 hour stop date. 600 mg, Oral, Every 6 hours while awake, [] Give with food. "Followed by" Linked Panel Page 18 of 19
Use NSAIDS with caution in patients with heart failure, renal dysfunction, or if receiving other nephrotoxic medications. Use ketorolac 15 mg max dose if: Age 65 years or greater OR weight less than 50 kg OR CrCl less than or equal to 50 ml/min. May use ketorolac 30 mg only if: Age under 65 years AND weight 50 kg or greater AND CrCl greater than 50 ml/min. Do NOT use ketorolac if CrCl less than 10 ml/min. Toradol has an automatic 48 hour stop date. [ ] ketorolac (TORADOL) injection 30mg IV every 6 hours while awake x 48 hours 30 mg, Intravenous, Every 6 hours while awake, Starting S, For 48 Hours, [] For 48 hours. [] Ketorolac has an automatic 48 hour stop date. 600 mg, Oral, Every 6 hours while awake, [] Give with food. [ ] ibuprofen (ADVIL,MOTRIN) tablet 600mg oral every 6 hours while awake ( ) tramadol (ULTRAM) tablet 50 mg, Oral, Every 6 hours while awake, [] Hold for sedation. Pain Management Consider Serum Creatinine [ ] If ordering Toradol: Consider Creatinine Serum due to no result in last 72 hours [ ] Creatinine, Serum Once, Starting S For 1 Occurrences, Page 19 of 19