Total Knee Replacement Post Op Plan PACU Ortho Phase PHYSICIAN S Weight Allergies DETAILS Admit/Discharge/Transfer Request Patient Bed Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights), Post Op Total Knee Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights), George Brindley, M.D., Post Op Total Knee Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights), Jules Dumais, M.D., Post Op Total Knee Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights), Jerry Grimes Jr., M.D., Post Op Total Knee Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights), Mark Jenkins, M.D., Post Op Total Knee Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights), Stanley Lehman, M.D., Post Op Total Knee Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights), Desirae McKee, M.D., Post Op Total Knee Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights), Robert Schutt, M.D., Post Op Total Knee Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights), Mimi Zumwalt, M.D., Post Op Total Knee Requested Location: Pedi, Pt Status: Inpatient (LOS > 2 midnights), Michel Diab, M.D., Post Op Total Knee Patient Condition Acuity Level Floor Status Acuity Level Critical Acuity Level Intermediate Patient Care Apply Cold Therapy Device POC Hemoglobin and Hematocrit (istat Hgb and Hct) STAT POC Chem 8 (istat Chem 8) STAT Accucheck Communication Code Status Code Status: Full Code Code Status: DNR Do Not Resuscitate Code Status: DNI Do Not Intubate Code Status: DNR/DNI Do Not Resuscitate or Intubate Code Status: Partial Resuscitative Effort Laboratory CBC STAT, Comment: Pt in PACU Basic Metabolic Panel STAT, Comment: Pt in PACU Diagnostic Tests DX Knee 1or 2 vws (Left) STAT, Portable, Other (specify below), Post op. Pt in PACU DX Knee 1or 2 vws (Right) STAT, Portable, Other (specify below), Post op. Pt in PACU Order Taken by Signature: Page: 1 Total Knee Replacement Post Op Version: Plan3 Effective on: 11/11/13 **
Pt. Arrives to Room PHYSICIAN S DETAILS Patient Care Vital Signs Per Unit Standards, Post Op with SaO2 Per Unit Standards q1h q2h q4h q12h Perform Neurovascular Checks To: Operative Extremity, Check every 30 minutes x 2 then with Vital Signs q30min Strict Intake and Output Per Unit Standards q1h q2h q4h q12h Urinary Catheter Care (Foley Catheter Care) Patient Activity Assist as Needed, Daily Foot Pumping exercises x 10 every 30 minutes until night time Set Up for Overhead Trapeze and Frame Continuous Passive Motion Device CPM to Left Knee, initial application In PACU If on Bed, run for 1/2 4 hrs, frequency 1 3 x day, start at 0 45 degrees, increase by 5 10 degrees, speed: Medium, Turn off knee flexion on bed with bed flat. Patient does not have to sleep in CPM. CPM to Right Knee, initial application In PACU If on Bed, run for 1/2 4 hrs, frequency 1 3 x day, start at 0 45 degrees, increase by 5 10 degrees, speed: Medium, Turn off knee flexion on bed with bed flat. Patient does not have to sleep in CPM. CPM to Bilateral Knees, initial application In PACU If on Bed, run for 1/2 4 hrs, frequency 1 3 x day, start at 0 45 degrees, increase by 5 10 degrees, speed: Medium, Turn off knee flexion on bed with bed flat. Patient does not have to sleep in C Activity Precautions Knee Immobolizer When Out of Bed, with femoral nerve block Bed pillow between knees Abduction pillow between knees Wound Care by Nursing Reinforce dressing, Cover/Pack with ABD Pad, Secure with Hypafix Tape Located: Operative Knee, Change PRN Reinforce dressing, Cover/Pack with ABD Pad, Secure with Hypafix Tape Located: Operative Knee, Change PRN, Monitor drain output Every Shift LLE Weight Bearing Activity Weight Bearing as Tolerated Partial Weight Bearing Touch Down Weight Bearing Non Weight Bearing Order Taken by Signature: Page: 2 Total Knee Replacement Post Op Version: Plan3 Effective on: 11/11/13 **
Pt. Arrives to Room PHYSICIAN S DETAILS RLE Weight Bearing Activity Weight Bearing as Tolerated Partial Weight Bearing Touch Down Weight Bearing Non Weight Bearing Elevate Extremity Other, Elevate legs while out of bed Left Lower Extremity (LLE) Right Lower Extremity (RLE) Convert IV to INT When tolerating PO Communication Notify Provider/Primary Team of Pt Admit Notify: PCP, Upon Arrival to Unit Notify Provider of VS Parameters Notify Provider (Misc) Notify Nurse (DO NOT USE FOR MEDS) Dietary Advance Diet as Tolerated Advance Diet To: Regular Diet Advance Diet To: ADA 1800 Diet Advance Diet To: ADA 1600 Diet Advance Diet To: AHA Diet Clear Liquid Diet Full Liquid Diet Regular Diet ADA Diet Adult AHA Diet IV Solutions LR (Lactated Ringer s) IV, 75 ml/hr IV, 100 ml/hr IV, 125 ml/hr IV, 150 ml/hr IV, 200 ml/hr Order Taken by Signature: Page: 3 Total Knee Replacement Post Op Version: Plan3 Effective on: 11/11/13 **
Pt. Arrives to Room PHYSICIAN S DETAILS D5 1/2 NS + 20 meq KCl/L IV, 75 ml/hr IV, 100 ml/hr IV, 125 ml/hr IV, 150 ml/hr IV, 200 ml/hr 1/2 NS IV, 75 ml/hr IV, 100 ml/hr IV, 125 ml/hr IV, 150 ml/hr IV, 200 ml/hr NS (Normal Saline) IV, 75 ml/hr IV, 100 ml/hr IV, 125 ml/hr IV, 150 ml/hr IV, 200 ml/hr D5 1/2 NS IV, 75 ml/hr IV, 100 ml/hr IV, 125 ml/hr IV, 150 ml/hr IV, 200 ml/hr Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. aspirin 81 mg, PO, tab ec, Daily Antibiotics cefazolin 1 g, IVPB, ivpb, q6h, x 3 dose, Infuse over 30 min 2 g, IVPB, ivpb, q6h, x 3 dose, Infuse over 60 min clindamycin 600 mg, IVPB, ivpb, q6h, x 3 dose, Infuse over 30 min 900 mg, IVPB, ivpb, q6h, x 3 dose, Infuse over 30 min vancomycin 1000 mg, IVPB, ivpb, q12h, Infuse over 90 min 1000 mg, IVPB, ivpb, q24h, Infuse over 90 min 1250 mg, IVPB, ivpb, q12h, Infuse over 120 min 1500 mg, IVPB, ivpb, q12h, Infuse over 120 min Pain Study Analgesics investigational drug (Ortho Pain Study Gabapentin or Placebo) 300 mg, cap, PO, q8h, x 3 days Start within 8 hours of Pre Op dose. acetaminophen 1,000 mg, IVPB, inj, q6h, x 4 dose Do not exceed 4000 mg of acetaminophen per day from all sources. HYDROcodone acetaminophen (HYDROcodone acetaminophen 7.5 mg 325 mg oral tablet) 1 tab, PO, tab, q4h, PRN pain mild, Pain Scale: 1 5 Start after 24 hrs post op. Do not exceed 4g/day of acetaminophen. 2 tab, PO, tab, q4h, PRN pain moderate, Pain Scale: 5 7 Start after 24 hrs post op. Do not exceed 4g/day of acetaminophen. Order Taken by Signature: Page: 4 Total Knee Replacement Post Op Version: Plan3 Effective on: 11/11/13 **
Pt. Arrives to Room PHYSICIAN S DETAILS tramadol 50 mg, PO, tab, q6h, PRN pain, x 24 hr HYDROmorphone 1.5 mg, IVPush, inj, q2h, PRN pain severe, Pain Scale: 7 10 ***Slow IV Push*** Use if morphine ineffective or contraindicated. 1 mg, IVPush, inj, q2h, PRN pain severe, Pain Scale: 7 10 ***Slow IV Push*** Use if morphine ineffective or contraindicated. 0.5 mg, IVPush, inj, q2h, PRN pain severe, Pain Scale: 7 10 ***Slow IV Push*** Use if morphine ineffective or contraindicated. Gastrointestinal Agents docusate 100 mg, PO, cap, Nightly, PRN constipation *****IF docusate is contraindicated or ineffective after 12 hours, USE bisacodyl if ordered***** *****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 if ordered***** *****IF bisacodyl is contraindicated or ineffective after 6 hours, USE Fleet Enema***** sodium biphosphate sodium phosphate (Fleet Enema) 132 ml, rectally, enema, Daily, PRN constipation Antihistamines diphenhydramine 25 mg, IVPush, q6h, PRN itching *****IF diphenhydramine PO is ineffective or patient is NPO, USE diphenhydramine inj***** Antiemetics ondansetron 4 mg, IVPush, soln, q4h, PRN nausea/vomiting Use if promethazine ineffective or contraindicated. Laboratory CBC Next Day in AM, T+1;0300 CBC with Differential Next Day in AM, T+1;0300 Prothrombin Time with INR Next Day in AM, T+1;0300 PTT Next Day in AM, T+1;0300 Order Taken by Signature: Page: 5 Total Knee Replacement Post Op Version: Plan3 Effective on: 11/11/13 **
Pt. Arrives to Room PHYSICIAN S DETAILS Basic Metabolic Panel Next Day in AM, T+1;0300 Comprehensive Metabolic Panel Next Day in AM, T+1;0300 Respiratory Oxygen Therapy Via: Nasal cannula, Keep sats greater than %: 92 IS Instruct Physical Medicine and Rehab Consult PT Mobility for Eval & Treat Consult Occ Therapy for Eval & Treat T+1;N, ADL s Consults/Referrals Social Services for Assessment and Eval Disharge Planning Social Services for DME for Home (Durable Medical Equipment for Home) Bedside Commode Walker for Home Use Shower Chair Home CPM Social Services for Home Health Care Home Physical Therapy Home Care Nurse Home Wound Care...Additional Orders Order Taken by Signature: Page: 6 Total Knee Replacement Post Op Version: Plan3 Effective on: 11/11/13 **
Pt. Arrives to Room 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 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: 7 Total Knee Replacement Post Op Version: Plan3 Effective on: 11/11/13 **
Pt. Arrives to Room VTE Prophylaxis Plan PHYSICIAN S DETAILS 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: 8 Total Knee Replacement Post Op Version: Plan3 Effective on: 11/11/13 **
Pt. Arrives to Room Sliding Scale Insulin Protocol Plan PHYSICIAN S DETAILS 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... Order Taken by Signature: Page: 9 Total Knee Replacement Post Op Version: Plan3 Effective on: 11/11/13 **
Pt. Arrives to Room Sliding Scale Insulin Protocol Plan PHYSICIAN S DETAILS 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. Order Taken by Signature: Page: 10 Total Knee Replacement Post Op Version: Plan3 Effective on: 11/11/13 **
Pt. Arrives to Room Sliding Scale Insulin Protocol Plan PHYSICIAN S DETAILS 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... Order Taken by Signature: Page: 11 Total Knee Replacement Post Op Version: Plan3 Effective on: 11/11/13 **
Pt. Arrives to Room Sliding Scale Insulin Protocol Plan PHYSICIAN S DETAILS 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... Order Taken by Signature: Page: 12 Total Knee Replacement Post Op Version: Plan3 Effective on: 11/11/13 **
Pt. Arrives to Room Sliding Scale Insulin Protocol Plan PHYSICIAN S DETAILS 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... Order Taken by Signature: Page: 13 Total Knee Replacement Post Op Version: Plan3 Effective on: 11/11/13 **
Pt. Arrives to Room Sliding Scale Insulin Protocol Plan PHYSICIAN S DETAILS 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. Order Taken by Signature: Page: 14 Total Knee Replacement Post Op Version: Plan3 Effective on: 11/11/13 **
Pt. Arrives to Room PCA Med Plan PHYSICIAN S DETAILS IV Solutions ***CAUTION*** Ordering a continuous rate (Basal Dose), should be reserved for opioid tolerant patients who require high dose therapy. ***DOSING NOTES***: 1. Initial doses are for opioid naive patients. Chronic pain patients may require higher doses. 2. Decrease initial starting dose by 25 30% in patients > 65 yrs, or patients with renal, hepatic, or pulmonary impairment. 3. Hydromorphone and fentanyl are recommended for patients with renal impairment or those intolerant of morphine. 4. Avoid meperidine use in patients > 65 yrs, renal impairment, seizure disorders, MAO inhibitors, or duration > 72 hrs. Reserve meperidine use for patients intolerant to all other opioids. morphine (morphine 30 mg/30 ml PCA) 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) = 1, Lock out Interval (min) = 10, 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 HYDROmorphone (HYDROmorphone 6 mg/30 ml PCA) Start date/time T;N Dose (mg) = 0.1, Lock out Interval (min) = 10, 4 hour Limit (mg) = 2, Start date/time T;N Dose (mg) = 0.2, Lock out Interval (min) = 10, 4 hour Limit (mg) = 4, Start date/time T;N Dose (mg) = 0.3, Lock out Interval (min) = 10, 4 hour Limit (mg) = 6, Start date/time T;N fentanyl (fentanyl 300 mcg/30 ml PCA) Start date/time T;N Dose (mcg) = 10, Lock out Interval (min) = 10, 4 hour Limit (mcg) = 100, Start date/time T;N Dose (mcg) = 10, Lock out Interval (min) = 10, 4 hour Limit (mcg) = 150, Start date/time T;N Dose (mcg) = 10, Lock out Interval (min) = 10, 4 hour Limit (mcg) = 200, Start date/time T;N meperidine (meperidine 300 mg/30 ml PCA) Start date/time T;N Dose (mg) = 10, Lock out Interval (min) = 10, 4 hour Limit (mg) = 100, Start date/time T;N Dose (mg) = 10, Lock out Interval (min) = 10, 4 hour Limit (mg) = 150, Start date/time T;N Dose (mg) = 10, Lock out Interval (min) = 10, 4 hour Limit (mg) = 200, Start date/time T;N If no IV Fluid is currently infusing, start 0.9% sodium chloride at KVO for duration of PCA NS (Normal Saline) 1,000 ml final vol, IV, KVO Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. ACUTE MANAGEMENT OF RESPIRATORY DEPRESSION If respiratory rate is less than 10 breaths/min or patient is unresponsive 1. Stop PCA Pump 2. Dilute naloxone (Narcan) 0.4 mg / 1 ml in 9 ml NS and administer 0.1 mg (2.5 ml) by IVP every 2 3 minutes until respiratory rate is greater than 10 breaths/min. 3. Notify Physician Order Taken by Signature: Page: 15 Total Knee Replacement Post Op Version: Plan3 Effective on: 11/11/13 **
Pt. Arrives to Room PCA Med Plan PHYSICIAN S DETAILS naloxone (naloxone 0.4 mg/ml injectable solution) 0.1 mg, IVPush, inj, q2min, PRN bradypnea Dilute in 0.4 mg in 9 ml NS and administer 0.1 mg (2.5 ml) every 2 3 minutes until respiratory rate is greater than 10 breaths/ min. Respiratory Continuous Pulse Oximetry Order Taken by Signature: Page: 16 Total Knee Replacement Post Op Version: Plan3 Effective on: 11/11/13 **