Unique Plan Description: Bari Surg Enhanced Recovery Post op (MH/WH) EKM
Plan Selection Display: Bari Surg Enhanced Recovery Post op (MH/WH)
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2016-05-25 12:43:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2023-01-04 10:56:20
Available at all facilities: Yes

Bari Surg Enhanced Recovery Post op (MH/WH) EKM
Admit/Discharge/Transfer
	Admit to Inpatient Status
		T;N, Anticipated LOS 1 midnight or less
	Admit to Critical Care Inpatient Status (MH)
		T;N, Anticipated LOS 1 midnight or less
Vital Signs
	Vital Signs
		Routine
Activity
	Up in Chair
		T;N+240, TID
			Comment: starting 4 hours after surgery
	Ambulate
		T;N+240, With assistance, TID
			Comment: starting 4 hours after surgery
	Elevate head of bed
		Elevate head of bed 30 degrees
			Comment: Continuously
Diet
	Bariatric Clear Liquid Diet
		T;N
			Comment: start once patient alert.
	Bariatric Full Liquid Diet
		T+1;0600
			Comment: start on post op day 1 at 0600 if tolerating clear liquids
	NPO
		T;N
Laboratory
	CBC with Diff
		T+1;0400, Routine, Q24H, 3 Dose(s)/Time(s), spec type = Blood
	BMP
		T+1;0400, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T+1;0400, Routine, spec type = Blood
Diagnostic Tests
	Upper GI Series
		T+1;0600, Routine, Abnormal Findings
			Comment: Status post bariatric surgery
IV Solutions
	NS
		1,000 mL, IV, 100 ml/hr
			Comment: Convert to 50ml per hour at 0600 morning after surgery and once tolerating clear
Medications
	pantoprazole IV
		40 mg, Injection, IV Push, DAILY, 1 Dose(s)/Time(s)
	Protonix
		40 mg, Tablet-Enteric-Coated, By Mouth, DAILY, T+1;0900
	labetalol  injection
		20 mg = 4 mL, Injection, IV Push, Q2H, PRN, systolic blood pressure > (see comment)
			Comment: systolic blood pressure > 160. May be repeated every 15 minutes up to a total of 100mg.  Use only if pulse > 65.
	hydrALAZINE
		10 mg, Injection, IV Push, Q2H, PRN, systolic blood pressure > (see comment)
			Comment: systolic blood pressure > 160, Use if pulse < 65 or Labetalol not effective.  May be repeated every 15 minutes up to a total of 60mg.
	Mefoxin IVPB
		2,000 mg, Injection-Premix, IVPB, Q6H, Surgical prophylaxis, 3 Dose(s)/Time(s)
			Comment: start 6 hrs after pre op dose given
	Flagyl IVPB (NMH/WH/FH)
		500 mg, Injection-Premix, IVPB, Q8H, Surgical prophylaxis, 3 Dose(s)/Time(s), 100 ml/hr
			Comment: start 6 hours after pre op dose given
	Tylenol
		650 mg, Tab, By Mouth, Q4H, T+1;0600, 48 hr
			Comment: Start on post op day1 at 0600, once patient tolerating clear liquids. Please be advised that the nonnarcotic pain meds are scheduled and not PRN.  Please give to the patients even if not in pain, do not give both oral and IV APAP, start 6 hr after any pre-op/intra-op dose.  Goal is to limit administration of narcotic medications.
	acetaminophen 10 mg/mL intravenous solution
		1,000 mg, Solution-Injection, IVPB, Q6H, T;N+360, duration: 3 Dose(s)/Time(s)
			Comment: Start 6 hours after dose given in surgery. Convert to oral Tylenol and discontinue IV order at 0600 hours on post op day 1, once patient tolerating clear liquids.
	ketorolac injectable
		30 mg, Injection, IV Push, Q6H, T;N+360, 6 Dose(s)/Time(s)
			Comment: Do not give if systolic blood pressure is < 90mm Hg or if serum creatinine is greater than 1.5mg/dL (or creatinine clearance < 50ml/min).  Notify MD of any dose not given with a note in the chart.   Please be advised that the nonnarcotic pain meds are scheduled and not PRN.  Please give to the patients even if not in pain. Begin 6 hrs after preop NSAID; modify dose to 15mg for patients <50kg or >65 years old.
		For patients <50kg or >65 years old.(NOTE)*
		15 mg, Injection, IV Push, Q6H, T;N+360, 6 Dose(s)/Time(s)
			Comment: Do not give if systolic blood pressure is < 90mm Hg or if serum creatinine is greater than 1.5mg/dL (or creatinine clearance < 50ml/min).  Notify MD of any dose not given with a note in the chart.   Please be advised that the nonnarcotic pain meds are scheduled and not PRN.  Please give to the patients even if not in pain. Begin 6 hrs after preop NSAID
	traMADol
		50 mg, Tab, By Mouth, Q6H, PRN, pain-moderate, T+1;0600
			Comment: start at 0600 post op day 1, once patient tolerating clear liquids
	oxyCODONE
		5 mg, Tab, By Mouth, Q4H, PRN, pain-severe, T+1;0600
			Comment: start at 0600 post op day 1, once patient tolerating clear liquids. This is for pain rated 4-7, and greater than patient stated comfort goal after scheduled medications given. For patients who received intrathecal analgesia start 24 hours after intrathecal dose given. Note pain score before and after administration; may cause drowsiness.  Goal of ERAS order set is to limit opiates as they have a deleterious effect on return of bowel function.  Please limit the administration of opiates unless the pain score is more than 4.
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-moderate, T+1;0600
			Comment: If inadequate relief after 1 hour, may repeat dose if pain level moderate to severe.  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe, T+1;0600
			Comment: start at 0600 post op day 1, once patient tolerating clear liquids This is for pain rated 8-10, and greater than patient stated comfort goal. Overall goal is to limit narcotic pain medication.
	acetaminophen-hydrocodone 325 mg-10 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-moderate, T+1;0600
			Comment: start at 0600 post op day 1, once patient tolerating clear liquids This is for pain rated 4-7, and greater than patient stated comfort goal. Overall goal is to limit narcotic pain medication.
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe, T+1;0600
			Comment: start at 0600 post op day 1, once patient tolerating clear liquids This is for pain rated 8-10, and greater than patient stated comfort goal. Overall goal is to limit narcotic pain medication.
	Buprenex
		0.15 mg, Injection, IV Push, Q4H, PRN, pain-severe, 12 hr
	ondansetron
		4 mg, Injection, IV PUSH, Q6H, PRN for nausea and/or vomiting
			Comment: discontinue IV order, once oral medications started
	prochlorperazine
		10 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron, ineffective. Discontinue IV order, once oral medications started.
	Phenergan (MH/WH)
		6.25 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron and prochlorperazine ineffective. Discontinue IV order, once oral medications started.
	Benadryl
		12.5 mg, Injection, IV Push, Q6H, PRN, itching
			Comment: discontinue IV order, once oral medications started
	ondansetron (MH/WH)
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN, nausea and/or vomiting, T+1;0600
			Comment: start at 0600 post op day 1, once patient tolerating clear liquids
	Benadryl
		25 mg, Tab, By Mouth, Q6H, PRN, itching, T+1;0600
			Comment: start at 0600 post op day 1, once patient tolerating clear liquids
	Phenergan (MH/WH)
		25 mg, Tab, By Mouth, BID, PRN, nausea and/or vomiting, T+1;0600
			Comment: start at 0600 post op day 1, once patient tolerating clear liquids. Give if ondansetron, ineffective; avoid in patients > 65yo
Patient Care
	Resuscitation Status
		Full Code
		No Code
	VTE Advisor
		Bariatric surgery
	Foley Catheter
		T;N, Foley, Insert, Pt. undergoing abdominal/pelvic surgery, PRN, unable to void, 8 hours after arrival to floor and bladder scan >350ml.  If foley catheter needed, enter order for foley catheter insert, once, and select the appropriate criteria for inser
			Comment: urinary retention
	Discontinue Urinary Catheter
		T+1;0600
			Comment: If patient has foley in place and urine output >30ml/hr.
	Foley Catheter
		T;N, To dependent drainage, Major Abdominal Surgery with Organ Edema
	Notify MD
		urine output <120 ml in 4 hours
		T;N Temp >101.5, sustained pulse >120 after rest
		Systolic bp < 90 or >160 after treatment with hydralazine and or labetalol
	Wound Drain
		T;N, Bulb Suction
	Incentive Spirometer
		Q1HAWAKE, 10x per hour
	Anti Embolism Stockings
		Apply, Once
			Comment: ok to leave off if stockings do not fit patient's legs
	Shower
		T+1;0600
	Intake and Output
		Q4H-Sch, 24, hr
			Comment: then routine
Therapies
	CPAP/Bipap from home
		T;2200, Q24H
			Comment: use CPAP/BiPAP in PACU and for sleep
Consults/Follow-up
	Consult Physical Therapy, Evaluate and Treat
		T+1;0600, Reason to See: Evaluate and Treat
			Comment: to see if patient not able to ambulate 100 feet. Post Op Bariatric Surgery
	Consult Dietitian
		T;N, Regarding: Diet instructions
			Comment: post bariatric surgery diet instructions
	Consult Social Work
		T;N, Evaluation
			Comment: discharge planning
	Consult Care Management
		T;N
			Comment: discharge planning
	Consult Hospitalist
		Reason for Referral: management of multiple medical issues post op bariatric surgery., Refer to/Consult with: hospitalist on call

Oxygen Protocol
Therapies
Respiratory Therapy
	Oxygen Therapy
		T;N
	Pulse Oximetry Spot Check RT
		T;N, BID
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID

Insulin Sliding Scale - NovoLOG
Laboratory

	Glucose POC - RN
		T;N, QIDACHS
		T;N, 15 minutes after carbohydrate source or medication administered
	Hemoglobin A1C
		T+1;0400, Routine, spec type = Blood
	Order Lab
		T;N
			Comment: Blood Glucose (POC) as needed for signs and symptoms of hypoglycemia for patients with diabetic medication orders or known diabetic.
Medications
	Standard Dose NovoLOG
		2 - 12 units, Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale, Routine
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 2 units,200 - 249 = 4 units,250 - 299 = 6 units,300 - 349 = 8 units,350 - 399 = 10 units.Over 399 = 12 units,<< Sliding Scale Comments >> Check  POC in 3 hours; notify physician if repeat POC  greater than or equal to 400mg or less than or equal to 100.  Do not give insulin based on repeat POC value.  RN may change sliding scale insulin order and POC glucose order to every 6 hours if patient is NPO or not on oral diet (tube/enteral feedings, TPN, etc).  Enter as Q6H-SCH  PRN
	Moderate Dose NovoLOG
		4 - 24 units, Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 4 units,200 - 249 = 8 units,250 - 299 = 12 units,300 - 349 = 16 units,350 - 399 = 20 units.Over 399 = 24 units,<< Sliding Scale Comments >> Check  POC in 3 hours; notify physician if repeat POC  greater than or equal to 400mg or less than or equal to 100.  Do not give insulin based on repeat POC value.  RN may change sliding scale insulin order and POC glucose order to every 6hours if patient is NPO or not on oral diet (tube/enteral feedings,TPN, etc). Enter as Q6H-SCH PRN
	High Dose NovoLOG
		5 - 30 units, Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 5 units,200 - 249 = 10 units,250 - 299 = 15 units,300 - 349 = 20 units,350 - 399 = 25 units.Over 399 = 30 units, << Sliding Scale Comments >>Check  POC in 3 hours; notify physician if repeat POC  greater than or equal to 400mg or less than or equal to 100.  Do not give insulin based on repeat POC value.  RN may change sliding scale insulin order and POC glucose order to every 6hours if patient is NPO or not on oral diet (tube/enteral feedings, TPN, etc).  Enter as Q6H-SCH  PRN
	glucose oral gel (JE)
		15 gm, Gel, By Mouth, Q15MIN, PRN, low blood sugar
			Comment: For blood glucose is 60-70mg/dL as an alternative to apple juice. Notify provider if given with corresponding POC glucose recheck value
	Dextrose 50%
		25 mL, Injection, IV PUSH, Q15MIN, PRN for low blood sugar, Routine
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
	Dextrose 10% in Water (FH)
		250 mL, Injection, IVPB, Q30MIN, PRN for low blood sugar, infuse over 30 min(s)
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
	glucagon
		1 mg, Injection, IV Push, Q15MIN, PRN for low blood sugar, T;N
			Comment: Give if blood glucose < 70mg/dL AND if dextrose 50% injectable unavailable OR inadequate response to IV dextrose 50%. May give SubQ or IM if patient does not have IV access. Notify provider if given with corresponding POC glucose recheck value.
Patient Care
	Order Lab
		T;N, RN may change schedule of point of care glucose and sliding scale insulin order to every 6 hours if patient is NPO or not on oral diet (tube/enteral feedings, TPN, etc).. Enter POC order as Q6H-SCH, TIMED and medication order as Q6H-SCH PRN.
	Diabetic Snack
		T;N, Give snack (1 complex carb (15g), 1 protein snack (7g) ) anytime insulin is administered after the evening meal is complete and POC glucose is <150mg/dL.
	IV-Maintain
		T;N
			Comment: Patient should have IV site while on hypoglycemia protocol
	Hypoglycemia Treatment Parameters
		T;N, Hypoglycemia protocol initiated for patients with glucose <70mg/dl. Patient should have an IV while in Hypoglycemia protocol.
		T;N, glucose <60 mg/dL treat with Dextrose 50% 25 mL OR glucagon 1mg as per medication orders. Notify provider as per critical result protocol.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy
		T;N, glucose 60-70 mg/dL, administer 4 oz apple juice, 4 oz non-diet soda, or glucose gel (MJE/MFH).  If patient NPO or unable to tolerate oral intake, give Dextrose 50% 25 mL OR glucagon 1mg as per medication orders.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, After initial treatment of any glucose value </= 70 mg/dL, repeat POC glucose in 15 min; if result </= 70mg/dL continue treating as per protocol and rechecking glucose 15 min after treatment until glucose >70mg/dL.
			Comment: Notify provider of all treatments given and corresponding POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, Once glucose is within normal limits, give 1 complex carb and 1 protein source (such as ½ sandwich OR 1 individual container of peanut butter and 3 packs of crackers) or patient meal if patient able to take orals to prevent recurrent hypoglycemia.
			Comment: When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase