Unique Plan Description: CT Surg Cardiac Surgery, ERA (MH) Post-op EKM
Plan Selection Display: CT Surg Cardiac Surgery, ERA (MH) Post-op
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-11-04 20:46:12
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2025-06-03 16:24:58
Available at all facilities: Yes

CT Surg Cardiac Surgery, ERA (MH) Post-op EKM
Vital Signs
	Vital Signs
		T;N, PACU vital signs, then routine postop vital signs after extubation
Activity
	Ambulate
		T+1;0600, In hall, QID
			Comment: 25 feet or more as tolerated
	Dangle
		T;N+240
			Comment: 4 hours post extubation
	Up in Chair
		T;N+360, Once
			Comment: 6 hours post extubation, with legs elevated
		T+1;N, TIDAC
			Comment: for meals, with legs elevated
Diet
	Regular Diet
		
	Oral Supplement
		T+1;, Boost Glucose Control Shake, AM and HS
		T+1;, Breakfast Essentials Shake, AM and HS
Laboratory
Today's Lab
	Comprehensive Metabolic Panel
		Stat, spec type = Blood
	Blood Gases Arterial (ABG) - MH/WH/JE
		Stat, spec type = Blood
	CBC with Diff
		Stat, spec type = Blood
	Blood Gases Arterial (ABG) - MH/WH/JE
		T;N+240, Routine, spec type = Blood
	CBC with Diff
		T;N+240, Routine, spec type = Blood
	Magnesium Level
		T;N, Stat, spec type = Blood
	Ionized Calcium
		T;N, Stat, spec type = Blood
	Potassium Level
		T;N+240, Routine, spec type = Blood
	Ionized Calcium
		T;N+240, Routine, spec type = Blood
Tomorrow's Lab
	Blood Gases Arterial (ABG) - MH/WH/JE
		T+1;0400, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T+1;0400, Routine, spec type = Blood
	CBC with Diff
		T+1;0400, Routine, spec type = Blood
Diagnostic Tests

	Chest 1 View
		Stat, Post Op F/U
		T+1;0600, Routine, Post Op F/U
	ECG
		T+1;0600, Routine, Indication: Post Op Cardiac Surgery
			Comment: do post op day 1
		T+2;0600, Routine, Indication: Post Op Cardiac Surgery
			Comment: do post op day 2
IV Solutions
	Dextrose 5% with 0.45% NaCl w/KCl 20 mEq
		1,000 mL, IV, 24 hr, 50 ml/hr
			Comment: Start after initial lab returns. Discontinue Post Op Day 1 @ 0600
	Dextrose 5% with 0.45% NaCl
		1,000 mL, IV, 24 hr, 50 ml/hr
			Comment: Discontinue Post Op Day 1 @ 0600
	nitroglycerin 50 mg/D5W 250 mL Premix IV
		250 mL, route of administration: IV, pharmacy order priority: Routine, requested start date/time T;N, Maintain Parameter: SBP< Parameter Goal: 130, Increment Dose Increase: 5 mcg/min, Increment Dose Decrease: 5 mcg/min, Increment Freq: 5 min(s), Max Dose:
			Comment: If SBP remains greater than 150, and/or nitroglycerin infusion is at 120mcg/min, notify surgeon.  If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached.  IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that reduced SBP. Discontinue order after 12hr if patient does not require IV re-initiation.
		50 mg, EVERY BAG, 5 mcg/min
Medications
	Ancef IVPB (MH/WH)
		1,000 mg, Injection-Premix, IVPB, Q8H, Surgical prophylaxis, 3 Dose(s)/Time(s)
			Comment: 1st dose to be given 8 hrs after last OR dose.
		For patients with severe penicillin allergy(NOTE)*
	vancomycin IVPB
		1,000 mg, Injection-Premix, IVPB, Q12H, Surgical prophylaxis, T;N+720, 2 Dose(s)/Time(s)
			Comment: Infuse over 90 minutes.
	aztreonam
		1,000 mg, INT, IVPB, Q8H, Indication: Surgical prophylaxis, 3 Dose(s)/Time(s)
			Comment: 1st dose 8 hours after last OR dose; For patients with severe penicillin allergy.
	aspirin
		325 mg, Tablet-Enteric-Coated, BY MOUTH, Once, T;N+240
		162 mg, Tablet-Chew, BY MOUTH, DAILY, T+1;0900
	Pacerone
		600 mg, Tab, BY MOUTH, Q8H, T;N+240, 9 Dose(s)/Time(s)
			Comment: Give with food. To be started 4 hours PostOp
		200 mg, Tab, BY MOUTH, DAILY, T+4;0900
			Comment: Give with food. To be started 8 hours after 9th 600mg dose.
	mupirocin 2% topical ointment
		1 appl, Ointment, NARE, EACH, BID, 2 Day(s)
	albumin human 5% intravenous solution
		25 gm, 500 mL, Solution-Injection, IVPB, Q10MIN, PRN, see comment, 2 Dose(s)/Time(s)
			Comment: Rate: 900 mL/hr. SBP less than or equal to 100 mmhg PRN for a total of 1000mL. Call surgeon if SBP less than or equal to 100 mmhg after albumin. Discontinue PostOp Day 1.
	Lipitor
		10 mg, Tab, BY MOUTH, QHS, T+1;2100
			Comment: Start Post Op Day 1
	magnesium sulfate IVPB
		2 gm, IVPB, Once, T;N+240, 25 ml/hr
			Comment: Do not give if creatinine > 1.5 or patient on dialysis.  Do not give if Mg >2.0
		DISCONTINUE IF SBP < 100(NOTE)*
	metoprolol TARTRATE
		12.5 mg, Tab, By Mouth, BID, T+1;0900
			Comment: If HR < 55 and /or SBP < 100 since the last dose given, Contact mD for further instructions prior to administration. These parameters apply unless otherwise specified by physician. DISCONTINUE IF PATIENT ON IONOTROPIC DRIP.
	melatonin
		3 mg, Tab, By Mouth, QHS, PRN for insomnia
	Tylenol
		650 mg, Tab, BY MOUTH, Q6H, PRN, pain-mild
			Comment: /headache
	sodium chloride 0.9% flush injectable soln
		10 mL, Syringe, IV PUSH, BID, IV line flush
	potassium chloride IVPB - Central line
		20 mEq, Injection-Premix, IVPB, Q2H, PRN for see comment, infuse over 2 hr, T;N+720, duration: 2 Dose(s)/Time(s)
			Comment: If K+ is 3.6-4 within the first 12 hr postop.  Do not initiate potassium infusion if creatinine is >1.5 or patient is on dialysis. Order potassium level stat, or with next lab draw after infusion complete.
		40 mEq, Injection-Premix, IVPB, Q2H, PRN for see comment, infuse over 2 hr, T;N+720, duration: 2 Dose(s)/Time(s)
			Comment: If K+ is 3.5 or less within the first 12 hr post op. Do not initiate potassium infusion if creatinine is >1.5 or patient is on dialysis. Order potassium level stat or with next lab draw after infusion complete.
	Pepcid
		20 mg Tab BY MOUTH BID
	Plavix
		75 mg, Tab, BY MOUTH, DAILY, T+1;0900
			Comment: Start PostOp day 1.
	Reglan
		10 mg, Injection, IV PUSH, Q6H, 4 Dose(s)/Time(s)
	acetaminophen 10 mg/mL intravenous solution
		1,000 mg, Solution-Injection, IVPB, Q8H, duration: 3 Dose(s)/Time(s)
			Comment: start 4 hours after any pre-op/intra-op dose or immediately post-op if no dose given.
	Tylenol
		650 mg, Tab, By Mouth, Q6H, T;N+1440
			Comment: Scheduled medication. Start after scheduled IV APAP complete.  Do not give both oral and IV APAP.
	gabapentin
		100 mg, Capsule, By Mouth, TID
			Comment: Start evening of surgery. Do not give if >75 years old. Pharmacy to adjust for renal function.  If patient takes at home restart home dose
		NOTE: NSAIDs cannot be used (ARE CONTRAINDICATED) in the following cases:  Allergy to aspirin or any NSAID, During pregnancy, During breast feeding, On blood thinning agents (anticoagulants), Suffering from a defect of the blood clotting system (coagulati(NOTE)*
	ketorolac injectable
		7.5 mg, Injection, IV PUSH, Q6H, PRN for pain-breakthrough, T;N+720, duration: 2 Dose(s)/Time(s)
			Comment: Do not give if systolic blood pressure is < 100mm Hg or if serum creatinine is greater than 1mg/dL (or creatinine clearance < 50ml/min).
		15 mg, Injection, IV PUSH, Q6H, PRN for pain-breakthrough, T;N+720, duration: 2 Dose(s)/Time(s)
			Comment: Do not give if systolic blood pressure is < 100mm Hg or if serum creatinine is greater than 		1mg/dL (or creatinine clearance < 50ml/min).
	ibuprofen
		400 mg, Tab, BY MOUTH, Q6H, PRN for pain-mild
	oxyCODONE
		2.5 mg, Tab, By Mouth, Q4H, PRN for pain-mild
			Comment: 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 5 if possible.
		5 mg, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rated 4 or greater and greater than patient stated comfort goal after scheduled medications given.  Give for pain rated 4-6.  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 5 if possible.
		10 mg, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: : For pain rated 7 or greater and greater than patient stated comfort goal after scheduled medications given.  Give for pain rated 7-10.  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 5 if possible.
	fentaNYL
		25 mcg, Injection, IV PUSH, Q5MIN, PRN for pain-mild, T;N, duration: 12 Dose(s)/Time(s)
			Comment: ONLY if patient is intubated, Maximum 300 mcg. Start at 25mcg for mild to moderate pain and for patients > 65 years old
		50 mcg, Injection, IV PUSH, Q5MIN, PRN for pain-moderate, T;N, duration: 6 Dose(s)/Time(s)
			Comment: ONLY if patient is intubated, Maximum 300 mcg.
	Dilaudid Injectable
		0.5 mg, Injection, IV PUSH, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10 if NPO or for breakthrough pain if on oral analgesics. Use 0.4mg if over age 70.
	morphine  IV
		4 mg, Syringe, IV PUSH, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10; may give if NPO or for breakthrough pain if on oral analgesics.
	Narcan
		0.4 mg, Injection, IV PUSH, Q5MIN, PRN for see comment
			Comment: if patient has received opiate agents in the past 24 hours and/or if patient becomes somnolent with minimal or no response to stimuli or respiratory rate is 8 or less per minute.  RN may administer naloxone prior to contacting MD.  Notify MD immediately upon administration of naloxone
		Ionized Calcium Replacement(NOTE)*
	calcium gluconate IVPB
		0.5 gm, INT, IVPB, Once, PRN for see comment, infuse over 30 min(s)
			Comment: Ionized Calcium 1.10-1.15
		1 gm, Injection-Premix, IVPB, Once, PRN for see comment, infuse over 1 hr
			Comment: Ionized Calcium <1.10
Constipation
	docusate
		100 mg, Capsule, By Mouth, DAILY
			Comment: Hold for diarrhea
	Senokot S 50 mg-8.6 mg oral tablet
		2 TAB, Tab, By Mouth, QHS
	MiraLax oral powder for reconstitution
		17 gm, Packet, By Mouth, DAILY
			Comment: Mix in 6 oz juice or water
	Milk of Magnesia 8% oral suspension
		30 mL, Suspension, By Mouth, DAILY, PRN for constipation
			Comment: If Miralax not effective; do not use if creatinine clearance or GFR < 30mL/min
	Dulcolax
		10 mg, Suppository, RECTALLY, DAILY, PRN, constipation
			Comment: If MOM ineffective or if patient NPO
		10 mg, Suppository, RECTALLY, Q12H, PRN, constipation
			Comment: If MOM ineffective or if patient NPO
	Fleet Enema 19 gm-7 gm rectal enema
		1 EA, Enema, RECTALLY, Q12H, PRN, constipation
			Comment: If bisacodyl ineffective
	Enema-Administer
		Tap water, Q1H, constipation
			Comment: if suppository ineffective
Nausea Vomiting
	ondansetron (MH/WH)
		4 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED and unable to take oral meds
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN, nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED
	ondansetron (JE)
		4 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED and unable to take oral meds
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN, nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED
		Select either promethazine or prochlorperazine orders(NOTE)*
	prochlorperazine
		10 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures.
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures, give if IV access not available.
	Phenergan (MH/WH)
		25 mg, Tab, By Mouth, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures.
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Phenergan (JE)
		25 mg, Tab, By Mouth, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Reglan
		10 mg, Injection, IV Push, Q6H, PRN for nausea and/or vomiting, T;N+1440
			Comment: Give if ondansetron and phenothiazine ineffective; avoid in patients > 65 y/o.
		10 mg, Injection, IM-Intramuscular, Q6H, PRN for nausea and/or vomiting, T;N+1440
			Comment: Give if ondansetron and phenothiazine ineffective; avoid in patients > 65 y/o.
Patient Care

	Neurological Assessment-Focused
		T;N
			Comment: Q1H to affected limb. Mechanical Assist Device
	Resuscitation Status
		Full Code
		No Code
	Discontinue Urinary Catheter
		T+1;2100, unless hemodynamically unstable
			Comment: remove at HS on post op day 1.
	Arterial Line Monitoring
		T;N, assess arterial line q1h while in place
	Discontinue Arterial Line
		T+1;0600, see comment
			Comment: Post Op Day 1Remove arterial line and CVP when SaO2 >/=92% on 6L/min or less, BP S>/=100 x 4 hours, chest tube drainage, <100 mL/8 hours.
	Anti Embolism Stockings
		T+1;0600, Apply, DAILY
			Comment: TED hose, knee high, size to patient
		T+1;0600, Once
			Comment: Measure patient, TED hose, knee high and apply
	Ace Wrap
		T+1;0600
			Comment: Remove on POD #1
	Dressing Care
		T+2;0600, Remove, 2, Day(s)
			Comment: Remove sternal dressing & Endovascular site dressing 48 hours after surgery.
		T+2;0600, Change, Q48H
			Comment: Change chest tube/surgical drain dressing changes every 48 hours and PRN.
	VTE Advisor
		Cardiac surgery
	Wound Drain
		T;N, Q1H, 8, hr
			Comment: strip bulb suction
		T;N+480, Q4H-Sch
			Comment: strip bulb suction
	Chest Tube
		Maintain suction at -20cm H2O
			Comment: milk q10-15 minutes until dry.
	Discontinue Chest Tube
		see comment
			Comment: When drainage </=100 ml per 8 hours, no air leak present, and patient has dangled
	Elevate upper extremity continuously
		see comment
			Comment: Radial artery harvest site with pillow
	Intake and Output
		Bulb suction | Chest tube, Q1H, 24, hr
		GU tube, Q1H, 24, hr
	Notify MD
		BP S<100, >130; P<50, >120; urine output <50 ml per 2 hours; chest tube and wound drain output >200 ml per hour; rhythm changes
		if SBP remains >130 and/or nitroglycerine infusion is at 120 mcg/min
		when extubated to restart routine po medications.
		to address po medications (convert to IV or discontinue) if patient remains on ventilator.
	Order Lab
		T;N, Enter order for coagulation panel, STAT if chest drainage greater than 200ml/hr
	Incentive Spirometer
		T;N, Q1H
	Sequential Compression Device
		T;N, Apply, Once
			Comment: Knee High
	Straight Catheter
		T;N, if PVR >  (see comment)
			Comment: 250 mL or bladder scan> 400ml and unable to void, straight cath x 2. If 3rd catheterization required, insert foley catheter.
	Central Line-Insert
		T;N, Criteria for Insertion: Introducer for CVP/Pulm artery catheter
Therapies
	Oxygen Therapy
		T;N
	Pulse Oximetry Spot Check RT
		T+1;N, BID
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
			Comment: 24hrs. discontinue post op day 1, then spot check BID
	EZ PAP Treatment
		T;N, Q6H-Sch, 72, hr
		T;N, Stat, Q1H, Scheduled / PRN, shortness of breath
	Edema Management Program
		Order Dx: post op cardiac surgery
	Rapid Ventilator Weaning Protocol
		
	Extubate
		T;N
Consults/Follow-up
	Consult Diabetes Educator
		Needs Diabetic Assessment
	Consult Cardiac Rehab: Inpatient
		T+1;0600, Indications CABG
		T+1;0600, Indications Angioplasty/stent
		T+1;0600, Indications Valve replacement/repair
	Consult Cardiac Rehab: Outpatient
		T+1;0600, Indications CABG
		T+1;0600, Indications Angioplasty/stent
		T+1;0600, Indications Valve replacement/repair
	Consult Cardiologist
		Refer to/Consult with: MPC Cardiology if established patient
	Consult Intensivist

Coagulation Panel
Laboratory
	.Protime - MH/WH/JE
		T;N, Stat, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Stat
	PTT - MH/WH/JE
		T;N, Stat, spec type = Blood
	Partial Thromboplastin Time (PTT) - FH
		T;N, Stat, spec type = Diagnostic Blood
	Fibrinogen Level - MH/WH/JE
		T;N, Stat, spec type = Blood
	Fibrinogen Level - FH
		T;N, Stat, spec type = Blood
	Platelet Count
		T;N, Stat, spec type = Blood

Dexmedetomidine (Precedex) MultiModal Post-op prot
Vital Signs
	Vital Signs
		Q 15min upon initiation until RASS target achieved, or when titrating medication until RASS target achieved; then every 1hr and PRN
IV Solutions
	dexmedetomidine 400 mcg/NS 100 mL
		400 mcg, 0.2 mcg/kg/hr, T;N
		100 mL, drug form: IV Large Volume, route of administration: IV, pharmacy order priority: Routine, requested start date/time T;N, duration: 48 hr, RASS Sedation Goal: 0 to -1, incremental dose increase 0.1 mcg/kg/hr, incremental dose decrease 0.1 mcg/kg/h
			Comment: This infusion is meant to be part of a multimodal treatment approach for surgery, not meant for extended sedation for anxiolysis or to interfere with any routine post-op cares. Okay to target moderate to alert and calm sedation (RASS -3 -0) during PACU intubation phase per the dosing rate ordered by provider or anesthesia. Once the patient is extubated, target RASS Goal 0 - -1. If sedation occurs with a RASS score of -2, hold dose for 30 minutes; may resume by decreasing previous rate by 0.1mcg/kg/hr. If RASS < -2, discontinue the order and do not resume. Discontinue if RASS < -2,  HR<50, SBP<100mmHg or MAP<50 and notify MD;  Use with caution if patient on vasopressors or inotropic agents; duration of use should not exceed 48 hours.
	dexmedetomidine 400 mcg/NS 100 mL Premix IV
		100 mL, drug form: IV Large Volume, route of administration: IV, pharmacy order priority: Routine, requested start date/time T;N, duration: 48 hr, RASS Sedation Goal: 0 to -1, incremental dose increase 0.1 mcg/kg/hr, incremental dose decrease 0.1 mcg/kg/h
			Comment: This infusion is meant to be part of a multimodal treatment approach for surgery, not meant for extended sedation for anxiolysis or to interfere with any routine post-op cares. Okay to target moderate to alert and calm sedation (RASS -3 -0) during PACU intubation phase per the dosing rate ordered by provider or anesthesia. Once the patient is extubated, target RASS Goal 0 - -1. If sedation occurs with a RASS score of -2, hold dose for 30 minutes; may resume by decreasing previous rate by 0.1mcg/kg/hr. If RASS < -2, discontinue the order and do not resume. Discontinue if RASS < -2,  HR<50, SBP<100mmHg or MAP<50 and notify MD;  Use with caution if patient on vasopressors or inotropic agents; duration of use should not exceed 48 hours.
		400 mcg, EVERY BAG, 0.2 mcg/kg/hr
Medications
		Contraindications to use include: Left ventricular ejection fraction <30%, Heart rate <50, Systolic blood pressure <100mmHg despite use of vasopressors and/or fluids, Heart block. Use with caution if patient on vasopressors or inotropic agents(NOTE)*
Patient Care
	Notify MD
		If HR<50, SBP<100mmHg, MAP<50 or if RASS < -2, and hold dexmedotomidine infusion.

*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