Unique Plan Description: DVT Treatment
Plan Selection Display: DVT Treatment
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2020-04-19 12:52:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2022-03-25 09:11:57
Available at all facilities: Yes

DVT Treatment
Vital Signs
	Vital Signs
		T;N
			Comment: Routine
Activity
	Bedrest with Bathroom Privileges
		T+1;N
	Activity-As Tolerated
		T;N+24
Diet
	Regular Diet
		T;N
Laboratory
Tomorrow's Lab
	INR - MH/WH/JE
		T+1;0400, Routine, Q24H, spec type = Blood
	Prothrombin Time (PT) - FH
		T+1;0400, Routine, spec type = Diagnostic Blood
		T+1;0400, Routine, spec type = Therapeutic Blood
	Pregnancy Test Urine
		Nurse Collect, spec type = Urine
			Comment: If patient of child bearing ability one time only prior to warfarin administration
IV Solutions

	Dextrose 5% with 0.45% NaCl w/KCl 20 mEq
		1,000 mL, IV, 75 ml/hr
		1,000 mL, IV, 100 ml/hr
Medications
	Lovenox
		1 mg/kg, Syringe, SUBCUTANEOUS, Q12H, STAT
		1.5 mg/kg, Syringe, SUBCUTANEOUS, Q24H, STAT
		1 mg/kg, Syringe, SUBCUTANEOUS, Q24H, STAT
			Comment: For ClCr < 30ml/min
	Arixtra
		5 mg, Injection, SUBCUTANEOUS, Q24H
			Comment: For patients less than 50kg and ClCr >30ml/min
		7.5 mg, Injection, SUBCUTANEOUS, Q24H
			Comment: For patients 50-100kg and ClCr >30ml/min
		10 mg, Injection, SUBCUTANEOUS, Q24H
			Comment: For patients > 100kg and ClCr >30ml/min
	rivaroxaban
		15 mg, By Mouth, BIDWM, T;N, 21 Day(s)
		20 mg, By Mouth, DAILYW/SUPPER, T+21;N
	apixaban
		10 mg, By Mouth, BID, T;N, 7 Day(s)
		5 mg, By Mouth, BID, T+7;N
	warfarin
		1 mg, Tab, By Mouth, DAILY, T;1600
		10 mg, Tab, By Mouth, DAILY, T;1600
		2 mg, Tab, By Mouth, DAILY, T;1600
		2.5 mg, Tab, By Mouth, DAILY, T;1600
		3 mg, Tab, By Mouth, DAILY, T;1600
		4 mg, Tab, By Mouth, DAILY, T;1600
		5 mg, Tab, By Mouth, DAILY, T;1600
		6 mg, Tab, By Mouth, DAILY, T;1600
		7.5 mg, Tab, By Mouth, DAILY, T;1600
		1 mg, Tab, By Mouth, Once, T;1600
		10 mg, Tab, By Mouth, Once, T;1600
		2 mg, Tab, By Mouth, Once, T;1600
		2.5 mg, Tab, By Mouth, Once, T;1600
		3 mg, Tab, By Mouth, Once, T;1600
		4 mg, Tab, By Mouth, Once, T;1600
		5 mg, Tab, By Mouth, Once, T;1600
		6 mg, Tab, By Mouth, Once, T;1600
		7.5 mg, Tab, By Mouth, Once, T;1600
	Ambien
		5 mg Tab BY MOUTH QHS, PRN insomnia
	Tylenol
		650 mg, Tab, BY MOUTH, Q4H, PRN, temperature > ....
			Comment: 100.9
Patient Care
	Anti Embolism Stockings
		T;N, TED hose, knee high, Remove for 30 minutes and re-apply, Both legs
	Notify MD
		T;N, Notify admitting MD if platelets less than 100,000
		T;N, if SAO2 < 92%.
Therapies
	Pulse Oximetry Spot Check RT
		T;N, BID
Consults/Follow-up
	Consult Social Work
		T;N, Evaluation
			Comment: check on enoxaparin/Arixtra coverage
	Pharmacy Consult - Warfarin (Coumadin) Therapy
		T;N, Pharmacy to dose coumadin
	Consult Primary Care Provider
		Reason for Referral: To manage Coumadin as an outpatient, Requested Time Frame Today
	Notify MD
		T;N, To manage warfarin as outpatient upon discharge. Dr. ____________

Heparin Non DVT/PE (Low dose) Xa Monitoring
Admit/Discharge/Transfer
		This plan is to be used for patients with the following diagnoses: atrial fibrillation, chest pain, stroke, MI(NOTE)*
		MH/WH/JE only: Consider using PTT monitoring if enoxaparin/apixaban/rivaroxaban received in previous 48hr.(NOTE)*
Laboratory
	INR - MH/WH/JE
		Stat, spec type = Blood
	PTT - MH/WH/JE
		Stat, spec type = Blood
		T+2;0400, Timed, Q48H, spec type = Blood
	Heparin Anti-Xa Heparin
		Stat, spec type = Blood
		T;N+360, Timed, Q6H, spec type = Blood
IV Solutions
	HEParin 25,000 units/premixed diluent 250 mL
		250 mL, IV
			Comment: conc: 100 units/mL. Titrate according to Low Dose Weight Based Heparin Protocol.  Maximum weight for dosing 110kg.  MAXIMUM INITIAL rate is 1000unit/hr.1)  Anti-factor Xa UFH <than 0.2 units/mL, bolus 60 units/kg & increase rate by 4 units/kg/hr.2)  Anti-factor Xa UFH = 0.2-0.29 units/mL, bolus 30 units/kg & increase rate by 2 units/kg/hr.3)  Anti-factor Xa UFH = 0.3-0.7 units/mL, (therapeutic range) Do not give bolus & do not change rate.4)  Anti-factor Xa UFH = 0.71-0.95 units/mL, do not bolus. Decrease rate by 2 units/kg/hr.5)  Anti-factor Xa UFH = 0.96 units/mL or more, do not give bolus. Stop infusion for 60 mins & decrease rate by 3 units/kg/hr.Upper hard limits for weight based and non-weight based infusions are as follows: 40 units/kg/hour and 3000 units/hour, respectively; if patient needs require exceeding these limits, contact pharmacy and prescriber.MH/WH/JE only: Consider using PTT monitoring if enoxaparin/apixaban/rivaroxaban received in previous 48hr.
		25,000 units, EVERY BAG, 12 unit/kg/hr
Medications
		No IM injections while on anticoagulants(NOTE)*
	HEParin 1000 units/mL injectable soln
		60 units/kg, Injection, IV Push, Once, STAT
			Comment: Dose = 60 units/kg Bolus.  Patient on Low Dose Heparin Protocol.  Pharmacy to calculate dose. Begin heparin bolus and infusion immediately after initial stat labs are drawn.  (MAXIMUM INITIAL bolus = 4000 units)
		60 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 60 units/kg Bolus.  Anti-factor Xa UFH level < 0.2 units/mL, Patient on Low Dose Heparin Protocol.  Pharmacy to calculate dose. (MAXIMUM bolus = 6600 units)
		30 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 30 units/kg Bolus.  Anti-factor Xa UFH level between 0.2-0.29 units/mL.  Patient on Low Dose Heparin Protocol.  Pharmacy to calculate dose.  (MAXIMUM bolus = 3300 units)
Patient Care
	Notify MD
		T;N, For surgical patients, contact surgeon for approval to start heparin protocol if ordered post surgery
		T;N, if 2 consecutive 60 unit/kg boluses of heparin given and the resulting anti-factor-Xa UFH is not in therapeutic range within 12 hours
		T;N, if 2 consecutive anti-factor-Xa UFHs are greater or equal to 0.96 units/ml
		T;N, if initial stat anti-factor-Xa UFH comes back elevated.
		T;N, If baseline PTT is >42 seconds (5 seconds above upper normal limit of 22-37 seconds).
		T;N, if critical PTT >135.
		T;N, MH/WH/JE only: If patient has received enoxaparin/apixaban/rivaroxaban in previous 48hr and/or has an elevated baseline UFH antiXa level, please contact prescriber/pharmacy to consider switching to PTT monitoring protocol.
	Order Lab
		T;N, Enter orders for anti-factor-Xa UFH Q6Hr timed after initiation of therapy or any dosage change until 2 consecutive anti-factor-Xa UFH in therapeutic range, then q24h in am.
	Avoid IM Injections if possible while on anticoagulants

Heparin Non DVT/PE (Low dose) PTT Monitoring
Admit/Discharge/Transfer
		This plan is to be used for patients with the following diagnoses: atrial fibrillation, chest pain, stroke, MI(NOTE)*
Laboratory
	INR - MH/WH/JE
		Stat, spec type = Blood
	PTT - MH/WH/JE
		Stat, spec type = Blood
		T;N+360, Timed, Q6H, spec type = Blood
IV Solutions
	HEParin 25,000 units/premixed diluent 250 mL
		250 mL, IV
			Comment: conc: 100 units/mL. Titrate according to Low Dose Weight Based Heparin Protocol.  Maximum weight for dosing 110kg.  MAXIMUM INITIAL rate is 1000 units per hr.1)  PTT < 52 seconds, bolus 60 units/kg & increase rate by 4 units/kg/hr.2)  PTT = 52-64 seconds, bolus 30 units/kg & increase rate by 2 units/kg/hr.3)  PTT = 65-110 seconds, (therapeutic range) Do not give bolus & do not change rate.4)  PTT = 111-135 seconds, do not bolus. Decrease rate by 2 units/kg/hr.5)  PTT = 136 seconds or more, do not give bolus. Stop infusion for 60 mins & decrease rate by 3 units/kg/hr.Upper hard limits for weight based and non-weight based infusions are as follows: 40 units/kg/hour and 3000 units/hour, respectively; if patient needs require exceeding these limits, contact pharmacy and prescriber
		25,000 units, EVERY BAG, 12 unit/kg/hr
Medications
	HEParin 1000 units/mL injectable soln
		60 units/kg, Injection, IV Push, Once, STAT
			Comment: Dose = 60 units/kg Bolus.  Patient on Low Dose Heparin Protocol.  Pharmacy to calculate dose.  Begin heparin bolus and infusion immediately after initial stat labs are drawn.  (MAXIMUM INITIAL bolus = 4000 units)
		60 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 60 units/kg Bolus. PTT level < 52 seconds, Patient on Low Dose heparin Protocol.  Pharmacy to calculate dose.  (MAXIMUM bolus = 6600 units)
		30 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 30 units/kg Bolus. PTT level between 52-64 seconds.  Patient on Low Dose Heparin Protocol.  Pharmacy to calculate dose.  (MAXIMUM bolus = 3300 units)
Patient Care
	Notify MD
		T;N, For surgical patients, contact surgeon for approval to start heparin protocol if ordered post surgery
		T;N, if PTT is not in therapeutic range within 24 hours
		T;N, if 2 consecutive 60 unit boluses of heparin given and the resulting PTT value is not in therapeutic range within 12 hours
		T;N, For any critical PTT >135 AND with any 2 consecutive PTTs >135
		T;N, If baseline PTT is >42 seconds (5 seconds above upper normal
	Order Lab
		T;N, Enter orders for PTT Q6Hr timed after initiation of therapy or any dosage change until 2 consecutive PTT in therapeutic range, then q24h in am.
	Avoid IM Injections if possible while on anticoagulants
		T;N

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

Heparin DVT/PE (High Dose) PTT Monitoring (MH WH)
Admit/Discharge/Transfer

		This plan is to be used for patients with diagnoses of deep vein thrombosis or pulmonary embolism(NOTE)*
Laboratory
	INR - MH/WH/JE
		Stat, spec type = Blood
	PTT - MH/WH/JE
		Stat, spec type = Blood
		T;N+360, Timed, Q6H, spec type = Blood
IV Solutions
	HEParin 25,000 units/premixed diluent 250 mL
		250 mL, IV, STAT, T;N
			Comment: conc: 100 units/mL. Titrate according to High Dose Weight Based Heparin Protocol.  Maximum weight for dosing 110kg.1) PTT < 52 seconds, bolus 70 units/kg & increase rate by 4 units/kg/hr.2) PTT = 52-64 seconds, bolus 35 units/kg & increase rate by 2 units/kg/hr.3) PTT = 65-110 seconds, (therapeutic range) Do not give bolus & do not change rate.4) PTT = 111-135 seconds, do not bolus. Decrease rate by 2 units/kg/hr.5) PTT = 136 seconds or more, do not give bolus. Stop infusion for 60 mins & decrease rate by 3 units/kg/hr.Upper hard limits for weight based and non-weight based infusions are as follows: 40 units/kg/hour and 3000 units/hour, respectively; if patient needs require exceeding these limits, contact pharmacy and prescriber
		25,000 units, EVERY BAG, 18 unit/kg/hr
Medications
	HEParin 1000 units/mL injectable soln
		70 units/kg, Injection, IV Push, Once, STAT
			Comment: Dose = 70 units/kg Bolus. Patient on High Dose Heparin Protocol.  Pharmacy to calculate dose.  Begin heparin bolus and infusion immediately after initial stat labs are drawn. (MAXIMUM bolus = 7700 units)
		70 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 70 units/kg Bolus.  PTT < 52 seconds, Patient on High Dose heparin Protocol.  Pharmacy to calculate dose. (MAXIMUM bolus = 7700 units)
		35 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 35 units/kg Bolus.  PTT level between 52-64 seconds.  Patient on High Dose Heparin Protocol.  Pharmacy to calculate dose. (MAXIMUM bolus = 3800 units)
Patient Care
	Notify MD
		T;N, For surgical patients, contact surgeon for approval to start heparin protocol if ordered post surgery
		T;N, if PTT is not in therapeutic range within 24 hours
		T;N, if 2 consecutive 70 unit/kg boluses of heparin given and the PTT is not in therapeutic range within 12 hours
		T;N, For any critical PTT >135 AND with any 2 consecutive PTTs >135
		T;N, If baseline PTT is >42 seconds (5 seconds above upper normal limit of 22-37 seconds).
	Order Lab
		T;N, Enter orders for PTT Q6Hr timed after initiation of therapy or any dosage change until 2 consecutive PTT in therapeutic range, then q24h in am.
	Avoid IM Injections if possible while on anticoagulants
		T;N

Heparin DVT/PE (High Dose) Xa Monitoring
Admit/Discharge/Transfer
		This plan is to be used for patients with diagnoses of deep vein thrombosis or pulmonary embolism(NOTE)*
		MH/WH/JE only: Consider using PTT monitoring if enoxaparin/apixaban/rivaroxaban received in previous 48hr(NOTE)*
Laboratory
	INR - MH/WH/JE
		Stat, spec type = Blood
	PTT - MH/WH/JE
		Stat, spec type = Blood
		T+2;0400, Timed, Q48H, spec type = Blood
	Heparin Anti-Xa Heparin
		Stat, spec type = Blood
		T;N+360, Timed, Q6H, spec type = Blood
IV Solutions
	HEParin 25,000 units/premixed diluent 250 mL
		250 mL, IV, STAT
			Comment: conc: 100 units/mL. Titrate according to High Dose Weight Based Heparin Protocol.  Maximum weight for dosing 110kg.1)  Anti-factor Xa UFH <less than 0.2 units/mL,bolus 70 units/kg & increase rate by 4 units/kg/hr.2)  Anti-factor Xa UFH =0.2-0.29 units/mL,bolus 35 units/kg & increase rate by 2 units/kg/hr.3)  Anti-factor Xa UFH =0.3-0.7 units/mL,(therapeutic range) Do not give bolus & do not change rate.4)  Anti-factor Xa UFH =0.71-0.95 units/mL,do not bolus. Decrease rate by 2 units/kg/hr.5)  Anti-factor Xa UFH =0.96 units/mL or more, do not give bolus. Stop infusion for 60 mins & decrease rate by 3 units/kg/hr.Upper hard limits for weight based and non-weight based infusions are as follows: 40 units/kg/hour and 3000 units/hour, respectively; if patient needs require exceeding these limits, contact pharmacy and prescriber.MH/WH/JE only: Consider using PTT monitoring if enoxaparin/apixaban/rivaroxaban received in previous 48hr.
		25,000 units, EVERY BAG, 18 unit/kg/hr
Medications
	HEParin 1000 units/mL injectable soln
		70 units/kg, Injection, IV Push, Once, STAT
			Comment: Dose = 70 units/kg Bolus. Patient on High Dose Heparin Protocol.  Pharmacy to calculate dose.  Begin heparin bolus and infusion immediately after initial stat labs are drawn.  (MAXIMUM bolus = 7700 units)
		70 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 70 units/kg Bolus.  Anti-factor Xa UFH level < 0.2 units/mL, Patient on High Dose heparin Protocol.  Pharmacy to calculate dose.  (MAXIMUM bolus = 7700 units)
		35 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 35 units/kg Bolus.  Anti-factor Xa UFH level between 0.2-0.29 units/mL.  Patient on High Dose Heparin Protocol.  Pharmacy to calculate dose.  (MAXIMUM bolus = 3800 units)
Patient Care
	Notify MD
		T;N, For surgical patients, contact surgeon for approval to start heparin protocol if ordered post surgery
		T;N, if anti-factor-Xa UFH is not in therapeutic range within 24 hours
		T;N, if 2 consecutive 70 unit/kg boluses of heparin given and the resulting anti-factor-Xa UFH is not in therapeutic range within 12 hours
		T;N, if 2 consecutive anti-factor-Xa UFHs are greater or equal to 0.96 units/ml
		T;N, if initial stat anti-factor-Xa UFH comes back elevated.
		T;N, If baseline PTT is >42 seconds (5 seconds above upper normal limit of 22-37 seconds).
		T;N, if critical PTT >135.
		T;N, MH/WH/JE only: If patient has received enoxaparin/apixaban/rivaroxaban in previous 48hr and/or has an elevated baseline UFH antiXa level, please contact prescriber/pharmacy to consider switching to PTT monitoring protocol.
	Order Lab
		T;N, Enter orders for anti-factor-Xa UFH Q6Hr timed after initiation of therapy or any dosage change until 2 consecutive anti-factor-Xa UFH in therapeutic range, then q24h in am.
	Avoid IM Injections if possible while on anticoagulants
		T;N

zzHeparin DVT/PE (High Dose) Xa Monitoring (FH)
Admit/Discharge/Transfer
		This plan is to be used for patients with diagnoses of deep vein thrombosis or pulmonary embolism(NOTE)*
Laboratory
	Prothrombin Time (PT) - FH
		T;N, Stat, spec type = Therapeutic Blood
		T;N, Stat, spec type = Diagnostic Blood
	Partial Thromboplastin Time (PTT) - FH
		T;N, Stat, spec type = Diagnostic Blood
		T+2;0400, Q48H, Timed, spec type = Diagnostic Blood
	Heparin Anti-Xa Heparin
		Stat, spec type = Blood
		T;N+360, Timed, Q6H, spec type = Blood
IV Solutions
	HEParin 25,000 units/premixed diluent 250 mL
		250 mL, IV, STAT
			Comment: 100 units/mL. Titrate according to High Dose Weight Based Heparin Protocol.  1)  Anti-factor Xa UFH <less than 0.1 units/mL,bolus 80 units/kg & increase rate by 300 units/hr.2)  Anti-factor Xa UFH =0.1-0.19 units/mL,bolus 40 units/kg & increase rate by 200 units/hr.3)  Anti-factor Xa UFH =0.2-0.29 units/mL, No bolus, increase rate by 100 units/hr 4) Anti-factor Xa UFH = 0.3-0.7 (therapeutic range) Do not give bolus & do not change rate.5)  Anti-factor Xa UFH =0.71-0.8 units/mL,do not bolus. Decrease rate by 100 units/hr.6)  Anti-factor Xa UFH =0.81-1.7 units/mL or more, do not give bolus. Stop infusion for 60 mins & decrease rate by 200 units/hr. 7) Anti-factor Xa UFH > 1.7, Stop infusion for 2 hours and decrease rate by 300 units/hr
		25,000 units, EVERY BAG, 18 unit/kg/hr
Medications
	HEParin 1000 units/mL injectable soln
		80 units/kg, Injection, IV Push, Once, STAT
			Comment: Dose = 80 units/kg Bolus. Patient on High Dose Heparin Protocol.  Pharmacy to calculate dose.  Begin heparin bolus and infusion immediately after initial stat labs are drawn.
		80 units/kg, Injection, IV Push, Q6H, PRN see comment, T;N+360
			Comment: Dose = 80 units/kg Bolus.  Anti-factor Xa UFH level < 0.1 units/mL, Patient on High Dose heparin Protocol.  Pharmacy to calculate dose.
		40 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 40 units/kg Bolus.  Anti-factor Xa UFH level between 0.1-0.19 units/mL.  Patient on High Dose Heparin Protocol.  Pharmacy to calculate dose.
Patient Care
	Notify MD
		T;N, For surgical patients, contact surgeon for approval to start heparin protocol if ordered post surgery
		T;N, if anti-factor-Xa UFH is not in therapeutic range within 24 hours
		T;N, if 2 consecutive 70 unit/kg boluses of heparin given and the resulting anti-factor-Xa UFH is not in therapeutic range within 12 hours
		T;N, if 2 consecutive anti-factor-Xa UFHs are greater or equal to 0.96 units/ml
		T;N, if initial stat anti-factor-Xa UFH comes back elevated.
		T;N, If baseline PTT is >42 seconds (5 seconds above upper normal limit of 22-37 seconds).
		T;N, if critical PTT >135.
	Order Lab
		T;N, Enter orders for anti-factor-Xa UFH Q6Hr timed after initiation of therapy or any dosage change until 2 consecutive anti-factor-Xa UFH in therapeutic range, then q24h in am.
	Avoid IM Injections if possible while on anticoagulants
		T;N

zzHeparin Non DVT/PE (Low dose) Xa Monitoring (FH)
Admit/Discharge/Transfer
		This plan is to be used for patients with the following diagnoses: atrial fibrillation, chest pain, stroke, MI(NOTE)*
Laboratory
	INR - MH/WH/JE
		Stat, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Stat, spec type = Diagnostic Blood
		T;N, Stat, spec type = Therapeutic Blood
	PTT - MH/WH/JE
		Stat, spec type = Blood
		T+2;0400, Timed, Q48H, spec type = Blood
	Partial Thromboplastin Time (PTT) - FH
		T+2;0400, Q48H, Routine, spec type = Diagnostic Blood
		T;N, Stat, spec type = Diagnostic Blood
	Heparin Anti-Xa Heparin
		Stat, spec type = Blood
		T;N+360, Timed, Q6H, spec type = Blood
IV Solutions
	HEParin 25,000 units/premixed diluent 250 mL
		250 mL, IV, Routine
			Comment: conc: 100 units/mL. Titrate according to Low Dose Weight Based Heparin Protocol.  MAXIMUM INITIAL rate is 1000unit/hr.1)  Anti-factor Xa UFH <than 0.1 units/mL, bolus 60 units/kg & increase rate by 300 units/hr.2)  Anti-factor Xa UFH = 0.1-0.19 units/mL, bolus 30 units/kg & increase rate by 200 units/hr.3)  Anti-factor Xa UFH = 0.2-0.29 units/mL, Do not give bolus & increase rate by 100units/hr.  4) Anti-factor Xa UFH = 0.3-0.7 units/mL (therapeutic range)  Do not bolus and do not change rate.5)  Anti-factor Xa UFH = 0.71-0.8 units/mL, do not bolus. Decrease rate by 100 units/hr.6)  Anti-factor Xa UFH = 0.81-1.7 units/mL, do not give bolus.  Stop infusion for 60 minutes and decrease rate by 200 units/hr when restarted.  7) Anti-factor Xa UFH > 1.7 units/ml.  Stop infusion for 2 hours & decrease rate by 300 units/hr when restarted.
		25,000 units, EVERY BAG, 12 unit/kg/hr
Medications
		No IM injections while on anticoagulants(NOTE)*
	HEParin 1000 units/mL injectable soln
		60 units/kg, Injection, IV Push, Once, STAT
			Comment: Dose = 60 units/kg Bolus.  Patient on Low Dose Heparin Protocol.  Pharmacy to calculate dose. Begin heparin bolus and infusion immediately after initial stat labs are drawn.  (MAXIMUM INITIAL bolus = 5000 units)
		60 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 60 units/kg Bolus.  Anti-factor Xa UFH level < 0.1 units/mL, Patient on Low Dose Heparin Protocol.  Pharmacy to calculate dose. (MAXIMUM bolus = 5000 units)
		30 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 30 units/kg Bolus.  Anti-factor Xa UFH level between 0.1-0.19 units/mL.  Patient on Low Dose Heparin Protocol.  Pharmacy to calculate dose.  (MAXIMUM bolus = 5000 units)
Patient Care
	Notify MD
		T;N, For surgical patients, contact surgeon for approval to start heparin protocol if ordered post surgery
		T;N, if 2 consecutive 60 unit/kg boluses of heparin given and the resulting anti-factor-Xa UFH is not in therapeutic range within 12 hours
		T;N, if 2 consecutive anti-factor-Xa UFHs are greater or equal to 0.96 units/ml
		T;N, if initial stat anti-factor-Xa UFH comes back elevated.
		T;N, If baseline PTT is >42 seconds (5 seconds above upper normal limit of 22-37 seconds).
		T;N, if critical PTT >135.
	Order Lab
		T;N, Enter orders for anti-factor-Xa UFH Q6Hr timed after initiation of therapy or any dosage change until 2 consecutive anti-factor-Xa UFH in therapeutic range, then q24h in am.
	Avoid IM Injections if possible while on anticoagulants

Pain Constipation Nausea Protocol </= to 65 EKM
Medications
		Select only one medication in each category(NOTE)*
Mild Pain
	acetaminophen
		650 mg, Tab, By Mouth, Q4H, PRN for see comment
			Comment: Discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient
		650 mg, Suppository, RECTALLY, Q6H, PRN for see comment
			Comment: Discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient
	ibuprofen
		600 mg, Tab, By Mouth, Q6H, PRN for pain-mild
			Comment: pain rating 1-3
		800 mg, Tab, By Mouth, Q8H, PRN for pain-mild
			Comment: pain rating 1-3
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-mild
			Comment: pain rating 1-3
	oxyCODONE-acetaminophen 5/325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-mild
			Comment: Pain rating 1-3
	HYDROmorphone Injectable
		0.2 mg, Injection, IV Push, Q2H, PRN for pain-mild
			Comment: For pain rating 1-3 and if NPO
	morphine  IV
		2 mg, Syringe, IV Push, Q2H, PRN for pain-mild
			Comment: for pain rating 1-3 and if NPO
Moderate Pain
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	acetaminophen-hydrocodone 325 mg-7.5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	acetaminophen-hydrocodone 325 mg-10 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	oxyCODONE-acetaminophen 5/325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	oxyCODONE-acetaminophen 7.5/325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	oxyCODONE-acetaminophen 10/325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	oxyCODONE
		5 mg, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	morphine  oral immediate release
		15 mg, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: Pain rating 4-6
	HYDROmorphone Injectable
		0.2 mg, Injection, IV PUSH, Q2H, PRN for pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
		0.4 mg, Injection, IV PUSH, Q2H, PRN for pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
	morphine  IV
		2 mg, Syringe, IV Push, Q2H, PRN for pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
		4 mg, Syringe, IV Push, Q2H, PRN for pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
	ketorolac injectable
		15 mg, Injection, IV Push, Q6H, PRN for pain-moderate, duration: 48 hr
			Comment: For pain rating 4-6.
Severe Pain
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	acetaminophen-hydrocodone 325 mg-7.5 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	oxyCODONE-acetaminophen 5/325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	oxyCODONE-acetaminophen 7.5/325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	oxyCODONE-acetaminophen 10/325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	oxyCODONE
		10 mg, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	morphine  oral immediate release
		30 mg, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	HYDROmorphone Injectable
		0.4 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.
		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.
		0.6 mg, Injection, IV PUSH, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10 if NPO
		0.8 mg, Injection, IV PUSH, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10 if NPO
		1 mg, Injection, IV PUSH, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10 if NPO
	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.
		6 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.
		Opiate Reversal(NOTE)*
	Narcan
		0.2 mg, Injection, IV Push, Q2MIN, 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 10 or less per minute.  RN may administer naloxone prior to contacting MD.  Notify MD immediately upon administration of naloxone.  May give 0.2mg every 2 min up to 1mg total dose.
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, Q12H, PRN, constipation
			Comment: Mix in 6 oz juice or water
		17 gm, Packet, By Mouth, DAILY, PRN, constipation
			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
		30 mL, Suspension, By Mouth, Q12H, 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
		4 mg, Injection, IV PUSH, Q6H, PRN for nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN for 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.
		6.25 mg, Injection, IM-Intramuscular, Q6H, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Phenergan (FH)
		12.5 mg, INT, IVPB, Once, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
		25 mg, INT, IVPB, Once, PRN for 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
		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.
	metoclopramide
		10 mg, Injection, IV PUSH, Q6H, PRN for nausea and/or vomiting
			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
			Comment: Give if ondansetron and phenothiazine ineffective; avoid in patients > 65 y/o.
Patient Care

	Notify MD
		If patient develops itching
		if no results from enema.

Pain Constipation Nausea Protocol > 65 Geriatric E
Medications
		Select only one medication in each category(NOTE)*
Mild Pain
	acetaminophen
		1,000 mg, Tab, By Mouth, Q8H-Sch, T;N
			Comment: For pain rating 1-3; Consider IV Acetaminophen (Ofirmev) if NPO.
		1,000 mg, Tab, By Mouth, Q8H, PRN for pain-mild
			Comment: For pain rating 1-3; Consider IV Acetaminophen (Ofirmev) if NPO.
		1,000 mg, Tab, By Mouth, Q8H-Sch, T+1;N
			Comment: For pain rating 1-3; Consider IV Acetaminophen (Ofirmev) if NPO.
	acetaminophen 10 mg/mL intravenous solution
		1,000 mg, Solution-Injection, IVPB, Q8H, T;N, duration: 3 Dose(s)/Time(s)
			Comment: For pain rating 1-3.
Moderate Pain
	oxyCODONE
		2.5 mg, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6
	traMADol
		25 mg, Tab, By Mouth, Q6H, PRN for pain-moderate
			Comment: For pain rating 4-6; Screen for drug interactions (e.g.SSRI), and adjust dose for CrCl<30ml/min; avoid use if history of seizures.
	HYDROmorphone Injectable
		0.2 mg, Injection, IV PUSH, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics.
Severe Pain
	oxyCODONE
		5 mg, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: For pain rating 7-10.
	traMADol
		50 mg, Tab, By Mouth, Q6H, PRN for pain-severe
			Comment: For pain rating 7-10; screen for drug interactions (e.g.SSRI), and adjust dose for CrCl<30ml/min; avoid use if history of seizures.
	HYDROmorphone Injectable
		0.4 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.
		Opiate Reversal(NOTE)*
	Narcan
		0.2 mg, Injection, IV Push, Q2MIN, 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 10 or less per minute.  RN may administer naloxone prior to contacting MD.  Notify MD immediately upon administration of naloxone.  May give 0.2mg every 2 min up to 1mg total dose.
PRN Discomfort
	trolamine salicylate 10% topical cream
		1 appl, Cream, TOPICAL, TID, PRN for discomfort
			Comment: Apply to affected area.
	menthol-methyl salicylate topical
		1 appl, Cream, TOPICAL, TID, PRN for discomfort
			Comment: Apply to affected area.
	lidocaine 4% topical patch
		1 patch, Patch, TransDERMAL, DAILY
	lidocaine Patch Removal
		Patch Removal, Patch, TransDERMAL, QHS
	Medication patch site check
		T;N+720, Q12H
Constipation
	Senokot S 50 mg-8.6 mg oral tablet
		1 TAB, Tab, By Mouth, BID, PRN for constipation
			Comment: Hold for loose stools
	MiraLax oral powder for reconstitution
		17 gm, Packet, By Mouth, BID
			Comment: Hold for loose stools.  Mix in 6oz juice or water.
	Dulcolax
		10 mg, Suppository, RECTALLY, Q12H, PRN for constipation
			Comment: If other agents ineffective or if patient NPO.
	Fleet Enema 19 gm-7 gm rectal enema
		1 EA, Enema, RECTALLY, Q12H, PRN for constipation
			Comment: If suppository ineffective.
	Enema-Administer
		Tap water, Q1H, see comment
			Comment: If suppository ineffective.
Nausea Vomiting
	ondansetron
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN for nausea and/or vomiting
		4 mg, Injection, IV Push, Q6H, PRN for nausea and/or vomiting
			Comment: If unable to take by mouth.

*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