Unique Plan Description: Gen Adm GI
Plan Selection Display: Gen Adm GI
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2011-11-30 15:27:31
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2023-01-24 09:47:20
Available at all facilities: Yes

Gen Adm GI
Admit/Discharge/Transfer
	Admit to Inpatient Status
		T;N, Anticipated LOS 2 midnight or more
	Admit to Observation Status
		T;N
	Admit to Critical Care Inpatient Status (MH)
		T;N, Anticipated LOS 2 midnight or more
	Admit to Critical Care Observation Status (MH)
		T;N
Vital Signs
	Vital Signs
		Per protocol
		Q1H
		Q2H-Sch
		Q4H-Sch
Activity
	Activity-As Tolerated
		
	Bedrest
		
	Up with Assistance
		
	Bedrest with Bathroom Privileges
		
	Up in Chair
		TIDWM
		TID
	Ambulate
		In hall, TID
		In hall, QID
Diet
	NPO
		T;N, NPO Except for: Medications
	Regular Diet
		T;N
	Sodium Restricted Diet
		T;N
	Cardiac Diet
		T;N
	Renal Diet
		T;N
	Diabetic Diet
		T;N
	Clear Liquid Diet
		T;N
Laboratory
STAT Lab
	CBC with Diff
		Stat, spec type = Blood
	INR - MH/WH/JE
		T;N, Stat, spec type = Blood
	D-Dimer - MH/WH/JE
		T;N, Stat, spec type = Blood
	Comprehensive Metabolic Panel
		Stat, spec type = Blood
	Amylase Level
		Stat, spec type = Blood
	Lipase Level
		Stat, spec type = Blood
	TSH
		Stat, spec type = Blood
	Magnesium Level
		T;N, Stat, spec type = Blood
	Phosphorus
		T;N, Stat, spec type = Blood
	Pregnancy Test Urine
		Stat, Stat, spec type = Urine
	Toxicology Screen DAU - MH/WH/JE
		T;N, Stat, Stat, Urine Random, spec type = Urine
	O and P Screen
		T;N, Stat, spec type = Stool
	Fecal Lactoferrin
		T;N, Stat, spec type = Stool
	Occult Blood - MH/WH/FH
		Stat, spec type = Stool
	Occult Blood Stool - JE
		spec type = Stool
	Acute Hepatitis Panel with Rflx to Hepatitis C Confirm
		T;N, Stat
	UA (Culture if Positive)
		T;N, Routine, Routine, spec type = Urine
	Culture Urine
		Stat, Urine
	Stool Pathogen Panel (PCR)
		T;N, Stat, spec type = Stool
		Includes targets for: Campylobacter, Salmonella, Shigella, Vibrio, Yersinia enterocolitica, Shiga Toxins 1 and 2, Norovirus and Rotavirus.(NOTE)*
Today's Lab
	CBC with Diff
		T;N, Routine, spec type = Blood
	INR - MH/WH/JE
		T;N, Routine, spec type = Blood
	D-Dimer - MH/WH/JE
		T;N, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Routine, spec type = Blood
	Magnesium Level
		T;N, Routine, spec type = Blood
	Phosphorus
		T;N, Routine, spec type = Blood
	TSH
		T;N, Routine, spec type = Blood
	Toxicology Screen DAU - MH/WH/JE
		Routine, Routine, spec type = Urine
	Pregnancy Test Urine
		Routine, Routine, spec type = Urine
	O and P Screen
		T;N, Routine, spec type = Stool
	Fecal Lactoferrin
		T;N, Routine, spec type = Stool
	Occult Blood Stool - MH/WH/FH
		T;N, Routine, spec type = Stool
	Toxigenic Clostridioides Difficile by EIA Reflex to PCR
		T;N, Routine, spec type = Stool
	Occult Blood Stool - JE
		T;N, Routine, spec type = Stool
	UA (Culture if Positive)
		T;N, Routine, Routine, spec type = Urine
	Stool Pathogen Panel (PCR)
		T;N, Routine, spec type = Stool
		Includes targets for: Campylobacter, Salmonella, Shigella, Vibrio, Yersinia enterocolitica, Shiga Toxins 1 and 2, Norovirus and Rotavirus.(NOTE)*
Tomorrow's Lab
	CBC with Diff
		T+1;0400, Routine, spec type = Blood
	Basic Metabolic Panel
		T+1;0400, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T+1;0400, Routine, spec type = Blood
	Magnesium Level
		T+1;0400, Routine, spec type = Blood
	Phosphorus
		T+1;0400, Routine, spec type = Blood
Diagnostic Tests

	Abd & Upright
		Stat, Abdominal Pain
	CT Abd Pelvis R/O Kidney Stone
		Stat, Renal Calculi
	CT Abd w/o Contrast
		Stat, Pain/ Abdominal
	CT Abd Pelvis for Appy
		Stat, Pain/ Abdominal
	CT Abd Pelvis w Contrast
		Stat, Pain/ Abdominal
	US Abd Complete
		Stat, Pain/ Abdominal
	US Abd Limited
		Stat, Pain/ Abdominal
	US Pelvis Complete Non OB
		Stat, Pain/ Pelvic
	US OB Transvaginal
		Stat, Pelvic Pain
IV Solutions
	Dextrose 5% with 0.45% NaCl
		1,000 mL, IV, 50 ml/hr
		1,000 mL, IV, 75 ml/hr
		1,000 mL, IV, 100 ml/hr
		1,000 mL, IV, 125 ml/hr
		1,000 mL, IV, 150 ml/hr
		1,000 mL, IV, 20 ml/hr
	Dextrose 5% with 0.45% NaCl w/KCl 20 mEq
		1,000 mL, IV, 50 ml/hr
		1,000 mL, IV, 75 ml/hr
		1,000 mL, IV, 100 ml/hr
		1,000 mL, IV, 125 ml/hr
		1,000 mL, IV, 150 ml/hr
		1,000 mL, IV, 20 ml/hr
	Sodium Chloride 0.9%
		1,000 mL, IV, 50 ml/hr
		1,000 mL, IV, 75 ml/hr
		1,000 mL, IV, 100 ml/hr
		1,000 mL, IV, 125 ml/hr
		1,000 mL, IV, 150 ml/hr
		1,000 mL, IV, 20 ml/hr
	Sodium Chloride 0.9% with KCl 20mEq
		1,000 mL, IV, 50 ml/hr
		1,000 mL, IV, 75 ml/hr
		1,000 mL, IV, 100 ml/hr
		1,000 mL, IV, 125 ml/hr
		1,000 mL, IV, 150 ml/hr
		1,000 mL, IV, 20 ml/hr
Medications
	Protonix
		40 mg, Tablet-Enteric-Coated, BY MOUTH, DAILY
		20 mg, Tablet-Enteric-Coated, BY MOUTH, DAILY
	pantoprazole IV
		40 mg, Injection, IV Push, Q24H
	Ambien
		5 mg, Tab, BY MOUTH, QHS, PRN, insomnia
Patient Care
	Resuscitation Status
		Full Code
		No Code
	Foley Catheter
		Foley, Insert
	GI Tube
		NG
Therapies
	Consult Occupational Therapy, Evaluate and Treat
		T;N, Reason to See: Evaluate and Treat
	Consult Physical Therapy, Evaluate and Treat
		T;N, Reason to See: Evaluate and Treat
Respiratory Therapy
	Pulse Oximetry Spot Check RT
		
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
Consults/Follow-up

	Consult Gastroenterologist
		
	Consult General Surgery
		
	Consult Infectious Disease

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

Adult C Diff Diagnosis and Initial Treatment
Laboratory

		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 11.00.9600.18953(NOTE)*
	Toxigenic Clostridioides Difficile by EIA Reflex to PCR
		T;N, Routine, spec type = Stool
Medications
		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 11.00.9600.18953(NOTE)*
		Choose 1(NOTE)*
	vancomycin oral
		125 mg, Capsule, BY MOUTH, Q6H, C difficile, 10 Day(s)
	fidaxomicin
		200 mg, Tab, By Mouth, Q12H, Other- type in, C difficle, 10 Day(s)
			Comment: (Restricted to ID & GI services)
		Initial Episode Fulminant (Hypotension or shock, ileus, megacolon)(NOTE)*
	vancomycin oral
		500 mg, Capsule, BY MOUTH, Q6H, C difficile
	metroNIDAZOLE IVPB
		500 mg, Injection-Premix, IVPB, Q8H, C difficile
		First recurrence choose 1(NOTE)*
	vancomycin oral
		125 mg, Capsule, BY MOUTH, Q6H, C difficile
	fidaxomicin
		200 mg, Tab, By Mouth, Q12H, Other- type in, C difficile, 10 Day(s)
			Comment: (restricted to ID and GI services) if vancomycin used for initial episode
		Second recurrence Consider ID or GI consult ( vancomycin tapering regimen, fidaxomycin, Fecal Microbiota Transplantation)(NOTE)*
Consults/Follow-up
	Pharmacy Consult
		assess that anti-diarrheal medications, laxatives and stool softeners are discontinued and assess for offending antibiotics and PPI's
	Consult Gastroenterologist
		Reason for Referral: C difficile
	Consult Infectious Disease
		Reason for Referral: C difficile
	Consult General Surgery
		Reason for Referral: C difficile

GI Cocktail Order Set
Medications
	Maalox Plus oral susp
		30 mL, Suspension, Oral, By Mouth, Once, STAT
			Comment: Administer with 15mL of Viscous Lidociane for GI cocktail.
	lidocaine Viscous 2% solution
		15 mL, Soln, By Mouth, Once, STAT
			Comment: Administer with 30mL of Maalox Plus oral susp for GI cocktail.

Peripheral Lock - Access
	sodium chloride 0.9% flush injectable soln
		10 mL Syringe IV PUSH BID
		10 mL, Syringe, IV PUSH, Q5MIN, PRN, IV line flush
	lidocaine 1% injectable solution (MH/WH/FH)
		0.1 mL, IntraDermal, Q1H, PRN, see comment
			Comment: For IV start
	sodium chloride bacteriostatic 0.9% injectable soln
		0.1 mL, Injection, IntraDermal, Q1H, PRN, see comment
			Comment: For IV start, use if patient has lidocaine allergy.
	Sodium Chloride 0.9% IVPB Flush
		25 mL, IVPB, Q1H, PRN, IV line flush, 5 min(s)
			Comment: Use if medication not compatible with primary line or there is no primary line;  infuse 25mL.
Patient Care
	Peripheral Lock-Insert
		T;N

Blood Culture Set
Laboratory
	.Blood Culture.
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
		Timed, spec type = Blood
		T+1;0400, Routine, spec type = Blood
	.Blood Culture
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
		Timed, spec type = Blood
		T+1;0400, Routine, spec type = Blood

PCA hydromorphone (Dilaudid)
IV Solutions
	Sodium Chloride 0.9%
		500 mL, IV, 20 ml/hr
			Comment: If no current IV fluid order.
Medications
		Standard protocol w/basal(NOTE)*
	Dilaudid Injectable
		0.5 mg, Injection, IV PUSH, Once, PRN, see comment, Routine, 2 hr
			Comment: May give as loading dose or if PCA pump not immediately available.
	HYDROmorphone 0.2 mg/mL PCA 30mL Standard IV
		Continuous Dose (mg/hr) 0 - 0.2 mg/hr, Patient Admin Bolus (mg) 0.1 - 0.2 mg, Lockout Interval (min) = 10, 4-hour Limit (mg) 3, Nurse Admin Bolus (mg) 0.2 mg breakthrough pain, Nurse Admin Bolus Freq 1 hr, 30 mL, PCA IV, PCA
			Comment: Adjust to patient's documented individual pain goal.  For continuous dosing, begin with no basal for mild/moderate pain; 0.1mg/hr for severe pain; adjust rate by 0.1mg/hr q30min up to a maximum of 0.2mg/hr as needed for moderate or severe pain (pain score>3) and down 0.1mg/hr q30 min as needed for mild or moderate.  DC basal rate if dose required is less than 0.1mg/hr (side effects present) and use patient controlled dosing only.  For patient controlled dose, start at 0.1mg for mild/moderate pain adjust by 0.1mg q30min up to a maximum of 0.2mg, For patient controlled dose, start at 0.2mg for severe pain and adjust by 0.1mg down q30 min as needed for mild or moderate pain. Dose adjustment of EITHER the continuous or patient administered dose may occur every 30 minutes, do not adjust both continuous or PCA dose at the same time (exception for comfort care patients)-  Stop PCA for 1 hour if patient develops respiratory depression (respiratory quality is shallow, respiratory rate is < or = 12 bpm), RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  Do not resume PCA unless RASS 0 to -1, RR > or = 12bpm and normal depth, alert.  Consider oxygen protocol.  -  When decreasing or resuming PCA infusion after holding, discontinue basal if running, and restart patient controlled dose at 0.1mg.-  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < or = 10 or RASS -3 to -5  and/or systolic blood pressure < 90mm Hg.  Do not resume PCA without MD order.
		6 mg, EVERY BAG
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
		Standard protocol NO basal(NOTE)*
	Dilaudid Injectable
		0.5 mg, Injection, IV Push, Once, PRN, see comment, Routine, 2 hr
			Comment: May give as loading dose or if PCA pump not immediately available.
	HYDROmorphone 0.2 mg/mL PCA 30mL Standard IV
		Continuous Dose (mg/hr) No basal rate, Patient Admin Bolus (mg) 0.1 - 0.2 mg, Lockout Interval (min) = 10, 4-hour Limit (mg) 3 mg, Nurse Admin Bolus (mg) 0.2 mg breakthrough pain, Nurse Admin Bolus Freq 1 hr, 30 mL, PCA IV, PCA
			Comment: STANDARD-NO BASAL.  .Adjust to patient's documented individual pain goal. Start patient controlled dose at 0.1mg for mild/moderate pain, and adjust by 0.1mg up to a maximum of 0.2mg or down q30min as needed for moderate or severe pain (pain score >3), Start patient controlled dose at 0.2mg for severe pain and adjust down by 0.1mg q30min as needed for mild/moderate pain.-  Stop PCA for 1 hour if patient develops respiratory depression (respiratory quality is shallow, respiratory rate is < or = 12 bpm), RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  Do not resume PCA unless RASS 0 to -1, RR > or = 12bpm and normal depth, alert.  Consider oxygen protocol.  -  When decreasing or resuming PCA infusion after holding, restart patient controlled dose at 0.1mg.-  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < or = 10 or RASS -3 to -5  and/or systolic blood pressure < 90mm Hg.  Do not resume PCA without MD order.
		6 mg, EVERY BAG
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
		High risk(NOTE)*
	Dilaudid Injectable
		0.3 mg, IV Push, Once, PRN, see comment, Routine, 2 hr
			Comment: May give as loading dose or if PCA pump not immediately available.
	HYDROmorphone 0.2 mg/mL PCA 30mL Standard IV
		Continuous Dose (mg/hr) No basal rate, Patient Admin Bolus (mg) 0.1 - 0.2 mg, Lockout Interval (min) = 15, 4-hour Limit (mg) 2 mg, Nurse Admin Bolus (mg) 0.2 mg breakthrough pain, Nurse Admin Bolus Freq 1 hr, 30 mL, PCA IV, PCA
			Comment: HIGH RISK PROTOCOL. Adjust to patient's documented individual pain goal. Start at 0.1mg and adjust by 0.1mg q30min to a maximum of 0.2mg as needed for moderate or severe pain (pain score >3). -  Stop PCA for 1 hour if patient develops respiratory depression (respiratory quality is shallow, respiratory rate is < or = 12 bpm), RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  Do not resume PCA unless RASS 0 to -1, RR > or = 12bpm and normal depth, alert.  Consider oxygen protocol.  -  When decreasing or resuming PCA infusion after holding,, and restart patient controlled dose at 0.1mg.-  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < or = 10 or RASS -3 to -5  and/or systolic blood pressure < 90mm Hg.  Do not resume PCA without MD order.
		6 mg, EVERY BAG
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
		Opiate tolerant(NOTE)*
	Dilaudid Injectable
		1 mg, Injection, IV Push, Once, PRN, see comment, Routine, 2 hr
			Comment: May give as loading dose or if PCA pump not immediately available.
	HYDROmorphone 0.2 mg/mL PCA 30mL Standard IV
		Continuous Dose (mg/hr) 0.3 - 0.6 mg/hr, Patient Admin Bolus (mg) 0.1 - 0.5 mg, Lockout Interval (min) = 10, 4-hour Limit (mg) 4 mg, Nurse Admin Bolus (mg) 0.3 mg breakthrough pain, Nurse Admin Bolus Freq 1 hr, 30 mL, PCA IV
			Comment: OPIATE TOLERANT PROTOCOL. Adjust to patient's documented individual pain goal. Start at 0.3mg/hr and adjust dose by 0.1mg/hr up to a maximum of 0.6mg/hr q30min as needed for moderate or severe pain (pain score >3) and down by 0.1mg/hr q30min as needed for mild or moderate pain; Patient controlled dose start at 0.2mg and increase by 0.1mg q30min up to a maximum of 0.5mg as needed for moderate or severe pain (pain score >3) or decrease by 0.1mg q30min as needed for mild or moderate pain. Dose adjustment of EITHER the continuous or patient administered dose may occur every 30 minutes do not adjust both continuous or PCA dose at the same time (exception for comfort care patients) - Stop PCA for 1 hour if patient develops respiratory depression (respiratory quality is shallow, respiratory rate is < or = 12 bpm), RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  Do not resume PCA unless RASS 0 to -1, RR > or = 12bpm and normal depth, alert.  Consider oxygen protocol.  -  When decreasing or resuming PCA infusion after holding, discontinue basal if running, and decrease patient controlled dose at 0.2mg.-  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < or = 10 or RASS -3 to -5  and/or systolic blood pressure < 90mm Hg.  Do not resume PCA without MD order.
		6 mg, EVERY BAG, 0.3 mg/hr
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
	Narcan
		0.1 mg, Injection, IV Push, Q5MIN, PRN, see comment
			Comment: Until desired response.  Follow with 10 mL NaCl Flush, for patients who are somnolent with minimal or no response to stimuli, RASS -3 to -5, or for respiratory rate less than or equal to 10/minute, notify physician while on PCA protocol.
Patient Care
	PCA Assessment
		T;N, Q15MIN, 4, Dose(s)/Time(s)
			Comment: Assessment to include vital signs, pain, RASS, resp rate, resp pattern, pump settings, and ETCO2 if appropriate.  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < 10 or systolic BP < 90
		T;N+60, Q1H, 4, Dose(s)/Time(s)
			Comment: Assessment to include vital signs, pain, RASS, resp rate, resp pattern, pump settings, and ETCO2 if appropriate. Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < 10 or systolic BP < 90
		T;N+420, Q2H-Sch
			Comment: Assessment to include vital signs, pain, RASS, resp rate, resp pattern, pump settings, and ETCO2 if appropriate. Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < 10 or systolic BP < 90
		T;N
			Comment: ongoing, with any patient controlled dose, basal rate change or nurse administered bolus. Assessment to include vital signs, pain, RASS, resp rate, resp pattern and pump settings. If resp rate <10, or SBP <90 reassess patient q15min x4, then q1h x4, then q2h.  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < 10 or systolic BP < 90
		T;N
	Notify MD
		T;N, if patient is on benzodiazepines (lorazepam, midazolam, diazepam etc.)
		T;N, if respirations </= 10, or  systolic BP < 90.
		T;N, if pain increases or unable to wean in 12 hr
		T;N, if ETCO2 greater than 50
	PCA Parameters
		T;N
			Comment: Stop PCA for 1 hour if patient develops respiratory depression (respiratory quality is shallow, respiratory rate is < or = 12 bpm), RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  Do not resume PCA unless RASS 0 to -1, RR < or = 12bpm and normal depth, alert.  Consider oxygen protocol.  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < or = 10 or RASS -3 to -5  and/or systolic blood pressure < 90mm Hg.  Do not resume PCA without MD order.
		T;N
			Comment: Do not initiate any PCA (continuous or patient administered doses) in patients with sleep apnea (OSA) without verbal verification from physician.  Basal (continuous) PCA dosing should not be used for patients with history of sleep apnea (OSA), or respiratory problems (lung disease, heart failure). Do not use patient controlled doses of PCA unless patient is fully able to understand and comply with instruction -this includes restricting use for patients with dementia, delirium, confusion. Start dosing at the lowest range possible for continuous and patient administered doses (exceptions comfort care patients, oncology patients routinely receiving opiates, chronic pain patient routinely receiving opiates), including starting with no basal rate.
	PCA weaning parameters
		T;N
			Comment: 1.  Administer oral opiate.2.  Provide patient education on weaning process3.  If a basal (continuous) rate is running, turn it off upon administration of oral opiate4.  Begin demand (patient controlled dose) wean 4hr after initial opiate dose.  Every 4hr decrease demand dose by 50% until adequate pain control is achieved (defined as a pain scale of <4 or meeting patient's goal for pain control).  Do not decrease demand below minimum dose in PCA protocol for patient controlled dosing (0.5mg morphine, 0.1mg hydromorphone)5.  If patient does not use demand dose in at least 4hr after receiving oral medication, discontinue PCA.6.  Notify MD if pain increases or unable to wean in 12hr.
Therapies
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
			Comment: RT, while on PCA

VTE Prophylaxis
Medications
	Lovenox
		40 mg, Syringe, SUBCUTANEOUS, DAILY, T;N
			Comment: (CrCl>30) Pharmacy to adjust dose based on pt weight. VTE Prophylaxis
		40 mg, Syringe, SUBCUTANEOUS, DAILY, T;N+480
			Comment: (CrCl>30) Start 8 hours after admission. Pharmacy to adjust dose based on pt weight. VTE Prophylaxis
		40 mg, Syringe, SUBCUTANEOUS, DAILY, T+1;0900
			Comment: (CrCl>30) Pharmacy to adjust dose based on pt weight. VTE Prophylaxis
	HEParin 5000 units/mL SUBCUTANEOUS
		5,000 units, Injection, SUBCUTANEOUS, Q8H-Sch, T;N
			Comment: VTE Prophylaxis
		5,000 units, Injection, SUBCUTANEOUS, Q8H-Sch, T;N+480
			Comment: Start 8 hours after admission. VTE Prophylaxis
		5,000 units, Injection, SUBCUTANEOUS, Q8H-Sch, T+1;0600
			Comment: VTE Prophylaxis
Patient Care
		Sequential Compression Device and Anti Embolism Device orders will not suppress the VTE Advisor(NOTE)*
	Sequential Compression Device
		T;N, Apply, Once
	Anti Embolism Stockings
		T;N, Apply, Once
			Comment: knee high
	VTE Prophylaxis Contraindication
		High Risk of Bleeding
		Procedure Planned
		ASA order meets prophylaxis requirement
		If patient is low risk or further evaluation needed, complete advisor:(NOTE)*
	VTE Advisor
		Medical

Pain Constipation Nausea Protocol </= to 65 EKM
Medications
		Select only one medication in each category(NOTE)*
Mild Pain
	Tylenol
		650 mg, Tab, By Mouth, Q4H, PRN, see comment
			Comment: discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient
		650 mg, Suppository, RECTALLY, Q6H, PRN, see comment
			Comment: discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient
	ibuprofen
		600 mg, Tab, By Mouth, Q6H, PRN, pain-mild
			Comment: pain rating 1-3
		800 mg, Tab, By Mouth, Q8H, PRN, pain-mild
			Comment: pain rating 1-3
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-mild
			Comment: pain rating 1-3
	Percocet 5 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-mild
			Comment: pain rating 1-3
	Dilaudid Injectable
		0.2 mg, Injection, IV Push, Q2H, PRN, pain-mild
			Comment: for pain rating 1-3 and if NPO
	morphine  IV
		2 mg, Syringe, IV Push, Q2H, PRN, 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, 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, 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, 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.
	Percocet 5 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, 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.
	Percocet 7.5 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, 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.
	Percocet 10 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, 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.
	Roxicodone
		5 mg, Tab, By Mouth, Q4H, PRN, 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, pain-moderate
			Comment: Pain rating 4-6
	Dilaudid Injectable
		0.2 mg, Injection, IV Push, Q2H, PRN, 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, 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, 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, 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, pain-moderate, 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, pain-severe
			Comment: Pain rating 7-10
	acetaminophen-hydrocodone 325 mg-7.5 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Percocet 5 mg-325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Percocet 7.5 mg-325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Percocet 10 mg-325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Roxicodone
		10 mg, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	morphine  oral immediate release
		30 mg, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Dilaudid 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, 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, pain-severe
			Comment: For pain rating 7-10 if NPO
		0.8 mg, Injection, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10 if NPO
		1 mg, Injection, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10 if NPO
	morphine  IV
		4 mg, Syringe, IV Push, Q2H, PRN, 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, 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, IV Push, Q6H, PRN, 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.
	Reglan
		10 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron and phenothiazine ineffective; avoid in patients > 65 y/o.
		10 mg, Injection, IM-Intramuscular, Q6H, PRN, 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.

hs Troponin T - MH/WH/JE
Laboratory
	hs Troponin T - MH/WH/JE
		Stat, spec type = Blood
		T;N+120, Timed, spec type = Blood
		T;N+360, Timed, spec type = Blood

hs Troponin I - FH (Stat and 2hr and 6hr)
	hs Troponin I - FH
		T;N, Stat, spec type = Blood
		T;N+120, Timed, spec type = Blood
		T;N+360, Timed, spec type = Blood

Insulin Sliding Scale - NovoLOG
	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.

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 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 pain-moderate
			Comment: For pain rating 4-6
	traMADol
		25 mg, Tab, By Mouth, Q6H, PRN 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.
	Dilaudid Injectable
		0.2 mg, Injection, IV Push, Q4H, PRN 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 pain-severe
			Comment: For pain rating 7-10.
	traMADol
		50 mg, Tab, By Mouth, Q6H, PRN 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.
	Dilaudid Injectable
		0.4 mg, Injection, IV Push, Q2H, PRN 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 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 discomfort
			Comment: Apply to affected area.
	menthol-methyl salicylate topical
		1 appl, Cream, TOPICAL, TID, PRN 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 constipation
			Comment: If other agents ineffective or if patient NPO.
	Fleet Enema 19 gm-7 gm rectal enema
		1 EA, Enema, RECTALLY, Q12H, PRN 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 nausea and/or vomiting
		4 mg, Injection, IV Push, Q6H, PRN 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