Unique Plan Description: GYNONC Enhanced Recovery Major/Abdominal Post-Op EKM
Plan Selection Display: GYNONC Enhanced Recovery Major/Abdominal Post-Op
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2017-02-27 11:30:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2023-11-14 15:43:27
Available at all facilities: Yes

GYNONC Enhanced Recovery Major/Abdominal Post-Op E
Vital Signs
	Vital Signs
		Routine post op
Activity
	Up in Chair
		T;N, TID
	Ambulate
		With assistance, TID
			Comment: start day of surgery
Diet
	Regular Diet
		T;N
	Oral Supplement
		Impact Advanced Recovery, AM and PM
Laboratory
	CBC with Diff
		T+1;0400, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T+1;0400, Routine, spec type = Blood
	Basic Metabolic Panel
		T+1; 0400, Routine, spec type = Blood
	Glucose POC - RN
		Q6H
IV Solutions
	Dextrose 5% with 0.45% NaCl w/KCl 20 mEq
		1,000 mL, IV, 40 ml/hr
	Discontinue IV Fluids
		T+1;0800
Medications
	Colace
		100 mg Capsule BY MOUTH BID
	Milk of Magnesia 8% oral suspension
		30 mL, Suspension, By Mouth, BID
	acetaminophen 10 mg/mL intravenous solution
		1,000 mg, Solution-Injection, IVPB, Q6H, PRN for see comment, T;N+360
			Comment: Administer only if unable to take oral or rectal formulation; convert to oral medication as soon as possible and discontinue IV order, start 6 hours after any pre-op/intra-op dose.
	Tylenol
		650 mg, Tab, By Mouth, Q4H, T;N
			Comment: Please be advised that the nonnarcotic pain meds are scheduled and not PRN.  Please give to the patients even if not in pain, do not give both oral and IV APAP, start 6 hr after any pre-op/intra-op dose.
	ketorolac injectable
		15 mg, Injection, IV PUSH, Q6H, T;N
			Comment: Do not give if systolic blood pressure is < 90mm Hg or if serum creatinine is greater than 1.5mg/dL (or creatinine clearance < 50ml/min).  Notify MD of any dose not given with a note in the chart Comment: Please be advised that the nonnarcotic pain meds are scheduled and not PRN.  Please give to the patients even if not in pain. Start 12 hours after any preoperative/intraoperative NSAID
		30 mg, Injection, IV PUSH, Q6H, T;N+720, 4 Dose(s)/Time(s)
			Comment: Do not give if systolic blood pressure is < 90mm Hg or if serum creatinine is greater than 1.5mg/dL (or creatinine clearance < 50ml/min).  Notify MD of any dose not given with a note in the chart Comment: Please be advised that the nonnarcotic pain meds are scheduled and not PRN.  Please give to the patients even if not in pain. Start 12 hours after any preoperative/intraoperative NSAID
	ibuprofen
		800 mg, Tab, By Mouth, Q8H, see comment, T;N
			Comment: Do not give if systolic blood pressure is < 90mm Hg or if serum creatinine is greater than 1.5mg/dL (or creatinine clearance < 50ml/min).  Notify MD of any dose not given with a note in the chart.  Please be advised that the nonnarcotic pain meds are scheduled and not PRN.  Please give to the patients even if not in pain. Please give on scheduled basis. Start 6 hours after IV ketorolac ends
	traMADol
		25 mg, Tab, By Mouth, Q6H, PRN, pain-mild
		50 mg, Tab, By Mouth, Q6H, PRN, pain-moderate
		If the patient has received an intrathecal/epidural anesthesia will order PO/IV opiods for the first 24hrs.(NOTE)*
	oxyCODONE
		5 mg, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: for pain rated 4 or greater and greater than patient stated comfort goal after scheduled medications given. Give for pain rated 4-6.
	Dilaudid Injectable
		0.5 mg, Injection, IV PUSH, Q2H, PRN, pain-severe
			Comment: for pain rating 7-10, use 0.4mg if age over 70.
	naloxone
		0.4 mg, Injection, IV PUSH, Q5MIN, 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 8 or less per minute.  RN may administer naloxone prior to contacting MD.  Notify MD immediately upon administration of naloxone.
Antiemetics
	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
	Reglan
		10 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron, phenothiazine or other anti-nausea medications ineffective. Avoid in patients >65 yrs
		10 mg, Injection, IM-Intramuscular, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron, phenothiazine or other anti-nausea medications ineffective Avoid in patients >65 yrs
	Benadryl
		12.5 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron, ineffective; avoid in patients > 65yo
	prochlorperazine
		10 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures;
Patient Care

	Resuscitation Status
		Full Code
		No Code
	Foley Catheter
		Foley, To dependent drainage, Pt. undergoing abdominal/pelvic surgery
	Do Not
		Remove foley
	Discontinue Urinary Catheter
		On arrival to unit
	VTE Advisor
		Gynecologic surgery
	Notify MD
		For Urine Output less than 10ml in 1 hr.
	Intake and Output
		Q4H
			Comment: record urine output q4h
	Patient Education
		T;N, Educate on lovenox injections for up to 28 days if malignant
	Dressing Care
		T+1;0600
			Comment: remove dressing post op day 1
	Patient to Chew Gum
		To increase GI motility
	May Shower
		use CHG soap or wipes
	Incentive Spirometer
		Q1H, Instructions, 10x per hour
Consults/Follow-up
	Consult Inpatient Palliative Care
		
	Consult Occupational Therapy, Evaluate and Treat
		Reason to See: Activities of Daily Living
	Consult Physical Therapy, Evaluate and Treat
		For: Progressive Ambulation
	Consult Dietitian
		T;N
			Comment: To provide high protein options prior to discharge

Nicotine Replacement/Tobacco Cessation
Medications
		Nicotine Replacement Warnings (Physician to determine risk vs benefit): Severe/life-threatening arrhythmias, severe/worsening angina pectoris, immediate postmyocardial infarction period (2 weeks), accelerated hypertension(NOTE)*
		Precautions:  pregnancy, breastfeeding; PUD, CAD, PVD, HTN, Hepatic disease, severe renal impairment, diabetes, previous allergy, sensitivity, or reaction to nicotine patch or gum; microvascular free flaps (immediate postop) and arthrodesis.(NOTE)*
		If patient is breastfeeding or pregnant, consider using OB Nicotine/Tobacco Cessation(NOTE)*
	nicotine
		2 mg, Gum, TransMUCOSAL, Q1H, PRN, smoking cessation
			Comment: <25 cigarettes/day; max 24 pieces/24 hours
		4 mg, Gum, TransMUCOSAL, Q1H, PRN, smoking cessation
			Comment: >25 cigarettes/day; max 24 pieces/24 hours
	Ativan
		0.5 mg, Tab, By Mouth, Q8H, PRN, anxiety
		1 mg, Tab, By Mouth, Q8H, PRN, anxiety
	Xanax
		0.25 mg, Tab, BY MOUTH, TID, PRN, anxiety
		0.5 mg Tab BY MOUTH TID, PRN anxiety
	Wellbutrin SR 150 mg/12 hours oral tablet, extended release
		150 mg, Tablet-Extended-Release, By Mouth, DAILY, 3 Day(s)
		150 mg, Tablet-Extended-Release, By Mouth, BID, 11 week(s)
	triamcinolone 0.1% topical cream
		1 appl, Cream, TOPICAL, TID, PRN, see comment
			Comment: for skin irritation from patch.
		nicotine 14 mg/24 hr Patch - For patients who smoke <10 cigarettes/day, 1 cigar per day, or uses < 1 can/pouch per week, but daily use, patients weighing less than 100lb, or patients with a history of cardiovascular disease.(NOTE)*
	nicotine
		14 mg, Patch, TOPICAL, DAILY
	nicotine Patch Removal
		Patch Removal, Patch, TOPICAL, DAILY, T+1;0900
	Medication patch site check
		T;N+720, Q12H
		nicotine 21 mg/24 hr Patch - For patients who smoke > 10 cigarettes/day; more than 1 cigar per day, or uses > 1 can or pouch/week). Weight>100lb. Do not use 21 mg for patients with history of cardiovascular disease.(NOTE)*
	nicotine
		21 mg, Patch, TOPICAL, DAILY
	nicotine Patch Removal
		Patch Removal, Patch, TOPICAL, DAILY, T+1;0900
	Medication patch site check
		T;N+720, Q12H
		nicotine 7 mg/24 hr Patch - For patients who don't use nicotine daily(NOTE)*
	nicotine
		7 mg, Patch, TOPICAL, DAILY
	nicotine Patch Removal
		Patch Removal, Patch, TOPICAL, DAILY, T;N+1440
	Medication patch site check
		T;N+720, Q12H

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

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

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