Unique Plan Description: Hospital Admission EKM
Plan Selection Display: Hospital Admission
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2020-04-22 18:58:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2025-06-25 09:50:38
Available at all facilities: Yes

Hospital Admission EKM
Admit/Discharge/Transfer
	Admit to Inpatient Status
		T;N, Anticipated LOS 2 midnight or more
	Admit to Critical Care Inpatient Status (MH)
		T;N, Anticipated LOS 2 midnight or more
	Admit to Observation Status
		T;N
	Admit to Critical Care Observation Status (MH)
		T;N
Vital Signs
	BP and Pulse, Orthostatic
		T;N, Once
		T;N, DAILY
		T;N, BID
	Vital Signs
		Per protocol, if temp >101, obtain blood cultures, UA (culture if positive), chest x-ray if not done in past 48 hours.
		Per protocol
		T;N, Routine post op
		T;N, Q1H
		T;N, Q2H-Sch
		T;N, Q4H-Sch
Activity
	Activity-Up as Tolerated
		T;N
		T;N
			Comment: With assistance
	Up in Chair
		T;N, TIDWM
	Ambulate
		T;N, With assistance, TID
		T;N, In hall, TID
		T;N, In hall, QID
	Up with Assistance
		
	Activity-Bedside Commode
		
	Bedrest
		T;N
Diet
	Regular Diet
		T;N
	NPO
		T;N, After Midnight
		T;N
	Diabetic Diet
		T;N, Calorie Level 2200 kcal
		T;N, Calorie Level 1500 kcal
		T;N, Calorie Level 2000 kcal
		T;N, Calorie Level 1800 kcal
	Clear Liquid Diet
		T;N
	Blenderized Liquid (Full) Diet
		T;N
	Sodium Restricted Diet
		T;N
			Comment: low sodium
	Renal Diet
		T;N
	Cardiac Diet
		T;N
	Consult Dietitian
		T;N
Laboratory
	Basic Metabolic Panel
		Stat, spec type = Blood
	CBC with Diff
		Stat, spec type = Blood
	Hemogram
		Stat, spec type = Blood
	Comprehensive Metabolic Panel
		Stat, spec type = Blood
	hsCRP
		Stat, spec type = Blood
	TSH
		Stat, spec type = Blood
	Lactate
		Stat, spec type = Blood
	hs Troponin T
		Stat, spec type = Blood
		Timed, spec type = Blood
		T;N+300, Routine, spec type = Blood
	Type and Screen (No Product on hold)
		Stat, spec type = Blood
	UA (Culture if Positive)
		Stat, Stat, spec type = Urine
	INR - MH/WH/JE
		T+1;0400, Routine, Q24H, spec type = Blood
	ProBNP
		T;N, Stat, spec type = Blood
	Procalcitonin
		Add On, spec type = Blood
	Magnesium Level
		T;N, Add On, spec type = Blood
	Phosphorus
		T;N, Add On, spec type = Blood
	Hemoglobin and Hematocrit
		T;N, Stat, spec type = Blood
	PT - MH/WH/JE
		T;N, 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
		T;N, Stat, spec type = Blood
	Partial Thromboplastin Time (PTT) - FH
		T;N, Stat, spec type = Diagnostic Blood
	Blood Gases Arterial (ABG) - MH/WH/JE
		T;N, Stat, spec type = Blood
	Blood Gases Arterial (ABG) - FH
		T;N, Stat, spec type = Blood
	Occult Blood Stool - MH/WH/FH
		T;N, Routine, spec type = Stool
	Occult Blood Stool - JE
		T;N, Routine, spec type = Stool
Tomorrow's Lab
	Basic Metabolic Panel
		T+1;0400, Routine, spec type = Blood
	CBC with Diff
		T+1;0400, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T+1;0400, Routine, spec type = Blood
	Hemoglobin and Hematocrit
		T+1;0400, Routine, spec type = Blood
	Hemoglobin A1C
		T+1;0400, Routine, spec type = Blood
	INR - MH/WH/JE
		T+1;0400, Routine, spec type = Blood
	Prothrombin Time (PT) - FH
		T+1;0400, Routine, spec type = Diagnostic Blood
		T+1;0400, Routine, spec type = Therapeutic Blood
	Lipid Panel
		T+1;0400, Routine, spec type = Blood
	hs Troponin T
		T+1;0400, Routine, spec type = Blood
	Lactate
		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

	Echo w Doppler resting
		Routine, Indication: Congestive heart failure
		Routine, Indication: Myocardial Infarction (Acute)
		Routine
		Stat, Indication: Congestive heart failure
		Stat, Indication: Myocardial Infarction (Acute)
		Stat
Radiology
	Chest 1 View
		T+1;0600, Routine
			Comment: At Bedside
		Stat, Once
	Chest 2 View
		T+1;0600, Routine
		Stat, Once
	Abd & Upright
		T+1;0600, Routine
		Stat, Once
Diagnostics
	ECG
		T;N
			Comment: if not done in ED
		Routine, Indication: Chest Pain of Uncertain Etiology
		Routine, Indication: Arrhythmia
		Stat, Indication: Chest Pain of Uncertain Etiology
		Stat, Indication: Arrhythmia
IV Solutions

	Sodium Chloride 0.9% with KCl 20mEq
		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
	Sodium Chloride 0.9%
		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
	Dextrose 5% with 0.9% NaCl
		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
	Dextrose 5% with 0.45% NaCl w/KCl 20 mEq
		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
	Dextrose 5% with 0.45% NaCl
		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
	Dextrose 5% with 0.9% NaCl w/KCl 20 mEq
		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
	Lactated Ringers Injection
		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
	Dextrose 5% in Lactated Ringers
		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
Bolus
	Sodium Chloride 0.9% Intravenous Solution (Bolus)
		250 mL, IV, 1 hr, Bolus, Total Volume = 250
		500 mL, IV, 1 hr, Bolus, Total Volume = 500
		1,000 mL, IV, 1 hr, Bolus, Total Volume = 1,000
		2,000 mL, IV, Bolus
	Lactated Ringers Intravenous (Bolus)
		250 mL, IV, 1 hr, Bolus, Total Volume = 250
		500 mL, IV, 1 hr, Bolus, Total Volume = 500
		1,000 mL, IV, 1 hr, Bolus, Total Volume = 1,000
		2,000 mL, IV, Bolus
Medications

	acetaminophen
		650 mg, Tab, By Mouth, Q6H, PRN for pain-mild
		1,000 mg, Tab, By Mouth, Q8H
		1,000 mg, Solution-Injection, IVPB, Q8H, PRN for pain-mild
	simethicone
		80 mg, Tablet-Chew, By Mouth, Q6H, PRN gas
	hydrALAZINE
		10 mg, Injection, IV Push, Q6H, PRN systolic blood pressure > (see comment)
			Comment: 190mmHg or diastolic >110 (first choice)   Place staff to provider communication note if using prn agents more than 2 times in 24 hr period.
	labetalol  injection
		10 mg 2 mL, Injection, IV Push, Q2H, PRN, systolic blood pressure > (see comment)
			Comment: ....190mmHg or diastolic >110 (use second if no response from first choice after 1 hour, do not use if HR <60)  Place staff to provider communication note if using prn agents more than 2 times in 24 hr period.
	cloNIDine
		0.1 mg, Tab, BY MOUTH, Q4H, PRN for systolic blood pressure > (see comment)
			Comment: ....190mmHg or diastolic >110. May use if no IV access. Place staff to provider communication note if using prn agents more than 2 times in 24 hr period.
	Pepcid
		20 mg, Injection, IV Push, Q12H
		20 mg, Tab, By Mouth, Q12H
	Tums
		500 mg, Tablet-Chew, By Mouth, QID, PRN for dyspepsia
	melatonin
		5 mg, Tab, By Mouth, QHS, PRN insomnia
	Ocean 0.65% nasal spray
		1 spray, Solution, NARE, EACH, Q4H, PRN for dryness
	ondansetron
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN, nausea
		4 mg, Injection, IV PUSH, Q6H, PRN, nausea
	LORazepam
		0.5 mg, Tab, BY MOUTH, Q6H, PRN for anxiety
	nicotine
		2 mg, Gum, BY MOUTH, Q1H, PRN for smoking cessation
		4 mg, Gum, BY MOUTH, Q1H, PRN for smoking cessation
Patient Care
	Glucose POC - RN
		T;N, QIDACHS
		T+1;0300, Q24H
	Neurological Assessment-Focused
		T;N, Q2H-Sch
		T;N, Q4H-Sch
	Notify MD
		T;N, if HR <60 or >120, SBP <90 or >180, DBP >100, SPO2 <90%
	Resuscitation Status
		T;N, Full Code
		T;N, No Code
	Straight Catheter
		T;N, unable to void
			Comment: Insert PRN PVR>250 or bladder scan >400 and unable to void. If 3rd catheterization required, enter order for Foley catheter insert, once and insert foley catheter.
	Seizure Precautions
		T;N
			Comment: Initiate
	Incentive Spirometer
		T;N, Q2H
		T;N, Q1H
	Patient Education
		T;N, Instructions: Provide patient with hospitalist brochure
	Cardiac Telemetry Monitoring
		T;N
	Communication to HOSPITAL RN
		
Therapies
	Consult Physical Therapy, Evaluate and Treat
		T;N, Reason to See: Evaluate and Treat
	Consult Occupational Therapy, Evaluate and Treat
		T;N, Reason to See: Evaluate and Treat
	Consult Speech Language (MH), Evaluate and Treat
		
	Consult Respiratory Therapy-Assess and Treat
		T;N
	Consult Speech Language (FH), Evaluate and Treat
		
	Bronchodilator Therapy per Respiratory Protocol (FH)
		T;N
	albuterol CFC free 90mcg/inh inh aerosol
		2 puff, Aerosol, Inhalation, QID
	Atrovent HFA 17 mcg/inh inhalation aerosol
		2 puff, Aerosol, Inhalation, QID
	albuterol-ipratropium 2.5 mg-0.5 mg/3 mL inhalation solution
		3 mL, Solution-Nebulization, NEBULIZED, QID
		3 mL, Solution-Nebulization, NEBULIZED, Q4H, PRN wheezing
	EZ PAP Treatment
		T;N
	Evaluate for home CPAP
		
Consults/Follow-up
	Consult Cardiologist
		
	Consult Cardio-Thoracic Surgery
		
	Consult Colorectal Surgery
		
	Consult Diabetes Educator
		Needs Diabetic Assessment
	Consult EP Cardiologist
		
	Consult Gastroenterologist
		
	Consult General Surgery
		
	Consult Infectious Disease
		
	Consult Nephrologist
		
	Consult Neurosurgery
		
	Consult Neurologist
		
	Consult Tele Neurology (JEFH)
		
	Consult Oncologist
		
	Consult Orthopedics
		
	Consult Pain Management, Inpatient MH/WH
		
	Consult Inpatient Palliative Care
		
	Consult Physical Medicine (Rehab)
		
	Consult Psychiatrist
		
	Consult Pulmonologist
		
	Consult Social Work
		T;N, Discharge Planning
	Consult Urology
		
	Consult Vascular Surgeon
		
	Consult Wound Care
		
	Smoking Cessation Education RT (FH)
		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

Tube Feeding Orders
Diet

	Tube Feeding
		T;N, Continuous
			Comment: Change the enteral feed tubing every 24 hours or as ordered.
	Tube Feeding Rate Change
		T;N, Increase to goal rate per dietitian recommendations. Discontinue TF Rate Change order once goal is reached
	Tube Feeding - Instill
		Tap water, 30 ml, Q4HR
Laboratory
	Basic Metabolic Panel
		T+1;0400, Routine, Q24H, 5, Day(s), spec type = Blood
			Comment: (Tube Feeding Orders)
		T;N, Routine, spec type = Blood
			Comment: (Tube Feeding Orders)
		T+10;0400, Routine, Q7D-Lab, spec type = Blood
			Comment: (Tube Feeding Orders)
	Magnesium Level
		T;N, Routine, spec type = Blood
			Comment: (Tube Feeding Orders)
		T+1;0400, Routine, Q24H, 5, Day(s), spec type = Blood
			Comment: (Tube Feeding Orders)
		T+10;0400, Routine, Q7D-Lab, spec type = Blood
			Comment: (Tube Feeding Orders)
	Phosphorus
		T;N, Routine, spec type = Blood
			Comment: (Tube Feeding Orders)
		T+1;0400, Routine, Q24H, 5, Day(s), spec type = Blood
			Comment: (Tube Feeding Orders)
		T+10;0400, Routine, Q7D-Lab, spec type = Blood
			Comment: (Tube Feeding Orders)
Diagnostic Tests
	Chest 1 View
		T;N, Routine, Tube Placement F/U
			Comment: Before initial feeding
Medications
	Dulcolax
		10 mg, Suppository, RECTALLY, DAILY, PRN, if no BM, T;N
			Comment: if no BM for 3 days.
	Reglan
		10 mg, Injection, IV Push, Q6H, PRN, see comment, T;N
			Comment: if holding tube feeding for residual.
		10 mg, Injection, IV Push, Q8H, see comment, T;N
			Comment: if holding tube feeding for residual.
	thiamine
		100 mg, Tab, NASOGASTRIC, DAILY, duration: 7 Day(s)
Patient Care
	Tube Feeding Residual Check
		T;N, hold feeding if gastric residual is greater than 500 ml
			Comment: After 4 hours, restart at previous rate if residual is acceptable. If the problem is not resolved, continue to hold for 4 hours and recheck. Residuals will not be checked for post pyloric feeding tube, or feeding tubes.
	Notify MD
		T;N, If residuals continue to be unacceptable after 8 hours of holding tube feeding.
	Discontinue IV Fluids
		T;N
			Comment: When tube feeding reaches goal rate
Consults/Follow-up
	Consult Dietitian
		T;N, Regarding: Tube feeding

nicotine 14 mg/24 hr Patch
Medications
	nicotine
		14 mg, Patch, TOPICAL, DAILY
	nicotine Patch Removal
		Patch Removal, Patch, TOPICAL, DAILY, T+1;0900
Patient Care
	Medication patch site check
		T;N+720, Q12H-Sch

nicotine 21 mg/24 hr Patch
Medications
	nicotine
		21 mg, Patch, TOPICAL, DAILY
	nicotine Patch Removal
		Patch Removal, Patch, TOPICAL, DAILY, T+1;0900
Patient Care
	Medication patch site check
		T;N+720, Q12H-Sch

nicotine 7 mg/24 hr Patch
Medications
	nicotine
		7 mg, Patch, TOPICAL, DAILY
	nicotine Patch Removal
		Patch Removal, Patch, TOPICAL, DAILY, T;N+1440
Patient Care
	Medication patch site check
		T;N+720, Q12H-Sch

Constipation Protocol
Medications
	MiraLax oral powder for reconstitution
		17 gm, Packet, BY MOUTH, Q12H, PRN, constipation
			Comment: Mix in 6 oz of 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, DAILY, PRN, constipation
			Comment: If bisacodyl ineffective
Patient Care
	Notify MD
		if no results from enema.
	Enema-Administer
		T;N, Tap water, Q12H, PRN, constipation
			Comment: if suppository ineffective

Peripheral Lock - Access
Medications
	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
		T+1;0400, Routine, spec type = Blood
	.Blood Culture
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
		T+1;0400, Routine, spec type = Blood

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

Acute Alcohol Withdrawal
Vital Signs
	Vital Signs
		every 4 hours if alcohol withdrawal score is 1-5, every 2 hours if alcohol withdrawal score is 6-10, every 1 hour if alcohol withdrawal score >11. Reassess alcohol withdrawal score with each set of vital signs.
Laboratory
Today's Lab
	Comprehensive Metabolic Panel
		Stat, spec type = Blood
	CBC with Diff
		Stat, spec type = Blood
	GGT
		Stat, spec type = Blood
	Magnesium Level
		Stat, spec type = Blood
	Phosphorus
		Stat, spec type = Blood
	Ethanol Level
		Stat, spec type = Blood
		T;N+720, Routine, spec type = Blood
	Toxicology Screen DAU
		T;N, Stat, spec type = Urine
IV Solutions

	Banana Bag IV
		100 mg, EVERY BAG
		1,000 mL, EVERY BAG
		1 mg, EVERY BAG
		10 mL, IVPB, Once, Routine, 125 ml/hr, T;N, duration: 1 Dose(s)/Time(s)
Medications
		chlordiazePOXIDE Taper(NOTE)*
	chlordiazePOXIDE
		25 mg, Capsule, BY MOUTH, QID, 3 Day(s)
		10 mg, Capsule, BY MOUTH, QID, T+3;N, duration: 3 Day(s)
		5 mg, Capsule, BY MOUTH, QID, T+6;N, duration: 3 Day(s)
		LORazepam Taper(NOTE)*
	LORazepam
		2 mg, Tab, By Mouth, Q6HAWAKE, T;N, duration: 3 Day(s)
			Comment: Hold if sleeping
		1 mg, Tab, By Mouth, Q6HAWAKE, T+3;N, duration: 3 Day(s)
			Comment: Hold if sleeping
		0.5 mg, Tab, By Mouth, Q6HAWAKE, T+6;N, duration: 3 Day(s)
			Comment: Hold if sleeping
		Discontinue previous PRN Ativan (lorazepam) orders.(NOTE)*
		1 mg, Tab, By Mouth, Once, NOW
		2 mg, Tab, By Mouth, Once, NOW
		     AWS score of 1-5 (LORazepam)(NOTE)*
		1 mg, Tab, By Mouth, Q4H, PRN for AWS score of 1-5
			Comment: Do Not Give if AWS score ONLY caused by tremors or nausea/vomiting.
		1 mg, Injection, IV Push, Q4H, PRN for AWS score of 1-5
			Comment: Do Not Give if AWS score ONLY caused by tremors or nausea/vomiting
		     AWS score of 6-10 (LORazepam)(NOTE)*
		2 mg, Tab, By Mouth, Q2H, PRN for AWS score of 6-10
			Comment: Watch for delierium; monitor respiratory status.
		2 mg, Injection, IM-Intramuscular, Q2H, PRN for AWS score of 6-10
			Comment: Watch for delierium; monitor respiratory status.
		2 mg, Injection, IV Push, Q2H, PRN for AWS score of 6-10
			Comment: Watch for delierium; monitor respiratory status.
		     AWS score >10 (LORazepam)(NOTE)*
		2 mg, Tab, By Mouth, Q1H, PRN for AWS score >10
			Comment: Watch for delirium; monitor respiratory status.
		2 mg, Injection, IM-Intramuscular, Q1H, PRN for AWS score >10
			Comment: Watch for delirium; monitor respiratory status.
		2 mg, Injection, IV Push, Q1H, PRN for AWS score >10
			Comment: Watch for delirium; monitor respiratory status.
	Notify MD
		Notify Provider if Lorazepam dose exceeds 12mg in 12hr or 24mg in 24hr
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	risperiDONE
		0.5 mg, Tab, By Mouth, TID, PRN for agitation
	haloperidol  Injectable
		2 mg, Injection, IV Push, Q4H, PRN for agitation
			Comment: If unable to administer antipsychotic by mouth
		5 mg, Injection, IV Push, Q4H, PRN for agitation
			Comment: If unable to administer antipsychotic by mouth
		2 mg, Injection, IM-Intramuscular, Q4H, PRN for agitation
			Comment: If unable to administer antipsychotic by mouth or IV
		5 mg, Injection, IM-Intramuscular, Q4H, PRN for agitation
			Comment: If unable to administer antipsychotic by mouth or IV
		Other(NOTE)*
	famotidine
		20 mg, Tab, By Mouth, BID, PRN for indigestion
	cloNIDine
		0.1 mg, Tab, By Mouth, Q1H, PRN for see comment
			Comment: For SBP>150 mmHg to a maximum of 0.6 mg/24 hours. Contact MD if ineffective
	folic acid
		1 mg, Tab, BY MOUTH, DAILY, 30 Day(s)
	thiamine
		100 mg, Tab, By Mouth, DAILY, duration: 5 Day(s)
		100 mg, Injection, IV Push, DAILY, duration: 5 Day(s)
	multivitamin Oral Tablet
		1 TAB Tab BY MOUTH DAILY
	ondansetron
		4 mg, Injection, IV PUSH, Q6H, PRN for nausea and/or vomiting
			Comment: use if patient unable to take PO
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN for nausea and/or vomiting
	traZODone
		100 mg, Tab, By Mouth, QHS, PRN, insomnia
			Comment: Do Not Give after 3:00am or during patient's normal wake hours
	nicotine
		2 mg, Gum, By Mouth, Q1H, PRN for smoking cessation
		4 mg, Gum, By Mouth, Q1H, PRN for smoking cessation
		7 mg, Patch, TOPICAL, DAILY
		14 mg, Patch, TOPICAL, DAILY
		21 mg, Patch, TOPICAL, DAILY
	nicotine Patch Removal
		Patch Removal, Patch, TOPICAL, DAILY, T;N+1440
Patient Care
	Cardiac Telemetry Monitoring
		Telemetry Indications: Other
	Medication patch site check
		T;N+720, Q12H-Sch

Arrhythmia [EBM] (FH)
Laboratory
Chemistry
		During follow-up, serum creatinine, potassium, and magnesium concentrations should be monitored periodically because proarrhythmia is increased by renal insufficiency, which can lead to drug accumulation, hyperkalemia, and hypermagnesemia. The presence of(NOTE)*
	Renal Function Panel
		T;N, Routine, spec type = Blood
	TSH
		T;N, Routine, spec type = Blood
	Free T4
		T;N, Routine, spec type = Blood
	Magnesium Level
		Timed, spec type = Blood
		T;N, Routine, spec type = Blood
		T+1;0500, Routine, spec type = Blood
Therapeutic Drug Levels
	Cordarone Level
		T;N, Routine, spec type = Blood
	Digoxin Level
		T;N, Routine, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Q24H, Timed, spec type = Diagnostic Blood
		T;N, Q24H, Timed, spec type = Therapeutic Blood
		T;N, Stat, spec type = Diagnostic Blood
		T;N, Stat, spec type = Therapeutic Blood
		T;N, Routine, spec type = Diagnostic Blood
		T;N, Routine, spec type = Therapeutic Blood
Diagnostic Tests

	EKG (ECG)
		T;N, Stat
		T;N, Routine, DAILY, 3, Day(s)
IV Solutions
	diltiazem 100 mg/NS 100 mL (FH)
		100 mg, EVERY BAG, 10 mg/hr
		100 mL, IV, Routine, Start: T;N, Maintain Parameter Goal: HR< 100, Increment Increase: 5 mg/hr, Increment Decrease: 5 mg/hr, Increment Freq: 15 min(s), Max Dose: 15 mg/hr
			Comment: ACTIVATION REQUIRED PRIOR TO USE.  increase infusion to 15mg/hr if heart rate greater than or equal to 120 after second bolus.  . Discontinue Diltiazem infusion 1 hour after oral dose initiated.  Begin  Tiazac 180 mg po when HR rate has been less than 100 bpm for 4 hours, and or sinus rhythm has returned, if infusion rate 5mg/hr. Begin Tiazac 240 mg po when heart rate has been less than 100 bpm for 4 hours, and or sinus rhythm has returned, if infusion rate 10 mg/h.  Begin Tiazac 300 mg po when heart rate has been less than 100 bpm for 4 hours, and or sinus rhythm has returned, if infusion rate 15 mg/hr.  Enter oral diltiazem order from Acute Atrial Fibrillation Powerplan.
	amiodarone 360mg/D5W 200mL Premix IV
		200 mL, IV, Routine, T;N
			Comment: 1 mg/min (33ml/hr) for 6hr (200mL) then 0.5 mg/min (16.7ml/hr) continuous
		360 mg, EVERY BAG, 1 mg/min, T;N
	amiodarone IV Push
		150 mg, Injection, IV Push, Once, STAT
Medications
		For patients with heart failure, UpToDate suggests amiodarone in preference to dofetilide (Grade 2B). Flecainide, propafenone, dronedarone, and sotalol are contraindicated in these patients.(NOTE)*
		Simvastatin in combination with amiodarone has been associated with reports of myopathy/rhabdomyolysis. Therefore, the dose of simvastatin should not exceed 20 mg/day.(NOTE)*
		For Tikosyn (dofetilide); order separate OS once done with this Power Plan(NOTE)*
	propafenone
		150 mg, Tab, By Mouth, Q8H
			Comment: Continuous Tele for 5 doses.  Ensure Daily EKG X3 qAM after morning doses.
	flecainide
		50 mg, Tab, By Mouth, BID
			Comment: Continuous Tele for 5 doses.  Ensure Daily EKG X3 qAM after morning doses.
		100 mg, Tab, By Mouth, BID
			Comment: Continuous Tele for 5 doses.  Ensure Daily EKG X3 qAM after morning doses.
	sotalol
		80 mg, Tab, By Mouth, BID
			Comment: CrCl >60 mL/min Continuous Tele for 5 doses.  Ensure Daily EKG X3 qAM after morning doses.
	amiodarone
		200 mg, Tab, By Mouth, BID
		100 mg, Tab, By Mouth, BID
		Beta blockers are modestly effective in maintaining sinus rhythm and can be tried first in selected patients, such as those without structural heart disease who are concerned about proarrhythmia.(NOTE)*
		Maintenance antiarrhythmic drug therapy is not recommended after cardioversion in a patient with a transient or reversible cause (such as cardiac surgery, pericarditis, or pulmonary embolism). An option in such patients is beta blocker therapy after resto(NOTE)*
	Lopressor
		5 mg, Solution-Injection, IV Push, Q6H
			Comment: Hold for SBP<100 or HR <60
		5 mg, Solution-Injection, IV Push, Once, T;N
			Comment: Hold for SBP<100 or HR <60
	metoprolol TARTRATE
		12.5 mg, Tab, By Mouth, BID
		25 mg, Tab, By Mouth, BID
		50 mg, Tab, By Mouth, BID
		100 mg, Tab, By Mouth, BID
	metoprolol SUCCINATE
		25 mg, Tablet-Extended-Release, By Mouth, DAILY
		50 mg, Tablet-Extended-Release, By Mouth, DAILY
	atenolol
		25 mg, Tab, By Mouth, DAILY
	nadolol
		40 mg, Tab, By Mouth, DAILY
	propranolol
		10 mg, Tab, By Mouth, BID
		20 mg, Tab, By Mouth, BID
		10 mg, Tab, By Mouth, TID
		20 mg, Tab, By Mouth, TID
	verapamil
		40 mg, Tab, By Mouth, TID
		80 mg, Tab, By Mouth, TID
		120 mg, Capsule-Extended-Release, By Mouth, DAILY
		180 mg, Tablet-Extended-Release, By Mouth, DAILY
		240 mg, Capsule-Extended-Release, By Mouth, DAILY
	dilTIAZem
		30 mg, Tab, By Mouth, QID
	diltiazem  ER
		120 mg, Capsule-Extended-Release, By Mouth, DAILY
		180 mg, Capsule-Extended-Release, By Mouth, DAILY
		240 mg, Capsule-Extended-Release, By Mouth, DAILY
		300 mg, Capsule-Extended-Release, By Mouth, DAILY
	Cardizem
		0.25 mg/kg, Injection, IV Push, Once, PRN see comment
			Comment: PRN heart rate >/= 120bpm, for 20 minutes. Give over 2 minutes, then begin diltiazem infusion at 10mg/hr. Max dose 20mg
		0.35 mg/kg, Injection, IV Push, Once, PRN see comment
			Comment: PRN heart rate > 120bpm 30 min after 1st bolus given. Give over 2 minutes, if heart rate greater than 120 bpm after bolus, increase infusion to 15mg/hr.  Max dose 25mg
		Digoxin is often used in patients with AF associated with systolic heart failure because of its beneficial effect on symptom control.(NOTE)*
		CrCl 10 to 50 mL/min: 25% to 75% of the normal dose or usual dose every 36 hours CrCl less than 10 mL/min or hemodialysis: 10% to 25% of the normal dose or usual dose every 48 hours(NOTE)*
	digoxin
		125 mcg, Injection, IV Push, Q4H, duration: 3 Dose(s)/Time(s)
		250 mcg, Injection, IV Push, Q4H, duration: 3 Dose(s)/Time(s)
		500 mcg, Injection, IV Push, Q4H, duration: 3 Dose(s)/Time(s)
		0.125 mg, Tab, By Mouth, DAILY
		0.0625 mg, Tab, By Mouth, DAILY
		0.25 mg, Tab, By Mouth, DAILY
		Chronic anticoagulation is required with either rhythm or rate control in most patients. An exception to this need for maintenance anticoagulation occurs in patients without structural heart disease who are at low risk for embolization; such patients can(NOTE)*
		However, anticoagulation is required for at least three weeks prior to, during, and for at least four weeks after cardioversion in patients with AF duration of longer than 48 hours. After four weeks of anticoagulation, individuals who do not require long-(NOTE)*
	dabigatran
		75 mg, Capsule, By Mouth, BID
		150 mg, Capsule, By Mouth, BID
	warfarin
		2.5 mg, Tab, By Mouth, DAILY
		5 mg, Tab, By Mouth, DAILY
		7.5 mg, Tab, By Mouth, DAILY
	aspirin
		325 mg, Tab, By Mouth, DAILY
	rivaroxaban
		15 mg, Tab, By Mouth, DAILYW/SUPPER
		20 mg, Tab, By Mouth, DAILYW/SUPPER
	apixaban
		2.5 mg, Tab, By Mouth, BID
		5 mg, Tab, By Mouth, BID
	enoxaparin
		1 mg/kg, Syringe, SUBCUTANEOUS, BID
		1.5 mg/kg, Syringe, SUBCUTANEOUS, BID
Patient Care
	Cardiac Telemetry Monitoring
		Monitor patient closely for: lethal arrhythmias, Torsades de pointes, V-fib, Bradycardia, Heart block, Hypotension
	Pulse Oximetry Spot Check by nurse
		
	Patient Education
		T;N, Instructions: arrhythmias related teaching
	Anticoagulation Education
		T;N
Consults/Follow-up
	Consult Cardiologist

DVT VTE Prophylaxis (FH)
Laboratory
	CBC with Diff
		T;N, Routine, spec type = Blood
		T+1;0500, Routine, EVERY OTHER DAY, spec type = Blood
		T+1;0500, Routine, Q24H 3 Day(s), spec type = Blood
		T+1;0500, Routine, Q24H, spec type = Blood
	BMP
		T;N, Routine, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Routine, spec type = Diagnostic Blood
		T+1;0500, Q24H, spec type = Therapeutic Blood
	Partial Thromboplastin Time (PTT) - FH
		T;N, Routine, spec type = Diagnostic Blood
Medications
		See VTE Risk Assessment for patient risk score(NOTE)*
	Lovenox
		40 mg, Syringe, SUBCUTANEOUS, DAILY
			Comment: NOTIFY physician if platelets < 130,000
		30 mg, Syringe, SUBCUTANEOUS, BID
			Comment: NOTIFY physician if platelets < 130,000
		For CrCl < 30 mL/min(NOTE)*
		30 mg, Syringe, SUBCUTANEOUS, DAILY
			Comment: NOTIFY physician if platelets < 130,000. D/C lovenox if INR > 1.8
		For Patients > 150 kg(NOTE)*
		40 mg, Syringe, SUBCUTANEOUS, BID
			Comment: NOTIFY physician if platelets < 130,000
		40 mg, Syringe, SUBCUTANEOUS, DAILY
			Comment: NOTIFY physician if platelets < 130,000
Anticoagulants
		Baseline INR required for Coumadin(NOTE)*
	warfarin
		5 mg, Tab, By Mouth, Once
			Comment: Notify MD and Hold Coumadin if INR > 2.5
		2.5 mg, Tab, By Mouth, Once
			Comment: Notify MD and Hold Coumadin if INR > 2.5
		10 mg, Tab, By Mouth, Once
			Comment: Notify MD and Hold Coumadin if INR > 2.5
		5 mg, Tab, By Mouth, DAILY
			Comment: Notify MD and Hold Coumadin if INR > 2.5
		2.5 mg, Tab, By Mouth, DAILY
			Comment: Notify MD and Hold Coumadin if INR > 2.5
		10 mg, Tab, By Mouth, DAILY
			Comment: Notify MD and Hold Coumadin if INR > 2.5
		ORTHO ONLY(NOTE)*
	Xarelto
		10 mg, Tab, By Mouth, DAILY
	dabigatran
		150 mg, Capsule, By Mouth, BID
			Comment: Check renal function
	Eliquis
		2.5 mg, Tab, By Mouth, BID
			Comment: Hip Replacement: Duration of therapy 35 days  Knee Replacement: 12 days
	HEParin 5000 units/mL SUBCUTANEOUS
		5,000 units, Syringe, SUBCUTANEOUS, TID
		5,000 units, Syringe, SUBCUTANEOUS, BID
Patient Care

	Impulse Foot Pumps
		To be worn at all time while patient is not bearing weight
	Sequential Compression Device
		T;N, Wear, Both legs
			Comment: To be worn at all times while patient is not bearing weight
	Anti Embolism Stockings
		TED hose, knee high, Both legs
		TED hose, knee high, Left leg
		TED hose, knee high, Right leg
		TED hose, thigh high, Both legs
		TED hose, thigh high, Left leg
		TED hose, thigh high, Right leg
	Notify MD
		Contact Physician if INR < 1.8 on Day of Dismissal
Therapies
	Consult Physical Therapy, Evaluate and Treat
		
Consults/Follow-up
	Pharmacy Consult
		D/C Lovenox if INR > 1.8
		D/C Lovenox if INR > 2.0
		Contact MD and Hold Coumadin if INR > 2.5
		Contact MD and Hold Coumadin if INR > 3.0
		Contact MD and Hold Coumadin if INR > 3.5

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

Respiratory Failure (FH)
Laboratory
	Culture Sputum
		T;N, Routine, Induced, spec type = Sputum, Sputum
	Blood Gases Arterial (ABG) - MH/WH/JE
		T;N, Stat, spec type = Blood
		T+1;0400, Routine, Q24H, spec type = Blood
		T+1;0400, Routine, spec type = Blood
		T;N+30, Timed, spec type = Blood
			Comment: To be done 30 min after intubation
	Blood Gases Arterial (ABG) - FH
		T;N, Stat, spec type = Blood
		T+1;0400, Routine, Q24H, spec type = Blood
	ProBNP
		T;N, Routine, spec type = Blood
	CK
		T;N, Routine, spec type = Blood
	hs Troponin T
		T;N, Routine, spec type = Blood
	CKMB
		T;N, Routine, spec type = Blood
	Thyroid Panel
		T;N, Routine, spec type = Blood
	Electrolytes
		T;N, Routine, spec type = Blood
	Hepatic Function Panel
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
	Renal Function Panel
		T;N, Routine, spec type = Blood
	Acetaminophen Level
		T;N, Routine, spec type = Blood
	Alcohol
		T;N, Routine, spec type = Blood
	Toxicology Screen DAU
		T;N, Routine, Urine Random, spec type = Urine
	Salicylate Level
		T;N, Routine, spec type = Blood
Diagnostic Tests
	Chest 1 View
		T;N, Respiratory Distress
	Chest 2 View
		T;N, Stat
		T;N, Routine
Cardiac
	ECG
		T;N, Routine, Indication: Abnormal Stress Test, DAILY, 3, Dose(s)/Time(s)
		T+1;0600, Routine
		T;N, Routine
		T;N, Stat
	Echo w Doppler resting
		T;N, Stat
		T;N, Routine
Medications

	albuterol 2.5 mg/3 mL (0.083%) inh soln
		3 mL, Solution-Nebulization, NEBULIZED, Q1H, PRN shortness of breath
		3 mL, Solution-Nebulization, NEBULIZED, Q4H, PRN shortness of breath
		3 mL, Solution-Nebulization, NEBULIZED, Q6H, PRN shortness of breath
		3 mL, Solution-Nebulization, NEBULIZED, Q4H, for shortness of breath
		3 mL, Solution-Nebulization, NEBULIZED, Q6H, for shortness of breath
	albuterol CFC free 90mcg/inh inh aerosol
		2 puff, Aerosol, Inhalation, QID
		1 puff, Aerosol, Inhalation, Q4H, PRN shortness of breath
		2 puff, Aerosol, Inhalation, Q4H, PRN shortness of breath
		2 puff, Aerosol, Inhalation, QID, PRN shortness of breath
	levalbuterol 1.25 mg/3 ml inhalation solution
		3 mL, Solution-Nebulization, NEBULIZED, Q8H
		3 mL, Solution-Nebulization, NEBULIZED, QID
		3 mL, Solution-Nebulization, NEBULIZED, Q2H, PRN for shortness of breath
		3 mL, Solution-Nebulization, NEBULIZED, Q2H
		3 mL, Solution-Nebulization, NEBULIZED, Q1H, PRN for shortness of breath
	albuterol-ipratropium 2.5 mg-0.5 mg/3 mL inhalation solution
		3 mL, Solution-Nebulization, NEBULIZED, TID
		3 mL, Solution-Nebulization, NEBULIZED, BID
		3 mL, Solution-Nebulization, NEBULIZED, Once
		3 mL, Solution-Nebulization, NEBULIZED, Q4H
		3 mL, Solution-Nebulization, NEBULIZED, QID, PRN wheezing and/or shortness of breath
			Comment: (maximum: 3 mL every 4 hours)
		3 mL, Solution-Nebulization, NEBULIZED, Q4H, PRN wheezing and/or shortness of breath
			Comment: (maximum: 3 mL every 4 hours)
		3 mL, Solution-Nebulization, NEBULIZED, Q6H, PRN wheezing and/or shortness of breath
			Comment: (maximum: 3 mL every 4 hours)
		3 mL, Solution-Nebulization, NEBULIZED, QID
	Combivent Respimat 20 mcg-100 mcg/inh inhalation aerosol
		1 puff, Aerosol, Inhalation, Q4H
		1 puff, Aerosol, Inhalation, QID
		1 puff, Aerosol, Inhalation, BID
	ipratropium 0.02% inhalation solution
		2.5 mL, Solution-Nebulization, NEBULIZED, Q6H-Sch
	Atrovent HFA 17 mcg/inh inhalation aerosol
		1 puff, Aerosol, Inhalation, QID
		For (ICU) patients who are able to receive enteral medications and in whom stress ulcer prophylaxis is indicated,  UpToDate recommends an oral (PPI) rather than an alternative prophylactic agent (Grade 1B)(NOTE)*
	pantoprazole
		40 mg, Tablet-Enteric-Coated, By Mouth, DAILY
	pantoprazole IV
		40 mg, Injection, IV Push, DAILY
			Comment: Change to PO [same dose and frequency]when patient tolerating oral / enteral nutrition and receiving other oral medications.  RP: Leave Ad Hoc on IDSR stating IV-->PO Conversion
	famotidine
		20 mg, Injection, IV Push, BID
			Comment: Change to PO [same dose and frequency]when patient tolerating oral / enteral nutrition and receiving other oral medications.  RP: Leave Ad Hoc on IDSR stating IV-->PO Conversion
		20 mg, Injection, IV Push, DAILY
			Comment: CrCl < 30ml/minChange to PO [same dose and frequency]when patient tolerating oral / enteral nutrition and receiving other oral medications.  RP: Leave Ad Hoc on IDSR stating IV-->PO Conversion
		UpToDate recommends NOT using uninterrupted sedative-analgesic infusions to sedate critically ill patients (Grade 1B). Intermittent infusions, continuous infusions directed by a sedation protocol, or daily interruption of continuous infusions are preferab(NOTE)*
		For patients receiving more than one sedative-analgesic medication, the opioid should be tapered last so that the patient does not awake in pain.((NOTE)*
	fentaNYL
		25 mcg, Injection, IV Push, Q10MIN, PRN sedation
	LORazepam Injectable
		0.5 mg, Injection, IV Push, Once
		1 mg, Injection, IV Push, Once
		0.5 mg, Injection, IV Push, Q4H, PRN anxiety
		1 mg, Injection, IV Push, Q4H, PRN anxiety
	midazolam
		2 mg, Injection, IV Push, Once
			Comment: Loading dose.
		2 mg, Injection, IV Push, Q15MIN, PRN sedation
		Adequate sedation and analgesia are essential prior to initiating therapy with neuromuscular blocking agents.(NOTE)*
		The body of evidence suggests that the administration of short-term (up to 48 hours) neuromuscular blockade to patients with acute respiratory distress syndrome (ARDS) who have severe gas exchange abnormalities (eg, PaO2/FiO2 less than or equal to 120 mmH(NOTE)*
	cisatracurium
		0.15 mg/kg, Solution-Injection, IV Push, Once
			Comment: Determine supramaximal TOF setting before giving cisatracurium, begin continuous infusion after bolus dose.  Use cisatracrium if patient has hepatic dysfunction or creatinine clearance <50 mL/min (do not give bolus).
	cisatracurium 100mg/NS 50 mL
		100 mg, EVERY BAG, 1 mcg/kg/min, T;N
		50 mL, IV, T;N
			Comment: Conc: 2 mg/mL.  Determine supramaximal TOF setting before giving cisatracurium, begin continuous infusion after bolus dose.  Use cisatracrium if patient has hepatic dysfunction or creatinine clearance <50 mL/min (do not give bolus). Rate: begin at 1 mcg/kg/min and titrate to keep at 2 twitches with TOF.  Range: 0.5 to 3 mcg/kg/min, up to 10 mcg/kg/min.  NMB infusion adjustments: 0 twitches= hold NMB for 60 minutes, reassess TOF, and adjust NMB.  If TOF remains at 0, notify physician.  1 twitch= decrease NMB infusion by 50%.  2 twitches(GOAL)= maintain current infusion rate.  3 twitches= increase infusion rate by 10%.  4 twitches= increase infusion rate by 25%.                                                                                                     Retest TOF 10-15 minutes after a bolus dose or when continuous infusion of NMBD is given/initiated/changed. Retest every 2 to 4 hours after a clinically stable and satisfactory level of blockade is achieved.
Patient Care
	Patient Education
		T;N, Instructions: Patient Education
	Cardiac Telemetry Monitoring
		
Therapies
	No Respiratory Protocol, per MD
		
	Pulse Oximetry Spot Check RT
		T;N, Once
	Bronchodilator Therapy per Respiratory Protocol (FH)
		T;N
	Consult Respiratory Therapy-Assess and Treat
		T;N, Routine
			Comment: Respiratory Failure, Evaluate pts respiratory care needs, determine indications for RT, and suggest appropriate modalities
	Pulse Oximetry Spot Check RT
		T;N, Once
Consults/Follow-up
	Consult Cardiologist
		Reason for Referral: respiratory failure
	Consult Pulmonologist
		Reason for Referral: respiratory failure
	Consult Infectious Disease
		Reason for Referral: respiratory failure

PICC line Access
Diagnostic Tests
	IV Team US Guidance
		T;N, PICC Line Insertion
Medications
	sodium chloride 0.9% flush injectable soln
		10 mL, Syringe, IV Push, BID
		10 mL, Syringe, IV Push, Q5MIN, PRN, IV line flush
		20 mL, Syringe, IV Push, Q5MIN, PRN, IV line flush
		30 mL, Syringe, IV Push, Q5MIN, PRN, IV line flush
	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.
	lidocaine 1% injectable solution (MH/WH/FH)
		5 mL, SUBCUTANEOUS, Q1H, PRN, see comment
			Comment: For PICC line insert
	sodium chloride bacteriostatic 0.9% injectable soln
		5 mL, Injection, SUBCUTANEOUS, Q1H, PRN, see comment
			Comment: For PICC line insert, use if patient has lidocaine allergy.
Patient Care
	PICC Line Insert (MH/WH)
		T;N
	PICC Line Insert (JE)
		T;N
	PICC line insert (FH)
		T;N

Heart Failure
Vital Signs
	Vital Signs
		T;N, Routine
	BP and Pulse
		T;N, Once
		T;N, DAILY
Activity
	Activity-As Tolerated
		with assistance
	Up in Chair
		T;N, TIDWM
	Ambulate
		T;N, QID
	Oral Care
		BID
	Elevate head of bed
		T;N
			Comment: for meals
Diet
	Sodium Restricted Diet
		T;N, 2000 mg (2 gm) Sodium (Low Sodium)
	Fluid Restriction
		2000ml/per day
Diagnostic Tests
	Echo w Doppler resting
		Indication: Congestive heart failure
Medications
Diuretic
		Diuretic-Select only one of the following groupings(NOTE)*
		Select the following if home diuretic equal to furosemide 20mg daily(NOTE)*
	Lasix Injection
		40 mg, IV Push, Once
			Comment: administer over 2-3 minutes
		40 mg, IV Push, Once, T;N+360
			Comment: give if urine output 500-1000ml 6hr after first diuretic dose; administer over 2-3 min
		80 mg, IV Push, Once, T;N+360
			Comment: give if urine output <500 6hr after first diuretic dose; administer over 3-5 min
	Notify MD
		Urine Output <500ml 6 hr after initial diuretic dose
		Select the following if home diuretic equal to furosemide 40mg daily, torsemide 20mg daily(NOTE)*
	Lasix Injection
		100 mg, IV Push, Once
			Comment: administer over 2-3 minutes
		100 mg, IV Push, Once, T;N+360
			Comment: give if urine output 500-1000ml 6hr after first diuretic dose; administer over 3-5 min
		200 mg, IVPB, Once, T;N+360
			Comment: give if urine output <500 6hr after first diuretic dose; administer over 60 min
	Notify MD
		Urine Output <500ml 6 hr after initial diuretic dose
		Select the following if home diuretic  to furosemide >/=80mg daily, torsemide >/=40mg daily(NOTE)*
	Lasix Injection
		200 mg, IVPB, Once
			Comment: administer over 60 minutes
		200 mg, IVPB, Once, T;N+360
			Comment: give if urine output <1000 6hr after first diuretic dose; administer over 60 min
	Notify MD
		Urine Output <500ml 6 hr after initial diuretic dose
		Select the following if home diuretic equal to bumetanide 1mg daily(NOTE)*
	bumetanide
		2.5 mg, Injection, IV Push, Once
			Comment: administer over 3 minutes
		2.5 mg, Injection, IV Push, Once, T;N+360
			Comment: give if urine output 500-1000ml 6hr after first diuretic dose; administer over 3 min
		5 mg, Injection, IV Push, Once, T;N+360
			Comment: give if urine output < 500ml 6hr after first diuretic dose; administer over 5 min
	Notify MD
		Urine Output <500ml 6 hr after initial diuretic dose
Miscellaneous
	Entresto 24 mg-26 mg oral tablet
		1 TAB, Tab, By Mouth, BID
	Entresto 49 mg-51 mg oral tablet
		1 TAB, Tab, By Mouth, BID
	Entresto 97 mg-103 mg oral tablet
		1 TAB, Tab, By Mouth, BID
	nitroglycerin 50 mg/D5W 250 mL Premix IV
		50 mg, EVERY BAG, 5 mcg/min
		250 mL, IV, Routine, Start: T;N, Maintain Parameter Goal: SBP> 90, Increment Increase: 5 mcg/min, Increment Decrease: 5 mcg/min, Increment Freq: 5 min(s), Max Dose: 200 mcg/min
			Comment: If no response at 20mcg/min, may increase by 10mcg/min every 5 min.  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 maintained Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation.
	nitroglycerin
		0.4 mg, Tab, SUBLINGUAL, Q5MIN, PRN chest pain, duration: 3 Dose(s)/Time(s)
	nitroglycerin 2% topical ointment
		1 in, Packet, TOPICAL, Q6H
	DOBUTamine 1000mg/D5W 250mL
		1,000 mg, EVERY BAG, 2.5 mcg/kg/min
		250 mL, IV, STAT, Start: T;N, Increment Increase: 1 mcg/kg/min, Increment Decrease: 1 mcg/kg/min, Increment Freq: 10 min(s), Max Dose: 40 mcg/kg/min
			Comment: Concentration: 4000mcg/mL. .Notify MD if > 20mcg/kg/min.  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 maintained Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation.
	DOBUTamine 500 mg/D5W 250 mL
		250 mL, IV, STAT, Start: T;N, Increment Increase: 1 mcg/kg/min, Increment Decrease: 1 mcg/kg/min, Increment Freq: 10 min(s), Max Dose: 40 mcg/kg/min
			Comment: Concentration: 2000mcg/mL. .Notify MD if > 20mcg/kg/min.  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 maintained Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation.
		500 mg, EVERY BAG, 2.5 mcg/kg/min
	hydrALAZINE
		10 mg, Tab, By Mouth, TID
		10 mg, Tab, By Mouth, QID
		25 mg, Tab, By Mouth, TID
		25 mg, Tab, By Mouth, QID
		50 mg, Tab, By Mouth, TID
		50 mg, Tab, By Mouth, QID
	isosorbide dinitrate
		5 mg, Tab, By Mouth, TID
		5 mg, Tab, By Mouth, QID
		10 mg, Tab, By Mouth, TID
		10 mg, Tab, By Mouth, QID
		20 mg, Tab, By Mouth, TID
		20 mg, Tab, By Mouth, QID
		30 mg, Tab, By Mouth, TID
		30 mg, Tab, By Mouth, QID
		40 mg, Tab, By Mouth, TID
		Digoxin not indicated for Primary HF treament per ACC/AHA guidelines(NOTE)*
	digoxin
		0.125 mg, Tab, By Mouth, DAILY
		0.25 mg, Tab, By Mouth, DAILY
ACE
		Class A Level of Evidence if EF < 40%(NOTE)*
	Lotensin
		5 mg, Tab, By Mouth, DAILY
		5 mg, Tab, By Mouth, BID
		10 mg, Tab, By Mouth, DAILY
		10 mg, Tab, By Mouth, BID
		20 mg, Tab, By Mouth, DAILY
	Vasotec
		2.5 mg, Tab, By Mouth, BID
		5 mg, Tab, By Mouth, BID
		10 mg, Tab, By Mouth, BID
		20 mg, Tab, By Mouth, BID
	lisinopril
		2.5 mg, Tab, By Mouth, DAILY
		5 mg, Tab, By Mouth, DAILY
		10 mg, Tab, By Mouth, DAILY
		20 mg, Tab, By Mouth, DAILY
		30 mg, Tab, By Mouth, DAILY
		40 mg, Tab, By Mouth, DAILY
ARB
		Class A Level of Evidence if EF < 40%(NOTE)*
	Diovan
		40 mg, Tab, By Mouth, BID
		40 mg, Tab, By Mouth, DAILY
		80 mg, Tab, By Mouth, BID
		80 mg, Tab, By Mouth, DAILY
		160 mg, Tab, By Mouth, BID
		160 mg, Tab, By Mouth, DAILY
		320 mg, Tab, By Mouth, DAILY
	Cozaar
		12.5 mg, Tab, By Mouth, DAILY
		25 mg, Tab, By Mouth, DAILY
		50 mg, Tab, By Mouth, DAILY
		100 mg, Tab, By Mouth, DAILY
	valsartan
		80 mg, Tab, By Mouth, QHS
		160 mg, Tab, By Mouth, QHS
		320 mg, Tab, By Mouth, QHS
Beta Blocker
		Class A Level of Evidence if EF < 40%(NOTE)*
		For patients who are not already taking a beta blocker, UpToDate suggests that they NOT be initiated at the time of presentation with an episode of ADHF (Grade 2B). Beta blockers are generally started later than ACE inhibitors or ARBs, when the patient is(NOTE)*
	Toprol-XL
		12.5 mg, Tablet-Extended-Release, By Mouth, DAILY
		25 mg, Tablet-Extended-Release, By Mouth, DAILY
		50 mg, Tablet-Extended-Release, By Mouth, DAILY
		100 mg, Tablet-Extended-Release, By Mouth, DAILY
		200 mg, Tablet-Extended-Release, By Mouth, DAILY
	Coreg
		3.125 mg, Tab, By Mouth, BIDWM
		6.25 mg, Tab, By Mouth, BIDWM
		12.5 mg, Tab, By Mouth, BIDWM
		25 mg, Tab, By Mouth, BIDWM
	bisoprolol
		1.25 mg, Tab, By Mouth, DAILY
		2.5 mg, Tab, By Mouth, DAILY
		5 mg, Tab, By Mouth, DAILY
		10 mg, Tab, By Mouth, DAILY
Aldosterone Antagonist
	Aldactone
		12.5 mg, Tab, By Mouth, DAILY
		25 mg, Tab, By Mouth, DAILY
	Inspra
		12.5 mg, Tab, By Mouth, DAILY
		25 mg, Tab, By Mouth, DAILY
Potassium Supplement
	potassium chloride Oral
		20 mEq, Tablet-Extended-Release, By Mouth, Once
		20 mEq, Tablet-Extended-Release, By Mouth, Q6H, duration: 2 Dose(s)/Time(s)
		40 mEq, Tablet-Extended-Release, By Mouth, Once
		40 mEq, Tablet-Extended-Release, By Mouth, Q6H, duration: 2 Dose(s)/Time(s)
Patient Care

	Intake and Output
		Q6H-Sch, 24, hr
	Notify MD
		if any of the following: no improvement in dyspnea c/o dyspnea at rest pt cannot lay flat secondary to dyspnea.
		Urine Output <500ml in first 6 hours of admission
	Foley Catheter
		Insert, PRN, unable to void, If foley catheter needed, enter order for foley catheter insert, once, and select the appropriate criteria for insertion and then insert the foley catheter.
	Patient Education
		Instructions: Provide the "Heart Failure Zone Log" Calendar"
	VTE Advisor
		Medical
	Cardiac Telemetry Monitoring
		Telemetry Indications: Acute Decompensated HF
	Notify Health Care Provider
		T;N
Therapies
	Smoking Cessation Education
		
	Smoking Cessation Education RT (FH)
		
	Oxygen Therapy
		T;N, Titrate/wean to keep: > or = to 90%
	Pulse Oximetry Spot Check RT
		T;N, BID
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
Consults/Follow-up
	Consult Cardiologist
		Reason for Referral: CHF, Refer to/Consult with: Heart Consultants, No Provider Notified
	Meds2Beds
		T;N
			Comment: From Heart Failure Plan
	Consult Social Work
		Discharge Planning
			Comment: Regarding: assess for patient resources including medication barriers, food insecurities, and transportation to appointments
	Consult Dietitian
		Regarding: Nutrition Assessment
	Consult Cardiac Rehab: Inpatient
		Indications Heart Failure
	Consult Cardiac Rehab: Outpatient
		Indications Heart Failure
	Consult Inpatient Palliative Care
		Reason for Referral: Regarding Advance Directive query for complex health management, Refer to/Consult with: Palliative care team, No Provider Notified
	Consult Care Navigator
		Education
	Consult APRN
		T;N, Consult Heart Failure Clinic APRN Call Heart Consultants at 402-391-5055 to schedule an appointment in the next 3-5 days.
		T;N, Consult Heart Failure NMH APRN 402-354-3938
	Consult Physical Therapy, Evaluate and Treat
		T;N, Reason to See: Evaluate and Treat

Cellulitis
Activity
	Activity-Position
		Elevate affected extremity
			Comment: Continuously
Laboratory
Today's Lab
	CBC with Diff
		Stat, spec type = Blood
	Comprehensive Metabolic Panel
		Stat, spec type = Blood
	hsCRP
		Stat, spec type = Blood
	Sed Rate
		Stat, spec type = Blood
	MRSA Screen
		Stat, Micro Swab, spec type = Nose
	MRSA Nasal Screen Rapid - JE
		Stat, Micro Swab, Nares
Tomorrow's Lab
	CBC with Diff
		T+1;0400, Routine, spec type = Blood
Diagnostic Tests

	Venous Duplex Unilat Upper or Lower
		T;N, Routine, Indication: Pain, Location Left Upper
		T;N, Routine, Indication: Pain, Location Left Lower
		T;N, Routine, Indication: Pain, Location Right Upper
		T;N, Routine, Indication: Pain, Location Right Lower
	Venous Duplex Bil Upper or Lower
		Indication: Pain, Location Upper Bilateral
		Indication: Pain, Location Lower Bilateral
Medications
	Eucerin topical cream
		1 appl, Cream, TOPICAL, TID
			Comment: to affected area
	LamISIL AT 1% topical cream
		1 appl, Cream, TOPICAL, TID
			Comment: to affected area
Non-purulent
		(Cellulitis/ Facial cellulitis/Erysipelas)(NOTE)*
		Mild: Select one of the following(NOTE)*
	cephalexin
		500 mg, Capsule, By Mouth, Q6H, Skin soft tissue
	Cleocin HCl
		450 mg, Capsule, BY MOUTH, Q6H, Skin soft tissue
		Moderate: Select one of the following(NOTE)*
	Ancef IVPB
		1,000 mg, Injection-Premix, IVPB, Q8H, Skin soft tissue
	Ancef IVPB (FH)
		1,000 mg, INT, IVPB, Q8H, Skin soft tissue
	Cleocin IVPB
		900 mg, Injection-Premix, IVPB, Q8H, Skin soft tissue
		Severe or severely immunocompromised (Consider ID consult)(NOTE)*
	vancomycin IVPB
		15 mg/kg, Injection-Premix, IVPB, PHARMACY TO DETERMINE, Skin soft tissue
	vancomycin IVPB (FH)
		15 mg/kg, INT, IVPB, PHARMACY TO DETERMINE, Skin soft tissue
	Rocephin IVPB (FH)
		2,000 mg, INT, IVPB, Q24H, Skin soft tissue, 5 Day(s)
	nafcillin
		2 gm, INT, IVPB, Q6H, Skin soft tissue, 5 Day(s)
	Zosyn IVPB (FH)
		4.5 gm, INT, IVPB, Q8H, Skin soft tissue, 5 Day(s)
Purulent
		(Furuncle/Carbuncle/Abcess), Incision and drainage plus:(NOTE)*
		Mild: Consider incision and drainage(NOTE)*
		Moderate: choose one of the following(NOTE)*
	Bactrim DS
		1 TAB, Tab, By Mouth, Q12H, Indication: Skin soft tissue
	doxycycline
		100 mg, Capsule, BY MOUTH, Q12H, Skin soft tissue
		Severe: Consider ID consult(NOTE)*
	vancomycin IVPB
		15 mg/kg, Injection-Premix, IVPB, PHARMACY TO DETERMINE, Skin soft tissue
	vancomycin IVPB (FH)
		15 mg/kg, INT, IVPB, PHARMACY TO DETERMINE, Skin soft tissue
	amoxicillin
		500 mg, Capsule, By Mouth, TID, Other- type in, Skin soft tissue, 5 Day(s)
	linezolid IVPB
		600 mg, Injection-Premix, IVPB, Q12H, Skin soft tissue, 5 Day(s)
	DAPTOmycin IVPB
		6 mg/kg, INT, IVPB, Q24H, Indication: Skin soft tissue, 5 Day(s)
		MSSA:(NOTE)*
	Ancef
		2,000 mg, Injection-Premix, IVPB, Q8H, Skin soft tissue, 5 Day(s)
	nafcillin
		2 gm, INT, IVPB, Q6H, Skin soft tissue, 5 Day(s)
	vancomycin IVPB
		15 mg/kg, Injection-Premix, IVPB, PHARMACY TO DETERMINE, Skin soft tissue
	vancomycin IVPB (FH)
		15 mg/kg, INT, IVPB, PHARMACY TO DETERMINE, Skin soft tissue
		B-Lactam Allergy/ Alternative Therapy(NOTE)*
	Cleocin IVPB
		900 mg, Injection-Premix, IVPB, Q8H, Skin soft tissue
		600 mg, Injection-Premix, IVPB, Q8H, Skin soft tissue
	vancomycin IVPB
		15 mg/kg, Injection-Premix, IVPB, PHARMACY TO DETERMINE, Skin soft tissue
	vancomycin IVPB (FH)
		15 mg/kg, INT, IVPB, PHARMACY TO DETERMINE, Skin soft tissue
Necrotizing Fasciitis
		(Empiric therapy) (Consider surgical and ID consults)(NOTE)*
	Cleocin IVPB
		900 mg, Injection-Premix, IVPB, Q8H, Skin soft tissue
	vancomycin IVPB
		15 mg/kg, Injection-Premix, IVPB, PHARMACY TO DETERMINE, Skin soft tissue
	vancomycin IVPB (FH)
		15 mg/kg, INT, IVPB, PHARMACY TO DETERMINE, Skin soft tissue
	Zosyn IVPB
		4.5 gm, Injection-Premix, IVPB, Q8H, Skin soft tissue
	Zosyn IVPB (FH)
		4.5 gm, INT, IVPB, Q8H, Skin soft tissue
Animal Bite
		(Choose one), If beta-lactam allergic, consider ID consult(NOTE)*
	Unasyn IVPB
		3,000 mg, Injection-Premix, IVPB, Q6H, Skin soft tissue
	Unasyn IVPB (FH)
		3,000 mg, INT, IVPB, Q6H, Skin soft tissue
	Rocephin IVPB
		2,000 mg, Injection-Premix, IVPB, DAILY, Skin soft tissue
	Rocephin IVPB (FH)
		2,000 mg, Injection-Premix, IVPB, DAILY, Skin soft tissue
	amoxicillin-clavulanate  875 mg-125 mg oral tablet
		1 TAB, Tab, BY MOUTH, Q12H, Skin soft tissue
Human Bite
		(Choose one) If beta-lactam allergic, consider ID consult(NOTE)*
	Unasyn IVPB
		3,000 mg, Injection-Premix, IVPB, Q6H, Skin soft tissue
	Unasyn IVPB (FH)
		3,000 mg, INT, IVPB, Q6H, Skin soft tissue
	amoxicillin-clavulanate  875 mg-125 mg oral tablet
		1 TAB, Tab, BY MOUTH, Q12H, Skin soft tissue
Patient Care

	Heat Therapy
		T;N
			Comment: Continuously
	Notify MD
		T;N, Notify Radiologist to insert PICC line
Consults/Follow-up
	Consult Wound Care
		Reason for Referral: Cellulitis
	vancomycin - Pharmacy to Dose
		treating cellulitis, Skin soft tissue
	Consult Infectious Disease
		Reason for Referral: bite injury
	Consult General Surgery
		
	Consult Infectious Disease
		Reason for Referral: suspect facial cellulitis
		Reason for Referral: suspect MRSA cellulitis
		Reason for Referral: suspect MRSA cellulitis, facial cellulitis, suspect necrotizing fasciitis, or
	Consult General Surgery
		Reason for Referral: suspect necrotizing fasciitis, Refer to/Consult with: Surgery West on call MD
	Pharmacy Consult
		T;N+2880, pharmacy to assess patient in 48 hours for IV to oral conversion
	Consult Physical Therapy, Evaluate and Treat
		T;N, Reason to See: Evaluate and Treat
			Comment: Cellulitis

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.

COPD
Vital Signs
	Vital Signs
		T;N, Per protocol
		Q1H, 4, hr
			Comment: Acute Respiratory Distress monitor vital signs Q1h x 4 hours, then Q2h x 10 for a total of 24 hours.  Then continue to monitor per patient condition. If BiPAP newly initiated or if patient requires > 5 L or > 40% FIO2 or Bipap, monitor vital signs and respiratory assessments hourly x 4 hours, then q2h x 24 hours. Continue to monitor per vital signs policy and procedures.
		T;N+240, Q2H-Sch, 10, Dose(s)/Time(s)
			Comment: Acute Respiratory Distress; monitor vital signs Q1h x 4 hours, then Q2h x 10 for a total of 24 hours.  Then continue to monitor per patient condition. If BiPAP newly initiated or if patient requires > 5 L or > 40% FIO2 or Bipap, monitor vital signs and respiratory assessments hourly x 4 hours, then q2h x 24 hours. Continue to monitor per vital signs policy and procedures.
Activity
	Activity-As Tolerated
		T;N
			Comment: With assistance
	Elevate head of bed
		
	Ambulate
		QID
	Up in Chair
		QID
			Comment: And with meals
	Oral Care
		BID
Laboratory
	Blood Gases Arterial (ABG) - MH/WH/JE
		Routine, spec type = Blood
	Blood Gases Arterial (ABG) - FH
		T;N, Routine, spec type = Blood
	Magnesium Level
		Routine, spec type = Blood
	Sputum Culture
		Routine, Expectorated, spec type = Sputum, Sputum
	Procalcitonin
		Routine, spec type = Blood
Diagnostic Tests
	Chest 1 View
		T+1;0400, Routine, Pneumonia
		T;N, Routine, Pneumonia
	Chest 2 View
		T+1;0400, Routine, Pneumonia
		T;N, Routine, Pneumonia
	CTA Chest
		T+1;0400, Routine
Diagnostics
	Discharge Diagnostics
		T;N, Complete pre and post PFTs. Schedule after discharge within 2-3 weeks.
	Complete pulmonary function
		
	Complete pre and post PFT's
		
Medications
Steroids
	predniSONE
		40 mg, Tab, By Mouth, DAILY, 5 Day(s)
		60 mg, Tab, By Mouth, DAILY, 48 hr
		40 mg, Tab, By Mouth, DAILY, 3 Day(s)
	SOLU-Medrol
		60 mg, Injection, IV Push, DAILY, 48 hr
	predniSONE
		40 mg, Tab, By Mouth, DAILY, 5 Day(s)
			Comment: start after 48hrs of IV solumedrol
	SOLU-Medrol
		40 mg, Injection, IV Push, Q6H, 48 hr
	predniSONE
		40 mg, Tab, By Mouth, DAILY, 5 Day(s)
			Comment: start after 48hrs of IV solumedrol
	SOLU-Medrol
		60 mg, Injection, IV PUSH, Q6H, duration: 5 Day(s)
		60 mg, Injection, IV PUSH, Q8H, duration: 5 Day(s)
		80 mg, Injection, IV PUSH, Q8H, duration: 5 Day(s)
		60 mg, Injection, IV PUSH, Q12H, duration: 5 Day(s)
		80 mg, Injection, IV PUSH, Q12H, duration: 5 Day(s)
Antibiotics
		Recommend 3-5 days antibiotic therapy. If IV antibiotic course recommended, review in 48-72 hours, and transition to oral.(NOTE)*
		Mild Exacerbation: select one from this section(NOTE)*
	doxycycline
		100 mg, Capsule, By Mouth, Q12H, COPD, 5 Day(s)
	Zithromax
		500 mg, Tab, By Mouth, DAILY, Other- type in, COPD, 5 Day(s)
	cefuroxime
		500 mg, Tab, By Mouth, BID, Other- type in, COPD, 5 Day(s)
		Moderate Exacerbation without Pseudomonas Risk Factors: select one from this section(NOTE)*
		Pseudomonas Risk Factors: 1. Recent hospitalization in past 90 days. 2. Frequent antibiotic courses in past year. 3. Severe COPD (FEV, <50%), 4. Previous isolation of pseudomonas.(NOTE)*
	amoxicillin-clavulanate  875 mg-125 mg oral tablet
		1 TAB, Tab, By Mouth, BID, Other- type in, COPD, 7 Day(s)
	Rocephin IVPB
		1,000 mg, Injection-Premix, IVPB, Q24H, Other- type in, COPD, 7 Day(s)
	Rocephin IVPB (FH)
		1,000 mg, INT, IVPB, Q24H, Other- type in, COPD, 7 Day(s)
	levoFLOXacin
		750 mg, Tab, By Mouth, DAILY, COPD, 7 Day(s)
	Levaquin IVPB
		750 mg, Injection-Premix, IVPB, Q24H, COPD, 7 Day(s)
		Moderate Exacerbation with Pseudomonas Risk Factors or severe exacerbation:NOTE: select one from this section(NOTE)*
		Severe exacerbation: requiring ventilation support, invasive or non invasive (BiPap/Vent)		Pseudomonas Risk Factors: 1. Recent hospitalization in past 90 days. 2. Frequent antibiotic courses in past year. 3. Severe COPD (FEV, <50%), 4. Previous isolatio(NOTE)*
	cefepime
		1,000 mg, Injection-Premix, IVPB, Q8H, Other- type in, COPD, 7 Day(s)
	cefepime IVPB (FH)
		1,000 mg, INT, IVPB, Q24H, Other- type in, COPD, 7 Day(s)
	Zosyn IVPB
		4.5 gm, Injection-Premix, IVPB, Q8H, Other- type in, COPD, STAT
	Zosyn IVPB (FH)
		4.5 gm, INT, IVPB, Q8H, Other- type in, COPD, STAT
		Severe beta lactam allergy:(NOTE)*
	Levaquin IVPB
		750 mg, Injection-Premix, IVPB, Q24H, COPD, 7 Day(s)
	levoFLOXacin
		750 mg, Tab, By Mouth, DAILY, COPD, 7 Day(s)
	aztreonam
		2,000 mg, INT, IVPB, Q8H, COPD, 7 Day(s)
		2,000 mg, INT, IVPB, Q8H, COPD, 7 Day(s)
	Zithromax IVPB
		500 mg, INT, IVPB, Q24H, Other- type in, COPD, T;N, 5 Day(s)
	doxycycline IVPB
		100 mg, INT, IVPB, Q12H, COPD, COPD, 5 Day(s)
		200 mg, INT, IVPB, Q12H, COPD, COPD, 5 Day(s)
		The U.S. Food and Drug Administration today approved safety labeling changes for a class of antibiotics, called fluoroquinolones, to enhance warnings about their association with disabling and potentially permanent side effects and to limit their use in p(NOTE)*
Nebulizers
	albuterol-ipratropium 2.5 mg-0.5 mg/3 mL inhalation solution
		3 mL, Solution-Nebulization, NEBULIZED, QID
		3 mL, Solution-Nebulization, NEBULIZED, Q2H, PRN, shortness of breath
	albuterol 2.5 mg/3 mL (0.083%) inh soln
		3 mL, Solution-Nebulization, NEBULIZED, QID
		3 mL, Solution-Nebulization, NEBULIZED, Q4H
		3 mL, Solution-Nebulization, NEBULIZED, Q2H, PRN, wheezing and/or shortness of breath
		For use in tachycardic arrhythmia that has been exacerbated by albuterol(NOTE)*
	levalbuterol 1.25 mg/3 ml inhalation solution
		3 mL, Solution-Nebulization, NEBULIZED, Q8H
	sodium chloride 0.9% inhalation solution
		3 mL, Solution-Nebulization, NEBULIZED, Q8H
	Pulmicort Respules
		0.5 mg, Solution-Nebulization, NEBULIZED, BID
Inhalers
	Breo Ellipta 100 mcg-25 mcg/inh inhalation powder
		1 puff, Powder, Inhalation, DAILY
	Anoro Ellipta 62.5 mcg-25 mcg/inh inhalation powder
		1 puff, Powder, Inhalation, DAILY
	Anoro Ellipta
		1 puff, Powder, Inhalation, DAILY
	Incruse Ellipta 62.5 mcg/inh inhalation powder
		1 puff, Powder-Inhalation, Inhalation, DAILY
Symptom Medications
	Daliresp
		500 mcg, Tab, By Mouth, DAILY, T+1;0900
	Mucinex
		600 mg, Tablet-Extended-Release, By Mouth, BID
		1,200 mg, Tablet-Extended-Release, By Mouth, BID
	dextromethorphan-guaifenesin 20 mg-200 mg/10 mL oral liquid
		10 mL, Liquid, By Mouth, QHS, PRN, cough
Patient Care

	Patient Education
		Regarding pneumonia and COPD
		DAILY, Instructions: Review My COPD Action Plan. Coordinate with CAT tool completion on day of discharge with RT.
	Obtain Medical Records
		Obtain outside PFTs if available and notify MD when received.
	Respiratory Assessment-Focused
		Q1H, 4, hr
			Comment: Acute Respiratory Distress monitor vital signs Q1h x 4 hours, then Q2h x 10 for a total of 24 hours.  Then continue to monitor per patient condition. If BiPAP newly initiated or if patient requires > 5 L or > 40% FIO2 or Bipap, monitor vital signs and respiratory assessments hourly x 4 hours, then q2h x 24 hours. Continue to monitor per vital signs policy and procedures.
		T;N+240, Q2H-Sch, 10, Dose(s)/Time(s)
			Comment: Acute Respiratory Distress; monitor vital signs Q1h x 4 hours, then Q2h x 10 for a total of 24 hours.  Then continue to monitor per patient condition. If BiPAP newly initiated or if patient requires > 5 L or > 40% FIO2 or Bipap, monitor vital signs and respiratory assessments hourly x 4 hours, then q2h x 24 hours. Continue to monitor per vital signs policy and procedures.
	Incentive Spirometer
		
	Notify MD
		T;N
			Comment: Temperature <36.1 C or >38.0 C, SBPressure <90 or >180     DBPressure >110     Heart rate < 50 or > 110     Respiratory rate <10 or >24     O2 sat <93%new onset rhythm changeblood glucose > 180 mg/dL (x 2 consecutive measurements)     urine output < 60 ml in 4 hours
Therapies
	NIV (BiPAP)
		T;N
			Comment: If newly initiated or if patient requires > 5 L or > 40% FIO2 or Bipap, monitor vital signs and respiratory assessments Q1H x 4 hours, then q2h x 10 hours for total of 24 hours. Continue to monitor per vital signs policy and procedures.
	Bronchodilator Therapy per Respiratory Protocol (FH)
		T;N
Consults/Follow-up
	Consult Pulmonary Rehab: Inpatient
		T;N, COPD
			Comment: Evaluate and treat inpatient
	Consult Pulmonary Rehab: Outpatient
		T;N, COPD
	Consult Respiratory Therapy-Assess and Treat
		T;N
			Comment: COPD patient. Obtain records from previous pulmonary function tests.
	Smoking Cessation Education
		T;N
			Comment: Patient to be seen prior to discharge
	Smoking Cessation Education RT (FH)
		T;N
	Consult Pulmonologist
		Reason for Referral: COPD, Refer to/Consult with: patient's pulmonologist
		Reason for Referral: COPD, Refer to/Consult with: Pulmonary Medicine Institute
		Reason for Referral: COPD, Refer to/Consult with: Pulmonary Medicine Specialists MPC
	Consult Inpatient Palliative Care
		Reason for Referral: COPD establish goals of care, Refer to/Consult with: Provider on call
	Consult Care Navigator
		Education
			Comment: COPD, MPC patients only
	Pharmacy Consult
		Pharmacy to determine if home inhalers are available to bring/use while in hospital
		Pharmacy to assess inhaler therapy based on admission information and contact MD if necessary.
		T;N+2880, Pharmacy and nursing to assess patient in 48 hours for IV to oral conversion

zzDKA HHS Protocol (MFH) [EBM]
Laboratory
	Glucose POC - RN
		T;N, Q1H
	CBC with Diff
		Stat, spec type = Blood
			Comment: IF NOT DONE IN ED
	CMP
		Stat, spec type = Blood
			Comment: IF NOT DONE IN ED
	Magnesium Level
		Stat, spec type = Blood
			Comment: IF NOT DONE IN ED
		T;N+720, Timed, Q12H, spec type = Blood
	Phosphorus
		T;N+720, Timed, Q12H, spec type = Blood
	BMP
		T;N+120, Q2H-Sch 6 hr, spec type = Blood
		T;N+480, Timed, Q4H 8 hr, spec type = Blood
		T;N+960, Timed, Q8H, spec type = Blood
	Blood Gases Arterial (ABG) - MH/WH/JE
		Nurse Collect, T+1;0500, Routine, Q24H, spec type = Blood
			Comment: DKA Protocol: Check with nursing before drawing
	Blood Gases Arterial (ABG) - FH
		Nurse Collect, T+1;0500, Routine, Q24H, spec type = Blood
	Blood Gases VENOUS (VBG)
		T+1;0500, Routine, Q24H, spec type = Blood
	UA (Culture if Positive)
		Stat, Stat, spec type = Urine
		T;N+240, Routine, Routine, spec type = Urine
	Beta-Hydroxybutyrate (Inpatient)
		Nurse Collect, spec type = Blood
			Comment: DKA HHS Protocol [EBM]
IV Solutions
		Patient sodium low (<145) and potassium level >4.0(NOTE)*
	Sodium Chloride 0.9%
		1,000 mL, IV, 250 ml/hr
			Comment: if sodium still < 145, potassium > 4.0 and glucose >=250.  If glucose < 250, start Dextrose 5% with 0.9% NaCl at 250ml/hr
		1,000 mL, IV, 500 ml/hr
			Comment: if sodium still < 145, potassium > 4.0 and glucose >=250.  If glucose < 250, start Dextrose 5% with 0.9% NaCl at 250ml/hr
		Patient sodium low (<145) and potassium level 3.1-4.0(NOTE)*
	Sodium Chloride 0.9% with KCl 20mEq
		1,000 mL, IV, 250 ml/hr
			Comment: if sodium still < 145, potassium 3.1-4.0 and glucose >=250.  If glucose < 250, start Dextrose 5% with 0.9% NaCl with KCl 20mEq at 250ml/hr
		Patient sodium low (<145) and potassium level <3.0(NOTE)*
	Sodium Chloride 0.9% with KCl 40mEq
		1,000 mL, IV, 250 ml/hr
			Comment: hr if sodium still < 145, potassium < 3.0 and glucose >=250.  If glucose < 250, start Dextrose 5% with 0.9% NaCl with KCl 40mEq at 250ml/hr
		Patient sodium low (>145) and potassium level >4(NOTE)*
	Sodium Chloride 0.45%
		1,000 mL, IV, 250 ml/hr
			Comment: if sodium > 145, potassium >4.0 and glucose >=250.  If glucose < 250, start Dextrose 5% with 0.45% NaCl at 250ml/hr
		Patient sodium low (>145) and potassium level <3.0(NOTE)*
	Sodium Chloride 0.45% with KCl 40 mEq
		1,000 mL, IV, Routine, 250 ml/hr
			Comment: if sodium still > 145, potassium < 3.0 and glucose >=250.  If glucose < 250, start Dextrose 5% with 0.45% NaCl with KCl 40mEq at 250ml/hr
		40 mEq, EVERY BAG
		Patient sodium low (>145) and potassium level 3.1-4.0(NOTE)*
	Sodium Chloride 0.45% with KCl 20 mEq
		1,000 mL, IV, Routine, 250 ml/hr
			Comment: if sodium still > 145, potassium 3.1-4.0 and glucose >=250.  If glucose < 250, start Dextrose 5% with 0.45% NaCl with KCl 20mEq at 250ml/hr
		20 mEq, EVERY BAG
		DESTROSE CONTAINING FLUIDS:(NOTE)*
	Dextrose 5% in Water
		1,000 mL, IV, 250 ml/hr
			Comment: if glucose < 250 and sodium < 145, potassium > 4.0
	Dextrose 5% with 0.9% NaCl w/KCl 20 mEq
		1,000 mL, IV, 250 ml/hr
			Comment: if glucose < 250 and sodium still < 145, potassium 3.1-4.0
	Dextrose 5% with 0.45% NaCl
		1,000 mL, IV, 250 ml/hr
			Comment: if glucose < 250 and  sodium > 145, potassium >4.0
	Dextrose 5% with 0.45% NaCl w/KCl 20 mEq
		1,000 mL, IV, 250 ml/hr
			Comment: if glucose < 250 and sodium still > 145, potassium 3.1-4.0
	Dextrose 5% with 0.45% NaCl w/KCl 40 mEq
		1,000 mL, IV, 250 ml/hr
			Comment: if glucose < 250 and sodium still > 145, potassium < 3.0
Medications
	insulin regular 100 units/NS 100 mL Premix
		100 mL, IV, Routine, T;N, Total Volume = 100
			Comment: Initial rate of 0.1units/kg/hr (max of 3 units/hr), When glucose is <250mg/dL ensure a D5% fluid is running.1.  If the glucose decreases >60mg/dl from the last glucose check, decrease insulin rate by 50%, and check     glucose in 30 minutes. 2.  For glucose <60, stop infusion, contact provider and follow DKA HHS Hypoglycemia protocol. Restart at 50% of    previous rate once the glucose is >120. Make sure there is D5% in IV fluid, if not add D5% to existing IV fluids. 3.  For glucose 60-120, HOLD infusion, Restart at 50% of previous rate once the glucose is >120, check POC BG    every 30 min4.  120-180 No change to infusion.  Make sure there is D5% in IV fluid, if not add D5% to existing IV fluids.5.  181-250 increase infusion by 0.5units/hr 6.  250-399 and is greater than or equal to the previous glucose, bolus with 5 units insulin and increase infusion by     0.5 unit/hr. 7.  >=400 and is less than previous glucose, bolus with 10 units insulin and increase infusion by 1unit/hr
		100 units, EVERY BAG, 0.1 unit/kg/hr
			Comment: INITIAL Infusion Rate: glucose 200-249mg/dl: 4 units/hr; 250-299mg/dl: 6 units/hr; 300-399md/dl: 8 units/hr; > 400mg/dl: 10 units/hr.  Titrate to a target glucose of 140-200.  MAXIMUM rate of 40 units/hr.  Call physician for direction if unable to reach goal range.  DO NOT enter as a basic infusion in pump1. If glucose is < 60, HOLD DRIP and give 1 amp 50% glucose and check POC glucose every 30 minutes until >   100mg/dl and then re-initiate drip at 50% previous rate2. If glucose is 60-80, HOLD DRIP and check POC glucose every 30 minutes until > 100mg/dl and then re-initiate   drip at 50% previous rate3. If glucose is 81-100 mg/dl    a. Previous glucose 60-80, decrease rate by 1 unit/hr    b. Previous glucose 81-139, decrease rate by 0.5units/hr    c. Previous glucose 140-250, decrease rate by 1 unit/hr    d. Previous glucose 251-300, decrease rate by 1.5units/hr    e. Previous glucose >300, decrease rate by 2 units/hr4. If glucose is 101-139 mg/dl    a. Previous glucose <101, NO CHANGE    b. Previous glucose 101-200, decrease rate by 0.5units/hr    c. Previous glucose > 200, decrease rate by 1unit/hr5. If glucose is 140-200 mg/dl    a. Previous glucose < 101, increase rate by 1 unit/hr    b. Previous glucose 101-250, NO CHANGE    c. Previous glucose > 250, decrease rate by 2 units/hr6. If glucose 201-250 mg/dl    a. When Blood Glucose is < 250 mg/dl, update IV fluid to dextrose containing fluid.  If no fluids on patient       profile,     start D5%-Normal Saline 0.9% at 50mL/hr.    b. Previous glucose < 139, increase rate by 2 units/hr    c. Previous glucose 140-300, increase rate by 1 unit/hr    d. Previous glucose >300, NO CHANGE7. If glucose 251-300 mg/dl    a. Previous glucose < 101, increase rate by 2.5 units/hr    b. Previous glucose 101-139, increase rate by 1.5 units/hr    c. Previous glucose 140-250, increase rate by 1 unit/hr    d. Previous glucose 251-300, increase rate by 1.5units/hr    e. Previous glucose 301-400, increase rate by 2 units/hr    f. Previous glucose > 400, NO CHANGE8. If glucose 301-400 mg/dl    a. Increase rate by 3 units/hr9. If glucose > 400 mg/dl    a. Increase rate by 4 units/hr
	insulin regular 100 units/NS 100 mL IV
		100 mL, IV, Routine, T;N+960, Total Volume = 100
			Comment: Initial rate of 0.1units/kg/hr (max of 3 units/hr), When glucose is <250mg/dL ensure a D5% fluid is running.1.  If the glucose decreases >60mg/dl from the last glucose check, decrease insulin rate by 50%, and check     glucose in 30 minutes. 2.  For glucose <60, stop infusion, contact provider and follow DKA HHS Hypoglycemia protocol. Restart at 50% of    previous rate once the glucose is >120. Make sure there is D5% in IV fluid, if not add D5% to existing IV fluids. 3.  For glucose 60-120, HOLD infusion, Restart at 50% of previous rate once the glucose is >120, check POC BG    every 30 min4.  120-180 No change to infusion.  Make sure there is D5% in IV fluid, if not add D5% to existing IV fluids.5.  181-250 increase infusion by 0.5units/hr 6.  250-399 and is greater than or equal to the previous glucose, bolus with 5 units insulin and increase infusion by     0.5 unit/hr. 7.  >=400 and is less than previous glucose, bolus with 10 units insulin and increase infusion by 1unit/hr
		100 units, EVERY BAG, 0.1 unit/kg/hr
Hypoglycemia
	Dextrose 50%
		25 mL, Injection, IV Push, Q15MIN, PRN low blood sugar, STAT
			Comment: For glucose < 70, May repeat as needed if blood sugar still less than 100.
		50 mL, Injection, IV Push, Q15MIN, PRN low blood sugar, STAT
			Comment: For glucose < 50, May repeat as needed if blood sugar still less than 100.
	glucagon
		1 mg, Injection, SUBCUTANEOUS, Q15MIN, PRN for low blood sugar, STAT
			Comment: :For glucose < 70, May repeat as needed if blood sugar still less than 100.
Potassium Supplement
	potassium chloride Oral
		20 mEq, Tablet-Extended-Release, By Mouth, DAILY, PRN see comment
			Comment: If potassium level 3.0-4.0 and Oral desired
		40 mEq, Tablet-Extended-Release, By Mouth, DAILY, PRN see comment
			Comment: If potassium level 2.5-3.0 and Oral desired.  Insure K+ containing fluids are running
	potassium chloride IVPB (FH)
		40 mEq, Injection-Premix, IVPB, Q4H, PRN see comment
			Comment: For potassium <3.0. Enter order for stat potassium level after infusion complete. For potassium < 2.0, contact provider. Contact provider prior to starting a 3rd dose of replacement.
		20 mEq, Injection-Premix, IVPB, Q4H, PRN see comment
			Comment: For potassium 3.0-4.0. Enter order for stat potassium level after infusion complete. Contact provider prior to starting a 3rd dose of replacement.
Phosphorous
	potassium phosphate-sodium phosphate 250 mg-280 mg-160 mg oral powder for reconstitution
		2 packet(s), Suspension, By Mouth, Once, PRN see comment
			Comment: For phosphorus level 1.1-2.0 and oral desired.  Contact provider prior to starting a 3rd dose of replacement.
	sodium phosphate IVPB
		30 mmol, INT, IVPB, Once, PRN, see comment, Infuse Over 4 hr
			Comment: For phosphorus level <= 1.0.  Contact provider for low level and prior to starting a 3rd dose of replacement
	potassium phosphate IVPB
		30 mmol, INT, IVPB, Once, PRN, see comment, Infuse Over 4 hr
			Comment: For phosphorus level <= 1.0  Contact provider for low level and prior to starting a 3rd dose of replacement
		15 mmol, INT, IVPB, Once, PRN, see comment, Infuse Over 2 hr
			Comment: For phosphorus level 1.1-2.0.  Watch for hypocalcemia.  Contact provider prior to starting a 3rd dose of replacement.
Magnesium
	magnesium sulfate IVPB
		2 gm, INT, IVPB, Q4H, PRN see comment
			Comment: For Mg 1-1.6.  Recheck level in 4 hours.  Contact provider prior to starting a 3rd dose of replacement.
		4 gm, INT, IVPB, Q4H, PRN see comment
			Comment: For Mg < 1.0.  Recheck level in 4 hours.  Contact provider for low level and prior to starting a 3rd dose of replacement.
Patient Care

	Notify MD
		If Blood Glucose not within goal range for 4 consecutive hours.
		If Blood Glucose less than 60mg/dl for 2 consecutive measurements
	Intake and Output
		
	Notify MD
		If IV dextrose source, TPN, or PO diet stopped for any reason, TURN OFF INSULIN infusion and notify physician.
		Once blood sugar < 250mg/dL to add dextrose to IV fluid once blood sugar < 250 mg/dl.  If no fluids ordered start D5% Normal Saline 0.9% at 50mL/hr
	Discontinue Medication
		T;N, Pt. started on insulin infusion...Discontinue all previous blood glucose monitoring orders
	Notify MD
		When BG is at goal, pH > 7.3, and HCO3 > 18 mEq/L, Contact provider to discontinue protocol and switch to sliding scale insulin protocol and order diet.
Consults/Follow-up
	Pharmacy Consult
		T;N, Pt. started on insulin infusion...Discontinue all previous insulin orders

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.

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.

Pneumonia Community Acquired
Activity

	Activity-As Tolerated
		
	Up in Chair
		TIDWM
	Ambulate
		QID
Laboratory
	CBC with Diff
		Stat, spec type = Blood
	Comprehensive Metabolic Panel
		Stat, spec type = Blood
	hsCRP
		Stat, spec type = Blood
	Influenza A and B Screen PCR - JE
		Stat, spec type = Nasopharynx
	Influenza A and B Screen PCR
		Stat, spec type = Nasopharynx
	Procalcitonin
		Stat, spec type = Blood
	Respiratory Panel Flu-RSV-Covid
		T;N, Stat, spec type = Nasopharynx
Diagnostic Tests
	Chest 1 View
		Stat, Pneumonia
	Chest 2 View
		Pneumonia, Stat, Pneumonia
	ECG
		Stat, Indication: Pneumonia
Medications
Pain
	Tylenol
		650 mg, Tab, BY MOUTH, Q4H, PRN, pain-mild
Non ICU
		PREFERRED REGIMEN (select first choice)(NOTE)*
	Rocephin IVPB
		2,000 mg, Injection-Premix, IVPB, Q24H, Indication: Pneumonia-Community acquired, STAT
			Comment: If unable to obtain blood cultures on initial attempt, start antibiotics.
	Rocephin IVPB (FH)
		2,000 mg, INT, IVPB, Q24H, Indication: Pneumonia-Community acquired, STAT
			Comment: If unable to obtain blood cultures on initial attempt, start antibiotics.
	Zithromax IVPB
		500 mg, INT, IVPB, Q24H, Indication: Pneumonia-Community acquired, STAT
			Comment: If unable to obtain blood cultures on initial attempt, start antibiotics.
	Levaquin IVPB
		750 mg, Injection-Premix, IVPB, Q24H, Indication: Pneumonia-Community acquired, STAT
			Comment: If unable to obtain blood cultures on initial attempt, start antibiotics.
	Rocephin IVPB
		2,000 mg, Injection-Premix, IVPB, Q24H, Indication: Pneumonia-Community acquired, STAT
			Comment: If unable to obtain blood cultures on initial attempt, start antibiotics.
	Rocephin IVPB (FH)
		2,000 mg, INT, IVPB, Q24H, Indication: Pneumonia-Community acquired, STAT
			Comment: If unable to obtain blood cultures on initial attempt, start antibiotics.
	doxycycline IVPB
		100 mg, INT, IVPB, Q12H, Indication: Pneumonia-Community acquired, STAT
			Comment: If unable to obtain blood cultures on initial attempt, start antibiotics.
ICU
		PREFERRED REGIMEN (select first choice)(NOTE)*
	Rocephin IVPB
		2,000 mg, Injection-Premix, IVPB, Q24H, Indication: Pneumonia-Community acquired, STAT
			Comment: If unable to obtain blood cultures on initial attempt, start antibiotics.
	Rocephin IVPB (FH)
		2,000 mg, INT, IVPB, Q24H, Indication: Pneumonia-Community acquired, STAT
			Comment: If unable to obtain blood cultures on initial attempt, start antibiotics.
	Zithromax IVPB
		500 mg, INT, IVPB, Q24H, Indication: Pneumonia-Community acquired, STAT
			Comment: If unable to obtain blood cultures on initial attempt, start antibiotics.
		Beta-lactam allergy(NOTE)*
	Levaquin IVPB
		750 mg, Injection-Premix, IVPB, Q24H, Indication: Pneumonia-Community acquired, STAT
			Comment: If unable to obtain blood cultures on initial attempt, start antibiotics.
	Azactam IVPB
		2,000 mg, INT, IVPB, Q8H, Indication: Pneumonia-Community acquired, STAT
			Comment: If allergic to penicillin and cephalosporin.  If unable to obtain blood cultures on initial attempt, start antibiotics.
	Levaquin IVPB
		750 mg, Injection-Premix, IVPB, Q24H, Indication: Pneumonia-Community acquired, STAT
	Rocephin IVPB (FH)
		2,000 mg, INT, IVPB, Q24H, Indication: Pneumonia-Community acquired, STAT
			Comment: If unable to obtain blood cultures on initial attempt, start antibiotics.
	Rocephin IVPB
		2,000 mg, Injection-Premix, IVPB, Q24H, Indication: Pneumonia-Community acquired, STAT
Pseudomonal Risk(ICU & non-ICU)
		Risk factors: structural lung disease (bronchiectasis, chronic bronchitis, COPD, emphysema, interstitial lung disease, pulmonary fibrosis) with chronic steroids or multiple rounds of antibiotics.(NOTE)*
		PREFERRED REGIMEN (select first choice)(NOTE)*
	Levaquin IVPB
		750 mg, Injection-Premix, IVPB, Q24H, Indication: Pneumonia-Community acquired, STAT
			Comment: If unable to obtain blood cultures on initial attempt, start antibiotics.
	Zosyn IVPB
		4.5 gm, Injection-Premix, IVPB, Q8H, Indication: Pneumonia-Community acquired, STAT
			Comment: If not allergic to penicillin.  If unable to obtain blood cultures on initial attempt, start antibiotics.
	Zosyn IVPB (FH)
		4.5 gm, INT, IVPB, Q8H, Indication: Pneumonia-Community acquired, STAT
			Comment: If not allergic to penicillin.  If unable to obtain blood cultures on initial attempt, start antibiotics.
		Quinolone alternative/allergy(NOTE)*
	Zosyn IVPB
		4.5 gm, Injection-Premix, IVPB, Q8H, Indication: Pneumonia-Community acquired, STAT
			Comment: If not allergic to penicillin.  If unable to obtain blood cultures on initial attempt, start antibiotics.
	Zosyn IVPB (FH)
		4.5 gm, INT, IVPB, Q8H, Indication: Pneumonia-Community acquired, STAT
			Comment: If not allergic to penicillin.  If unable to obtain blood cultures on initial attempt, start antibiotics.
	Zithromax IVPB
		500 mg, INT, IVPB, Q24H, Indication: Pneumonia-Community acquired, STAT
			Comment: If unable to obtain blood cultures on initial attempt, start antibiotics.
	gentamicin
		5 mg/kg, INT, IVPB, Q24H, Indication: Pneumonia-Community acquired, STAT
			Comment: Pharmacy to dose.  If unable to obtain blood cultures on initial attempt, start antibiotics.
	Zithromax IVPB
		500 mg, INT, IVPB, Q24H, Indication: Pneumonia-Community acquired, STAT
	cefepime IVPB
		2,000 mg, INT, IVPB, Q8H, Indication: Pneumonia-Community acquired, STAT
	cefepime (FH/WH)
		2,000 mg, INT, IVPB, Q8H, Indication: Pneumonia-Community acquired, STAT
			Comment: If not allergic to penicillin.  If unable to obtain blood cultures on initial attempt, start antibiotics.
		Beta-lactam allergy(NOTE)*
	Levaquin IVPB
		750 mg, Injection-Premix, IVPB, Q24H, Indication: Pneumonia-Community acquired, STAT
			Comment: If unable to obtain blood cultures on initial attempt, start antibiotics.
	Azactam IVPB
		2,000 mg, INT, IVPB, Q8H, Indication: Pneumonia-Community acquired, STAT
			Comment: If allergic to penicillin and cephalosporin.  If unable to obtain blood cultures on initial attempt, start antibiotics.
MRSA Risk
		Pneumonia requiring admission to ICU, necrotizing/cavity infiltrates, empyema, end stage renal disease, injection drug abuse, influenza prior to illness, prior anitbiotic therapy, diabetes mellitus, head trauma, smokers, COPD, HIV, hospitalization/nursing(NOTE)*
		In addition to the antibiotics chosen above:(NOTE)*
	vancomycin - Pharmacy to Dose
		Pharmacy to Dose, IVPB, PHARMACY TO DETERMINE, Pneumonia-Community acquired
	Zyvox IVPB
		600 mg, Injection-Premix, IVPB, Q12H, Indication: Pneumonia-Community acquired
Therapies
Respiratory Therapy
	Bronchodilator Therapy per Respiratory Protocol (FH)
		T;N
	Pulse Oximetry Spot Check RT
		T;N, BID
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
	Incentive Spirometer
		Q1HAWAKE
	Aerosol Treatment for sputum induction
		T;N
	albuterol-ipratropium 2.5 mg-0.5 mg/3 mL inhalation solution
		3 mL, Solution-Nebulization, NEBULIZED, QID
		3 mL, Solution-Nebulization, NEBULIZED, Q2H, PRN for wheezing and/or shortness of breath
	albuterol concentrate 2.5mg/0.5mL (0.5%) inh soln
		0.5 mL, Solution-Nebulization, NEBULIZED, Q2H, PRN for wheezing and/or shortness of breath
	sodium chloride 0.9% inhalation solution
		3 mL, Solution-Nebulization, Inhalation, Q2H, PRN for wheezing and/or shortness of breath
	levalbuterol 1.25 mg/3 ml inhalation solution
		3 mL, Solution-Nebulization, NEBULIZED, Q8H
		3 mL, Solution-Nebulization, NEBULIZED, Q4H, PRN for wheezing and/or shortness of breath
	Consult Pulmonary Rehab: Inpatient
		Pneumonia
	Smoking Cessation Education
		T;N
	Smoking Cessation Education RT (FH)
		T;N
	Consult Respiratory Therapy-Assess and Treat
		T;N
Consults/Follow-up

	Consult Pulmonologist
		Reason for Referral: Pneumonia
	Consult Infectious Disease
		Reason for Referral: Pneumonia

UTI Urinary Tract Infection
Laboratory
		Pyuria is present in almost all patients with complicated urinary tract infectious (UTI); its absence suggests an alternative diagnosis.((NOTE)*
	UA (Culture if Positive)
		T;N, Routine, Routine, UA Cult Clean Catch, Midvoid, spec type = Urine
		T;N, Routine, Routine, UA Cult Straight Cath, spec type = Urine
		T;N, Routine, Routine, UA Cult Suprapubic Cath, spec type = Urine
	Culture Routine
		T;N, Routine, Nurse collect
Medications
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	sulfamethoxazole-trimethoprim DS 800 mg-160 mg oral tablet
		1 TAB, Tab, By Mouth, BID, Indication: UTI, 3 Day(s)
	nitrofurantoin
		100 mg, Capsule, By Mouth, BID, Indication: UTI, 5 Day(s)
			Comment: NOTE: do not use nitrofurantoin in the last trimester of pregnancy or during labor for fear of causing hemolytic anemia in the newborn
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	fosfomycin
		3 gm, Suspension, By Mouth, Once
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	amoxicillin
		500 mg, Capsule, By Mouth, Q8H, Indication: UTI, 5 Day(s)
	amoxicillin-clavulanate  500 mg-125 mg oral tablet
		1 TAB, Tab, By Mouth, BID, Indication: UTI, 5 Day(s)
	cefdinir
		300 mg, Capsule, By Mouth, Q12H, Indication: UTI, 5 Day(s)
	levoFLOXacin
		250 mg, Tab, By Mouth, Q24H, Indication: UTI, 3 Day(s)
		250 mg, Injection-Premix, IVPB, Q24H, Indication: UTI, 3 Day(s)
			Comment: Change to PO [same dose and frequency] when patient tolerating oral / enteral nutrition and receiving other oral medications.
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	cefTRIAXone IVPB (FH)
		1,000 mg, INT, IVPB, Q24H, Indication: Other- type in, UTI-Pyelonephritis
			Comment: Change to PO Cefdinir when patient qualifies for IV to PO conversion Criteria: receiving other oral medications receiving oral or enteral nutrition CrCl >= 30 = Cefdinir 300mg BID CrCl < 30 = Cefdinir 300mg Daily
	cefTRIAXone IVPB
		1,000 mg, Injection-Premix, IVPB, Q24H, Indication: Other- type in, UTI, Pyelonephritis
			Comment: Change to PO Cefdinir when patient qualifies for IV to PO conversion Criteria: receiving other oral medications receiving oral or enteral nutrition CrCl >= 30 = Cefdinir 300mg BID CrCl < 30 = Cefdinir 300mg Daily
	levoFLOXacin
		750 mg, Tab, By Mouth, Q24H, Indication: Other- type in, UTI-Pyelonephritis, 5 Day(s)
		750 mg, Injection-Premix, IVPB, Q24H, Indication: Other- type in, UTI-Pyelonephritis, 5 Day(s)
			Comment: Change to PO [same dose and frequency]when patient tolerating oral / enteral nutrition and receiving other oral medications.
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	ertapenem
		1,000 mg, IVPB, Once, Indication: Other- type in, UTI-Pyelonephritis, STAT
			Comment: Only order if patient has history of MDRO on past cultures or there is suspicion of MDRO.
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	phenazopyridine
		200 mg, Tab, By Mouth, TID, PRN urinary discomfort
Consults/Follow-up
	Consult Infectious Disease
		
	Consult Nephrologist
		
	Consult Urology

*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