Unique Plan Description: OB C-Section, Post op EKM, ENHANCED RECOVERY
Plan Selection Display: OB C-Section, Post op ENHANCED RECOVERY
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2020-04-21 19:18:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2025-05-08 13:14:22
Available at all facilities: Yes

OB C-Section, Post op EKM, ENHANCED RECOVERY
Admit/Discharge/Transfer
	Admit to Inpatient Status
		
Vital Signs
	Vital Signs
		T;N, Once
			Comment: Routine Postop
Activity
	Bedrest
		T;N, Once
	Activity-As Tolerated
		T;N, Day of Surgery
			Comment: MWH/MJE ONLY: Patient may leave patient care unit while remaining on campus as desired when medically appropriate
	Dangle
		T;N+360, Once
Diet
	Regular Diet
		T;N
Laboratory
	Tissue Request Placenta
		T;N, Placenta
		Diabetes Monitoring(NOTE)*
	Glucose POC - RN
		ACBKFST
		TIDPC, 24, hr
		T;N, No Glycemic Monitoring
IV Solutions
		If Type 1 Diabetic - use Normal Saline instead of Lactated Ringers for mainline IV(NOTE)*
	Lactated Ringers Injection
		1,000 mL, IV, 125 ml/hr
			Comment: Begin when Pitocin complete. Discontinue when tolerating PO well.
	Sodium Chloride 0.9%
		1,000 mL, IV, 125 ml/hr
			Comment: Begin when Pitocin complete. Discontinue when tolerating PO well.
	oxytocin 30 units/500mL Premix IV
		30 units, EVERY BAG, 59.94 units/hr
		500 mL, IV, Routine, T;N, 24 hr
			Comment: Infuse 15 units over 15 minutes (999mL/hr) immediately post partumFollowed by 15 units over 3 hours (83.3mL/hr) immediately after first bolus dose is completed - The Initial postpartum infusion rate may be decreased prior to 15 minutes based on patient's clinical status and communication between the surgeon and anesthesia provider. - RN will be responsible to adjust IV rate.
Medications
		Pain Medications(NOTE)*
	ibuprofen
		800 mg, Tab, BY MOUTH, Q8H, T;N+240
			Comment: Alternate every 4 hours with acetaminophen
	acetaminophen
		1,000 mg, Tab, By Mouth, Q8H, T;N+480
			Comment: Alternate every 4 hours with ibuprofen
	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.
		10 mg, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: For pain rating 7-10.
	ketorolac injectable
		15 mg, Injection, IV Push, Q6H, PRN for pain-mild, duration: 48 hr
			Comment: For pain rating 1-3 and if NPO. Give at least 6 hours after last ibuprofen dose.
	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-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: RN may administer naloxone prior to contacting MD, if patient has received opiate agents in the past 24hrs, and if patient becomes somnolent with minimal or no response to stimuli or respiratory rate is less than or equal to 10bpm. May give 0.2mg every 2 minutes up to 1mg total dose.
		Constipation(NOTE)*
	Colace
		100 mg Capsule BY MOUTH DAILY
			Comment: hold if diarrhea
		100 mg Capsule BY MOUTH BID
			Comment: hold if 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 for constipation
			Comment: Mix in 6 oz juice or water
		17 gm, Packet, By Mouth, DAILY, for constipation
			Comment: Mix in 6 oz juice or water
	Milk of Magnesia
		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 for constipation
			Comment: If MOM ineffective or if patient NPO.
		10 mg, Suppository, RECTALLY, Q12H, PRN for constipation
			Comment: If MOM ineffective or if patient NPO.
		Nausea(NOTE)*
	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 and unable to take oral meds.
		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
	prochlorperazine
		10 mg, Injection, IV Push, Q6H, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures.
		25 mg, Suppository, RECTALLY, BID, PRN for 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 for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures.
		25 mg, Suppository, RECTALLY, BID, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
		6.25 mg, Injection, IV Push, Q6H, PRN 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; give if unable to take oral meds.
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Phenergan (FH)
		25 mg, Tab, By Mouth, BID, 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, Suppository, RECTALLY, BID, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
		12.5 mg, INT, IVPB, 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.
	Reglan
		10 mg, Injection, IV Push, Q6H, PRN for nausea and/or vomiting
			Comment: Give if ondansetron and phenothiazine ineffective.
		10 mg, Injection, IM-Intramuscular, Q6H, PRN for nausea and/or vomiting
			Comment: Give if ondansetron and phenothiazine ineffective.
	Tums E-X
		750 mg, Tablet-Chew, By Mouth, Q1H, PRN for indigestion
	Tums (JE-FH)
		500 mg, Tablet-Chew, By Mouth, Q1H, PRN for indigestion
	simethicone
		80 mg, Tablet-Chew, BY MOUTH, Q4H, PRN, gas
	Ambien
		5 mg, Tab, BY MOUTH, QHS, PRN, insomnia
	mupirocin 2% topical ointment
		1 appl, Ointment, TOPICAL, TID, PRN for see comment
			Comment: for nipple trauma: to nipples as needed for persistent cracks, fissures, yellow crusted lesions, weeping wound.
	Anusol-HC 2.5% rectal cream
		1 appl, Cream, RECTALLY, Q1H, PRN, hemorrhoids
			Comment: Use if Tucks ineffective.
	witch hazel pre-moistened pads
		1 appl, Pad, TOPICAL, Q1H, PRN, hemorrhoids
	Benadryl
		25 mg, Tab, By Mouth, Q6H, PRN for itching
Immunizations
		IF patient is rubella non immune or equivocal, RN may place MMR vaccine order below.(NOTE)*
	M-M-R II injection
		0.5 mL, Injection, SUBCUTANEOUS, Once, duration: 1 Dose(s)/Time(s)
Patient Care

	Resuscitation Status
		T;N, Full Code
		T;N, No Code
	VTE Advisor
		Cesarean section
	Patient to Chew Gum
		(patient supply) To increase GI motility
	Abdominal Binder
		
	Discontinue Peripheral Lock
		Once
	Heat Therapy
		T;N, Aqua K
			Comment: PRN as needed
	Discontinue Urinary Catheter
		T;N, Foley, Once
			Comment: May remove when ambulatory and adequate urinary output
	Glucose POC - RN
		T;N, ACBKFST
		T;N, TIDPC
	Straight Catheter
		Insert, unable to void
			Comment: If 3rd catheterization required, enter order for Foley catheter insert, once, ordered by urologist/GYNand insert foley catheter.
	Dressing Care
		T;N+1440, Once
			Comment: Cover incision for 24 hours post op.  May shower once dressing removed
	Transparent Dressing (FH)
		Keep dressing in place for 7 days.  May shower with dressing in place.
	Notify MD
		Obstetric Call Parameters: SBP >160 mmHg and/or DBP >110 mmHg, P: >120 or <50, O2 Sat: <90%, RR: <10 or >30, Oliguria: <60 mL in 2 hours, Single Temp > 39.0C (102.2F), OR 2 temps between 38.0C (100.4F) and 39C (102.2F), at least 30 min apart
		If blood sugar is > or = 300
	Pulse Oximetry Spot Check by nurse
		T;N
			Comment: If Sat <95%, notify Respiratory Therapy, and enter Oxygen Protocol, titrate/wean to keep sats > or = 90%
Consults/Follow-up
	Pharmacy Consult
		T;N, Consult pharmacy for allergy history and options for pain management

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

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

OB Hemorrhage Meds (FH)
Laboratory
	Type and Screen (No Product on hold)
		Routine, spec type = Blood
Medications
	Cytotec
		800 mcg, Tab, RECTALLY, Once, PRN, bleeding
	Methergine
		0.2 mg, Injection, IM-IntraMUSCULAR, Q2H, PRN, uterine relaxation
			Comment: Avoid in hypertensive patients
	Hemabate
		250 mcg, Injection, IM-IntraMUSCULAR, Q15MIN, PRN, uterine relaxation, 8 Dose(s)/Time(s)
			Comment: Avoid in asthmatic patients.  Relative contraindication if hepatic, renal and cardiac disease
	tranexamic acid
		1,000 mg, Solution, IV Push, Once, PRN for see comment
			Comment: Hemorrhage management, push slowly over 10 minutes to avoid hypotension.
	oxytocin 30 units/500mL Premix IV
		500 mL, IV, Routine, T;N
			Comment: infuse 15 units over 15 minutes (999ml/hr), if firm uterine tone present, change rate to 15 units over 3 hours (83.3ml/hr)
		30 units, EVERY BAG

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

*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