Unique Plan Description: Ortho Total Hip , Post op EKM
Plan Selection Display: Ortho Total Hip , Post op
PlanType: Medical                                 
Version: 5          
Begin Effective Date: 2021-04-05 07:14:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-05-13 15:41:39
Available at all facilities: Yes

Ortho Total Hip , Post op EKM
Vital Signs
	Vital Signs
		T;N, Routine post op
Activity
	Dangle
		T;N
			Comment: with assistance day of surgery as tolerated.
	Up in Chair
		T+1;0600, With assistance
			Comment: Start day of surgery
	Ambulate
		T;N, With assistance, TID
		T+1;0600, With assistance, TID
			Comment: with assistance start post op day 1
	Weight Bearing
		T;N, Weight bearing as tolerated
		T;N, Touch down weight bearing
	Hip Dislocation Precautions
		T;N
Diet
	Regular Diet
		T;N
	Diabetic Diet
		T;N, Calorie Level 2500 kcal
	Oral Supplement
		Boost Plus, AM and PM
		Boost Plus Shake, TID with Meals
		Impact Advanced Recovery, AM and PM
Laboratory
	CBC with Diff
		T;1800, Routine, spec type = Blood
	Hemogram
		T;1800, Routine, spec type = Blood
Tomorrow's Lab
	Hemoglobin and Hematocrit
		T+1;0400, Routine, Q24H, 3, Dose(s)/Time(s), spec type = Blood
	Hemogram
		T+1;0400, Routine, Q24H, 3, Dose(s)/Time(s), spec type = Blood
	CBC with Diff
		T+1;0400, Routine, Q24H, 3 Dose(s)/Time(s), spec type = Blood
		T+1;0400, Routine, spec type = Blood
	Basic Metabolic Panel
		T+1;0400, Routine, Q24H, 3 Dose(s)/Time(s), spec type = Blood
		T+1;0400, Routine, spec type = Blood
	Iron Panel - MH/WH/JE
		T+1;0400, Routine, spec type = Blood
	Glucose POC - RN
		T;N, QIDACHS
IV Solutions

	Lactated Ringers Injection
		1,000 mL, IV, 75 ml/hr
		1,000 mL, IV, 100 ml/hr
		1,000 mL, IV, 125 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
	0.45NaCl
		1,000 mL, IV, 75 ml/hr
		1,000 mL, IV, 100 ml/hr
		1,000 mL, IV, 125 ml/hr
	IVF-1/2NS20K
		1,000 mL, IV, 75 ml/hr
		1,000 mL, IV, 100 ml/hr
		1,000 mL, IV, 125 ml/hr
	Discontinue IV
		T+1;0600, See Order Comments
			Comment: if tolerating PO well
Medications
Antibiotics
	Ancef IVPB (JE)
		1,000 mg, Injection-Premix, IVPB, Q8H, Surgical prophylaxis, 3 Dose(s)/Time(s)
			Comment: Start in PACU
	Ancef IVPB (MH/WH)
		2,000 mg, Injection-Premix, IVPB, Q8H, Surgical prophylaxis, 2 Dose(s)/Time(s)
			Comment: First dose to be given 8 hours after last OR dose. Pharmacy to adjust scheduled time.
	Cleocin IVPB (JE)
		900 mg, Injection-Premix, IVPB, Q8H, Surgical prophylaxis, 2 Dose(s)/Time(s)
			Comment: Start in PACU
	Cleocin IVPB (MH/WH/FH)
		900 mg, Injection-Premix, IVPB, Q8H, Surgical prophylaxis, 2 Dose(s)/Time(s)
			Comment: First dose to be given 8 hours after last OR dose. Pharmacy to adjust scheduled time
	vancomycin - Pharmacy to Dose
		PHARMACY to DOSE, IVPB, Per protocol, Surgical prophylaxis
			Comment: Give x1 dose post-op at appropriate time based on time of pre-op dose. Dose per pharmacy.  Consider 24 hour proton pump inhibitor
	Zinacef IVPB (JE)
		750 mg, INT, IVPB, Q8H, Surgical prophylaxis, 3 Dose(s)/Time(s)
			Comment: Start in PACU
	Zinacef IVPB (MH/WH/FH)
		750 mg, INT, IVPB, Q8H, Surgical prophylaxis, 2 Dose(s)/Time(s)
			Comment: First dose to be given 8 hours after last OR dose. Pharmacy to adjust scheduled time
Scheduled Medications
	Tylenol
		500 mg, Tab, By Mouth, Q4H-Sch
	traMADol
		50 mg, Tab, By Mouth, Q6H-Sch
	CeleBREX
		100 mg, Capsule, By Mouth, Q12H, T;2100
		200 mg, Capsule, By Mouth, DAILY, T+1;0900
		200 mg, Capsule, By Mouth, Q12H, T;2100
	meloxicam
		15 mg, Tab, By Mouth, DAILY, T+1;0900
		7.5 mg, Tab, By Mouth, BID, T+1;0900
	Lyrica
		50 mg, Capsule, By Mouth, Q8H, T;2200
		75 mg, Capsule, By Mouth, DAILY, T;2100
	Decadron injectable
		4 mg, Injection, IV Push, Once, T+1;0900
	Vitamin C
		250 mg, Tab, By Mouth, BID, T+1;0900
	ferrous sulfate
		325 mg, Tab, By Mouth, BID, T+1;0900
			Comment: Administer with food
	multivitamin therapeutic
		1 TAB, Tab, By Mouth, DAILY
	MiraLax oral powder for reconstitution
		17 gm, Packet, By Mouth, BID, T;2100
			Comment: Mix in 6 oz of juice or water.
		17 gm, Packet, By Mouth, DAILY, T+1;0900
			Comment: Mix in 6 oz of juice or water
PRN
	Benadryl
		25 mg, Injection, IV Push, Q6H, PRN for itching-severe, duration: 5 Day(s)
			Comment: Use when patient intolerant to oral
		25 mg, Tab, By Mouth, Q6H, PRN for itching-severe, duration: 5 Day(s)
	melatonin
		3 mg, Tab, By Mouth, QHS, PRN for insomnia
			Comment: give 30min prior to bedtime
Patient Care

	Resuscitation Status
		T;N, Full Code
		T;N, No Code
	Notify MD of Lab results
		if glucose >150
		if glucose >200
		PCP if Hgb <7
		PCP if Hgb <8
	Notify MD
		T;N, Notify PCP or hospitalist if Respiratory rate < 8 or > 30 breaths per minute, DBP < 60 or > 90mmHg, SBP <90 or > 180mmHG, Heart rate < 50 or >120, O2 sats < 90%, Temp > 102F, Urine output < 30mls per hour for 2 consecutive hours or < 240ml in 8 hours
	Cold Therapy
		T;N, Ice bag, Hip, 48, hr
			Comment: Apply 20min, q4h
	Incentive Spirometer
		T;N, Q1H, while awake
	Discontinue Urinary Catheter
		T+1;0600, Foley
	Bladder Scan
		T;N, unable to void
		T;N, Q4H, If no void and assess for residual
	PVR-Post, Bladder Scan
		T;N, after first void to assess for residual
	Straight Catheter
		T;N, bladder scan >..., 300 mL
			Comment: If 3rd catheterization required, notify MD
	Intake and Output
		T;N, Q6H-Sch minus Q12 End of Shift, 24, hr
	Dressing Care
		T+2;0600, Change, Once
			Comment: Mepilex Border Post op Ag dressing once. Leave on for 7 days
		T+1;0600, Change, Once
			Comment: Apply gauze dressing and tape
		T;N
			Comment: Maintain, Incisional Wound Vac
	Wound VAC
		T;N
	Discontinue Wound Drain
		T+1;0600
	VTE Advisor
		Ortho surgery - elective hip replace
	Cardiac Telemetry Monitoring
		
Therapies
	Consult Occupational Therapy, Evaluate and Treat
		T;N, Reason to See: Evaluate and Treat
			Comment: post op total hip
		T+1;0600, Reason to See: Evaluate and Treat
			Comment: post op total hip
	Consult Physical Therapy, Evaluate and Treat
		T;N, Reason to See: Total Joint Protocol
			Comment: post op total hip
Consults/Follow-up
	Pharmacy Consult - Warfarin (Coumadin) Therapy
		T;N, Coumadin dosing in hospital
	Consult Hospitalist
		Reason for Referral: If PCP does not make hospital rounds, Refer to/Consult with: Hospitalist on call
	Consult Primary Care Provider
		Reason for Referral: for post operative medical management
	Consult Social Work
		T;N, Evaluation
			Comment: discharge planning and home meds
	Consult Primary Care Provider
		Reason for Referral: To manage Coumadin as an outpatient, Requested Time Frame Today

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

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

Pain Constipation Nausea Protocol </= to 65 EKM
Medications
		Select only one medication in each category(NOTE)*
Mild Pain
	acetaminophen
		650 mg, Tab, By Mouth, Q4H, PRN for see comment
			Comment: Discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient
		650 mg, Suppository, RECTALLY, Q6H, PRN for see comment
			Comment: Discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient
	ibuprofen
		600 mg, Tab, By Mouth, Q6H, PRN for pain-mild
			Comment: pain rating 1-3
		800 mg, Tab, By Mouth, Q8H, PRN for pain-mild
			Comment: pain rating 1-3
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-mild
			Comment: pain rating 1-3
	oxyCODONE-acetaminophen 5/325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-mild
			Comment: Pain rating 1-3
	HYDROmorphone Injectable
		0.2 mg, Injection, IV Push, Q2H, PRN for pain-mild
			Comment: For pain rating 1-3 and if NPO
	morphine  IV
		2 mg, Syringe, IV Push, Q2H, PRN for pain-mild
			Comment: for pain rating 1-3 and if NPO
Moderate Pain
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	acetaminophen-hydrocodone 325 mg-7.5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	acetaminophen-hydrocodone 325 mg-10 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	oxyCODONE-acetaminophen 5/325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	oxyCODONE-acetaminophen 7.5/325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	oxyCODONE-acetaminophen 10/325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	oxyCODONE
		5 mg, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	morphine  oral immediate release
		15 mg, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: Pain rating 4-6
	HYDROmorphone Injectable
		0.2 mg, Injection, IV PUSH, Q2H, PRN for pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
		0.4 mg, Injection, IV PUSH, Q2H, PRN for pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
	morphine  IV
		2 mg, Syringe, IV Push, Q2H, PRN for pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
		4 mg, Syringe, IV Push, Q2H, PRN for pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
	ketorolac injectable
		15 mg, Injection, IV Push, Q6H, PRN for pain-moderate, duration: 48 hr
			Comment: For pain rating 4-6.
Severe Pain
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	acetaminophen-hydrocodone 325 mg-7.5 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	oxyCODONE-acetaminophen 5/325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	oxyCODONE-acetaminophen 7.5/325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	oxyCODONE-acetaminophen 10/325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	oxyCODONE
		10 mg, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	morphine  oral immediate release
		30 mg, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	HYDROmorphone Injectable
		0.4 mg, Injection, IV PUSH, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10 if NPO or for breakthrough pain if on oral analgesics. Use 0.4mg if over age 70.
		0.5 mg, Injection, IV PUSH, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10 if NPO or for breakthrough pain if on oral analgesics. Use 0.4mg if over age 70.
		0.6 mg, Injection, IV PUSH, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10 if NPO
		0.8 mg, Injection, IV PUSH, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10 if NPO
		1 mg, Injection, IV PUSH, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10 if NPO
	morphine  IV
		4 mg, Syringe, IV Push, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10; may give if NPO or for breakthrough pain if on oral analgesics.
		6 mg, Syringe, IV Push, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10; may give if NPO or for breakthrough pain if on oral analgesics.
		Opiate Reversal(NOTE)*
	Narcan
		0.2 mg, Injection, IV Push, Q2MIN, PRN for see comment
			Comment: if patient has received opiate agents in the past 24 hours and/or if patient becomes somnolent with minimal or no response to stimuli or respiratory rate is 10 or less per minute.  RN may administer naloxone prior to contacting MD.  Notify MD immediately upon administration of naloxone.  May give 0.2mg every 2 min up to 1mg total dose.
Constipation
	docusate
		100 mg, Capsule, By Mouth, DAILY
			Comment: Hold for diarrhea
	Senokot S 50 mg-8.6 mg oral tablet
		2 TAB, Tab, By Mouth, QHS
	MiraLax oral powder for reconstitution
		17 gm, Packet, By Mouth, Q12H, PRN, constipation
			Comment: Mix in 6 oz juice or water
		17 gm, Packet, By Mouth, DAILY, PRN, constipation
			Comment: Mix in 6 oz juice or water
	Milk of Magnesia 8% oral suspension
		30 mL, Suspension, By Mouth, DAILY, PRN for constipation
			Comment: If Miralax not effective; do not use if creatinine clearance or GFR < 30mL/min
		30 mL, Suspension, By Mouth, Q12H, PRN for constipation
			Comment: If Miralax not effective; do not use if creatinine clearance or GFR < 30mL/min
	Dulcolax
		10 mg, Suppository, RECTALLY, DAILY, PRN, constipation
			Comment: If MOM ineffective or if patient NPO
		10 mg, Suppository, RECTALLY, Q12H, PRN, constipation
			Comment: If MOM ineffective or if patient NPO
	Fleet Enema 19 gm-7 gm rectal enema
		1 EA, Enema, RECTALLY, Q12H, PRN, constipation
			Comment: If bisacodyl ineffective
	Enema-Administer
		Tap water, Q1H, constipation
			Comment: if suppository ineffective
Nausea Vomiting
	ondansetron
		4 mg, Injection, IV PUSH, Q6H, PRN for nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN for nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED
		Select either promethazine or prochlorperazine orders(NOTE)*
	prochlorperazine
		10 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures.
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures, give if IV access not available.
	Phenergan (MH/WH)
		25 mg, Tab, By Mouth, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures.
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
		6.25 mg, Injection, IM-Intramuscular, Q6H, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Phenergan (FH)
		12.5 mg, INT, IVPB, Once, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
		25 mg, INT, IVPB, Once, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Phenergan (JE)
		25 mg, Tab, By Mouth, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	metoclopramide
		10 mg, Injection, IV PUSH, Q6H, PRN for nausea and/or vomiting
			Comment: Give if ondansetron and phenothiazine ineffective; avoid in patients > 65 y/o.
		10 mg, Injection, IM-Intramuscular, Q6H, PRN for nausea and/or vomiting
			Comment: Give if ondansetron and phenothiazine ineffective; avoid in patients > 65 y/o.
Patient Care

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

Pain Constipation Nausea Protocol > 65 Geriatric E
Medications
		Select only one medication in each category(NOTE)*
Mild Pain
	acetaminophen
		1,000 mg, Tab, By Mouth, Q8H-Sch, T;N
			Comment: For pain rating 1-3; Consider IV Acetaminophen (Ofirmev) if NPO.
		1,000 mg, Tab, By Mouth, Q8H, PRN for pain-mild
			Comment: For pain rating 1-3; Consider IV Acetaminophen (Ofirmev) if NPO.
		1,000 mg, Tab, By Mouth, Q8H-Sch, T+1;N
			Comment: For pain rating 1-3; Consider IV Acetaminophen (Ofirmev) if NPO.
	acetaminophen 10 mg/mL intravenous solution
		1,000 mg, Solution-Injection, IVPB, Q8H, T;N, duration: 3 Dose(s)/Time(s)
			Comment: For pain rating 1-3.
Moderate Pain
	oxyCODONE
		2.5 mg, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6
	traMADol
		25 mg, Tab, By Mouth, Q6H, PRN for pain-moderate
			Comment: For pain rating 4-6; Screen for drug interactions (e.g.SSRI), and adjust dose for CrCl<30ml/min; avoid use if history of seizures.
	HYDROmorphone Injectable
		0.2 mg, Injection, IV PUSH, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics.
Severe Pain
	oxyCODONE
		5 mg, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: For pain rating 7-10.
	traMADol
		50 mg, Tab, By Mouth, Q6H, PRN for pain-severe
			Comment: For pain rating 7-10; screen for drug interactions (e.g.SSRI), and adjust dose for CrCl<30ml/min; avoid use if history of seizures.
	HYDROmorphone Injectable
		0.4 mg, Injection, IV PUSH, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10 if NPO or for breakthrough pain if on oral analgesics.
		Opiate Reversal(NOTE)*
	Narcan
		0.2 mg, Injection, IV Push, Q2MIN, PRN for see comment
			Comment: If patient has received opiate agents in the past 24 hours and/or if patient becomes somnolent with minimal or no response to stimuli or respiratory rate is 10 or less per minute.  RN may administer naloxone prior to contacting MD.  Notify MD immediately upon administration of naloxone.  May give 0.2mg every 2 min up to 1mg total dose.
PRN Discomfort
	trolamine salicylate 10% topical cream
		1 appl, Cream, TOPICAL, TID, PRN for discomfort
			Comment: Apply to affected area.
	menthol-methyl salicylate topical
		1 appl, Cream, TOPICAL, TID, PRN for discomfort
			Comment: Apply to affected area.
	lidocaine 4% topical patch
		1 patch, Patch, TransDERMAL, DAILY
	lidocaine Patch Removal
		Patch Removal, Patch, TransDERMAL, QHS
	Medication patch site check
		T;N+720, Q12H
Constipation
	Senokot S 50 mg-8.6 mg oral tablet
		1 TAB, Tab, By Mouth, BID, PRN for constipation
			Comment: Hold for loose stools
	MiraLax oral powder for reconstitution
		17 gm, Packet, By Mouth, BID
			Comment: Hold for loose stools.  Mix in 6oz juice or water.
	Dulcolax
		10 mg, Suppository, RECTALLY, Q12H, PRN for constipation
			Comment: If other agents ineffective or if patient NPO.
	Fleet Enema 19 gm-7 gm rectal enema
		1 EA, Enema, RECTALLY, Q12H, PRN for constipation
			Comment: If suppository ineffective.
	Enema-Administer
		Tap water, Q1H, see comment
			Comment: If suppository ineffective.
Nausea Vomiting
	ondansetron
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN for nausea and/or vomiting
		4 mg, Injection, IV Push, Q6H, PRN for nausea and/or vomiting
			Comment: If unable to take by mouth.

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