Unique Plan Description: Pulm Tracheostomy (FH MH WH)
Plan Selection Display: Pulm Tracheostomy (FH MH WH)
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2020-04-20 23:34:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2021-12-14 09:08:45
Available at all facilities: Yes

Percutaneous Trach Pre
Diet
	NPO
		T;N
Laboratory
	INR - MH/WH/JE
		T+1;0400, spec type = Blood
	Prothrombin Time (PT) - FH
		T+1;0400, Routine, spec type = Diagnostic Blood
		T+1;0400, Routine, spec type = Therapeutic Blood
	PTT - MH/WH/JE
		T+1;0400, spec type = Blood
	Partial Thromboplastin Time (PTT) - FH
		T+1;0400, Routine, spec type = Diagnostic Blood
Diagnostic Tests
	Chest 1 View
		T;N, Stat, Tube Placement F/U
			Comment: at bedside
Medications
	lidocaine-EPINEPHrine 2%-1:100000 injectable solution
		20 mL, Injection, MISC, Once
			Comment: on call for percutaneous tracheostomy
	rocuronium
		100 mg, Injection, IV Push, Once, T;N
	Ativan
		5 mg, Injection, IV Push, Once
	midazolam
		10 mg, Injection, IV Push, Once, T;N
	fentaNYL
		100 mcg, Injection, IV Push, Once
			Comment: on call for percutaneous tracheostomy
	Polysporin 500 units-10,000 units/g topical ointment
		1 appl, Ointment, TOPICAL, Once, T;N
	Triple Antibiotic
		1 appl, Ointment, TOPICAL, Once, T;N
	Diprivan
		0.5 mg/kg, Injection, IV Push, Once, STAT
			Comment: Infuse over 3 to 5 minutes.
Patient Care
	Obtain Consent/Permit for:
		T;N
	Obtain supplies/equipment
		T;N
			Comment: have percutaneous trach set, sterile gown, mask, hat, sterile gloves size 8, extra trachs #8 and #9 single cannula shiley trach, 12ml syringe with 21 gauge needle, 28 gauge needle, #11 scapel, small curved hemostat, trach ties (velcro), surgifoam, and fiberoptic bronshoscope, sterile scissors, RT supply: omniflec adapter from the trache to then vent ciruit.  Polysporin 1 tube, lidocaine-epinephrine 2% 1:100,000 injectable solution and zemuron in room
Therapies
	Notify
		T;N, Notify Respiratory Therapy and Rehab Therapies, patient is  scheduled for Tracheostomy
Consults/Follow-up
	Pharmacy Consult
		T;N, notify pharmacy of plans for procedure

Tracheostomy Post op
Vital Signs
	Vital Signs
		T;N, Routine post op
Activity
	Activity-Position
		T;N, 2, hr
			Comment: Elevate head of bed >45 degrees
Diagnostic Tests
Radiology
	Chest 1 View
		T;N, Routine, Tube Placement F/U
Medications

	Polysporin 500 units-10,000 units/g topical ointment
		1 appl, Ointment, TOPICAL, TID, duration: 72 hr
	Triple Antibiotic
		1 appl, Ointment, TOPICAL, TID, duration: 72 hr
Patient Care
	VTE Advisor
		General surgery
	Resuscitation Status
		T;N, Full Code
		T;N, No Code
	Room/Environment
		T;N, If non patent upper airway, place sign at head of bed
	Airway Suction
		T;N, as needed
Therapies
	Trach Care
		T;N
			Comment: tracheostomy, Change site dressing  in ________days
		T;N
			Comment: tracheostomy, Change ties in ________days
	Trach Care: Dressing Change
		T;N
			Comment: tracheostomy, Change site dressing  in ________days
		T;N
			Comment: tracheostomy, Change ties in ________days
Consults/Follow-up
	Pharmacy Consult
		T;N, patient scheduled for tracheostomy

VTE Prophylaxis Pre Op
Medications
	HEParin 5000 units/mL SUBCUTANEOUS
		5,000 units, Injection, SUBCUTANEOUS, PREOP, T;N
	Lovenox
		40 mg, Syringe, SUBCUTANEOUS, PREOP, T;N
		30 mg, Syringe, SUBCUTANEOUS, PREOP, T;N
Patient Care
	Sequential Compression Device Pre Procedure
		T;N, Apply, Once
			Comment: knee high
	Anti Embolism Stockings Pre Procedure
		T;N, Apply, Once
			Comment: knee high

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

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

Mechanical Ventilation
Activity
	ICU Progressive Mobility Protocol
		
Diet
	NPO
		T;N
Laboratory
	Blood Gases Arterial (ABG) - MH/WH/JE
		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+1;0400, Routine, Q24H, spec type = Blood
		T+1;0400, Routine, spec type = Blood
		T;N+30, Timed, spec type = Blood
	Blood Gases VENOUS (VBG)
		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
	Comprehensive Metabolic Panel
		T+1;0400, Routine, Q24H, spec type = Blood
	CBC with Diff
		T+1;0400, Routine, Q24H, spec type = Blood
Diagnostic Tests
	Chest 1 View
		T;N, Stat, Tube Placement F/U
		T+1;0001, Routine, Infiltrate, Portable
		T+1; 0001, Routine, Infiltrate, DAILY, Portable
IV Solutions
Sedation
	Diprivan 1000 mg/100 mL vial Premix IV
		1,000 mg, EVERY BAG, 5 mcg/kg/min
		100 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 5 mcg/kg/min, Incremental Decrease: 5 mcg/kg/min, Incremental Freq: 5 min(s), Max Dose: 50 mcg/kg/min
			Comment: Notify ordering LIP if unable to titrate up or down or if max dose is reached and the desired RASS sedation goal OR BIS goal is not achieved. Change bottle and tubing q12hr.
	Triglycerides
		T+3;0400, Routine, Q3D-Lab, spec type = Blood
			Comment: Order if Diprivan ordered
	midazolam 50 mg/NS 50 mL Premix
		50 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 0.5 mg/hr, Incremental Decrease: 0.5 mg/hr, Incremental Freq: 30 min(s), Max Dose: 4 mg/hr
			Comment: Notify ordering LIP if unable to titrate up or down or if max dose is reached and the desired RASS sedation goal OR BIS goal is not achieved.  Give 1mg Midazolam IV push with an increase in rate of continuous Midazolam infusion.
		50 mg, EVERY BAG, 2 mg/hr
	midazolam 50 mg/NS 50 mL IV
		50 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 0.5 mg/hr, Incremental Decrease: 0.5 mg/hr, Incremental Freq: 30 min(s)
			Comment: Notify ordering LIP if unable to titrate up or down or if max dose is reached and the desired RASS sedation goal OR BIS goal is not achieved.  Give 1mg Midazolam IV push with an increase in rate of continuous Midazolam infusion.
		50 mg, EVERY BAG, 2 mg/hr
	dexmedetomidine 400 mcg/NS 100 mL
		100 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 0.1 mcg/kg/hr, Incremental Decrease: 0.1 mcg/kg/hr, Incremental Freq: 30 min(s), Max Dose: 1.5 mcg/kg/hr
			Comment: Begin at 0.2mcg/kg/hr and titrate to desired goal OR BIS goal, Notify MD if target RASS OR BIS not met at 0.7mcg/kg/hr. Hold if HR<50, SBP<100mmHg or MAP<50 and notify MD.
		400 mcg, EVERY BAG, 0.2 mcg/kg/hr
	dexmedetomidine 400 mcg/NS 100 mL Premix IV
		400 mcg, EVERY BAG, 0.2 mcg/kg/hr
		100 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 0.1 mcg/kg/hr, Incremental Decrease: 0.1 mcg/kg/hr, Incremental Freq: 30 mcg/kg/hr, Max Dose: 1.5 mcg/kg/hr
			Comment: Begin at 0.2mcg/kg/hr and titrate desired goal OR BIS goal. Notify MD if target RASS OR BIS not met at 0.7mcg/kg/hr. Hold if HR<50, SBP<100mmHg or MAP<50 and notify MD.
	fentaNYL 2500mcg/NS 250mL (MH)
		250 mL, IV, Routine, T;N
			Comment: Incremental dose increase: 25mcg/hr, incremental dose decrease 25mcg/hr, incremental frequency 30min; Titrate to target pain goal (CPOT 0-3). Max dose of 200mcg/hr.  Contact ordering LIP if unable to titrate up or down or if max dose is reached and the desired pain goal is not reached. Give 25mcg fentaNYL IV push with an increase in rate of continuous fentanyl infusion. Reorder from pharmacy 1 hr before needed.
		2,500 mcg, EVERY BAG, 25 mcg/hr
	fentaNYL 1000 mcg/100 mL Premix IV (JE/WH)
		100 mL, IV, Routine, T;N
			Comment: Incremental dose increase: 25mcg/hr, incremental dose decrease 25mcg/hr, incremental frequency 30min; Titrate to target pain goal (CPOT 0-3). Max dose of 200mcg/hr.  Contact ordering LIP if unable to titrate up or down or if max dose is reached and the desired pain goal is not reached. Give 25mcg fentaNYL IV push with an increase in rate of continuous fentanyl infusion. Reorder from pharmacy 1 hr before needed.
		1,000 mcg, EVERY BAG, 25 mcg/hr
	fentaNYL 1250mcg/NS 125mL
		125 mL, IV, Routine, T;N
			Comment: Incremental dose increase: 25mcg/hr, incremental dose decrease 25mcg/hr, incremental frequency 30min; Titrate to target pain goal (CPOT 0-3). Max dose of 200mcg/hr.  Contact ordering LIP if unable to titrate up or down or if max dose is reached and the desired pain goal is not reached. Give 25mcg fentaNYL IV push with an increase in rate of continuous fentanyl infusion. Reorder from pharmacy 1 hr before needed.
		1,250 mcg, EVERY BAG, 25 mcg/hr
Medications
	midazolam
		1 mg, Injection, IV Push, Q2H, PRN agitation
			Comment: agitation-mild (Rass +1 to +2) or with increase in rate of continuous midazolam drip
		2 mg, Injection, IV Push, Q2H, PRN for agitation
			Comment: agitation-moderate (Rass +3 to +4)
Analgesia
	Tylenol 325 mg/10.15 mL elixir
		650 mg, Elixir, NASOGASTRIC, Q4H, PRN see comment
			Comment: discomfort and/or pain-mild, or CPOT 1-2
	acetaminophen 160 mg/5 mL oral liquid
		650 mg, Elixir, NASOGASTRIC, Q4H, PRN see comment
			Comment: discomfort and/or pain-mild, or CPOT 1-2
	acetaminophen
		650 mg, Suppository, RECTALLY, Q4H, PRN see comment
			Comment: discomfort and/or pain-mild or CPOT 1-2
	oxyCODONE 5 mg/5 mL oral solution
		5 mg 5 mL, Solution, NASOGASTRIC, Q4H, PRN, pain-moderate
			Comment: or CPOT 3-5
		10 mg 10 mL, Solution, NASOGASTRIC, Q4H, PRN, pain-severe
			Comment: or CPOT 6-8
	acetaminophen-hydrocodone 108 mg-2.5 mg/5 mL oral liquid
		10 mL, Elixir, NASOGASTRIC, Q4H, PRN pain-moderate
			Comment: or CPOT 3-5
		20 mL, Elixir, NASOGASTRIC, Q4H, PRN pain-severe
			Comment: or CPOT 6-8
	acetaminophen-hydrocodone 325 mg-7.5 mg/15 mL oral solution
		10 mL, Elixir, NASOGASTRIC, Q4H, PRN pain-moderate
			Comment: or CPOT 3-5
		20 mL, Elixir, NASOGASTRIC, Q4H, PRN pain-severe
			Comment: or CPOT 6-8
	fentaNYL
		25 mcg, Injection, IV Push, Q15MIN, PRN pain-moderate
			Comment: (CPOT 3-5) or with an increase in rate of continuous fentanyl drip. First line treatment: IV Push Fentanyl, after 3 doses within 1 hour and unable to reach target pain goal, notify ordering LIP.  Max IV push dose 200mcg in 1 hour
		50 mcg, Injection, IV Push, Q15MIN, PRN pain-severe
			Comment: (CPOT 6-8) First line treatment: IV Push Fentanyl, after 3 doses within 1 hour and unable to reach target pain goal, notify ordering LIP Max IV push dose 200mcg in 1 hour
Miscellaneous
	pantoprazole IV
		40 mg, Injection, IV Push, DAILY
			Comment: Reconstitute with 10mL normal saline and infuse over 2 minutes.  Does NOT require filtration.
	famotidine
		20 mg, Injection, IV Push, BID
	Dulcolax
		10 mg, Suppository, RECTALLY, Q3D, PRN for constipation, T+4;N
			Comment: If no BM despite Miralax and Senna
	MiraLax oral powder for reconstitution
		8.5 gm, Packet, By Mouth, DAILY
	Senna
		8.8 mg, Syrup, By Mouth, BID, T+2;0900
			Comment: Give if no BM within the past 48 hours
	chlorhexidine 0.12% oral rinse
		15 mL, Solution, Mouthwash, BID
Patient Care

	Restraint non violent, initiate
		T;N
	Enteral Tube
		T;N Per Orogastric Tube (OG) Insert as needed, clamp
		T;N Per Orogastric Tube (OG) Insert as needed
		T;N Per Orogastric Tube (OG) Connect to low continuous suction
		T;N Per Nasogastric Tube (NG) Insert X Ray as needed, clamp
		T;N Per Nasogastric Tube (NG) Insert X Ray as needed
		T;N Per Nasogastric Tube (NG) Connect to low intermittent suction
	Foley Catheter
		T;N, Insert, Critically ill requiring accurate output
Therapies
	Mechanical Ventilator Settings
		
	Mechanical Ventilator Wean Protocol
		
	Perform Spontaneous Awakening Trial
		T;N, DAILY
			Comment: •	If all SAT Safety screening questions are answered NO (no exclusions present), the RN will conclude it is SAFE to perform a SAT and Proceed to awakening trial•	If on Precedex maintain current settings•	If on Fentanyl, turn infusion off.•	If on Fentanyl, if the patient should complain of or demonstrate sign/symptoms of pain while the continuous sedative infusion is off, the RN may administer bolus doses of analgesics as ordered or maintain the continuous analgesic if needed for active pain •	If on Propofol or Versed, turn infusion off. The RN will also hold all sedative PRN pushes.•	If the patient fails the SAT, the RN will attempt PRN doses if able to reach target. If the need to resume the continuous infusion exists, it will be restarted at ½ the previous dose.  RN will repeat SAT and next ordered interval•	If the patient is able to open his/her eyes to verbal stimulation without failure criteria or does not display any of the failure criteria after shutting off sedation, the RN will conclude the patient has passed the SAT and will contact the RT to complete the SBT safety screen
	Spontaneous Awakening Trial Tolerance
		T;N
			Comment: Fail: conditional:1.	Not able to wean continuous sedation off2.	Maintains SAT RASS > + 2 despite interventions3.	SPO2 < 90%4.	RR > 35 BPM > 5 mins5.	New arrhythmias6.	Symptomatic change in HR either increase or decrease7.	Use of accessory muscles8.	Abdominal paradox9.	Diaphoresis10.	Dyspnea11.	Other
	ARDS Protocol
		
	Consult Physical Therapy, Evaluate and Treat
		T;N, Reason to See: Evaluate and Treat
			Comment: Patient on ventilator.
	Consult Occupational Therapy, Evaluate and Treat
		T;N, Reason to See: Evaluate and Treat
			Comment: Patient on ventilator.
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: JE/FH ETCO2 monitoring to be done Q6H. MH continuous monitoring
Respiratory Therapy
	Oxygen Therapy
		T;N
	Pulse Oximetry Spot Check RT
		T;N, BID
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
Consults/Follow-up

	Consult Dietitian
		T;N, Regarding: Nutrition Assessment, Dietitian Assess and Treat
			Comment: initiate nutrition assessment as appropriate

*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