Unique Plan Description: UROGYN Pelvic Reconstruction, Post op EKM
Plan Selection Display: UROGYN Pelvic Reconstruction, Post op
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-11-05 08:34:52
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2022-03-25 13:09:36
Available at all facilities: Yes

UROGYN Pelvic Reconstruction, Post op EKM
Vital Signs
	Vital Signs
		T;N, Routine post op
Activity
	Dangle
		T;N+300, ONCE AT, 4 hours after transfer to floor
	Stand at Bedside
		T;N+720, 8 hours after transfer to floor
	Up in Chair
		With assistance, TID, begin evening of surgery
	Activity-Up as Tolerated
		T+1;0600
	Ambulate
		T+1;0600, QID, minimum 100 feet.
Diet
	Regular Diet
		T;N
	Diabetic Diet
		T;N
Laboratory
	Hemoglobin and Hematocrit
		T;2000, Routine, spec type = Blood
	CBC with Diff
		T+1;0600, Routine, spec type = Blood
	Basic Metabolic Panel
		T+1;0600, Routine, spec type = Blood
	Glucose POC - RN
		QAM
		TIDPC
IV Solutions
	Dextrose 5% in Lactated Ringers
		1,000 mL, IV, 125 ml/hr
		1,000 mL, IV, 150 ml/hr
	Lactated Ringers Injection
		1,000 mL, IV, 125 ml/hr
	Sodium Chloride 0.9%
		1,000 mL, IV, 125 ml/hr
Medications
	ibuprofen
		800 mg, Tab, By Mouth, Q8H, T;N+360
			Comment: Do not give if systolic blood pressure is < 90mm Hg or if serum creatinine is greater than 1.5mg/dL (or creatinine clearance < 50ml/min).  Notify MD of any dose not given with a note in the chart.
	Ultram
		50 mg, Tab, BY MOUTH, Q6H, PRN, pain-moderate
	Ambien
		5 mg, Tab, BY MOUTH, QHS, PRN, insomnia, T+1;N
Patient Care
	Resuscitation Status
		T;N, Full Code
		T;N, No Code
	VTE Advisor
		Urologic surgery
	Intake and Output
		Q4H-Sch, 24, hr
	Foley Catheter
		To dependent drainage, Pt. undergoing abdominal/pelvic surgery
			Comment: maintain
	Discontinue Urinary Catheter
		T+1;0600
			Comment: post op day 1 or when able to ambulate and out of bed. If urine output is <30ml/hr, do not remove.
	Foley Catheter
		T+1;2100, Insert, Pt. undergoing abdominal/pelvic surgery, Once
			Comment: if patient not voiding adequately by beditme, may reinsert foley catheter overnight.
	Discontinue Urinary Catheter
		T+2;0600
			Comment: If foley reinserted on post op day 1, remove on post op day 2 and start post op voiding trials.
	Notify MD
		temp >101, pulse >120, urine output <120ml/4 hrs, hgb <9, severe pruritis or inadequate pain relief.
	Vaginal Packing
		T+1;0600, ONCE AT, Remove
	Enema-Administer
		PRN constipation
	Heat Therapy
		Aqua K, PRN pain and/or discomfort
	Cold Therapy
		Ice bag, Perineum, PRN pain and/or discomfort
	Abdominal Binder
		PRN pain and/or discomfort, if vertical incision
	Wound Drain
		Connect to suction
	Incentive Spirometer
		Q2H-Sch
	Discontinue Anti Embolism Device
		T;N
			Comment: When ambulating 100 feet TID.

UROGYN Post Op Voiding Trial
	Bladder Scan
		T+1;0600, see comment
			Comment: After each voiding for a minimum of 4 hours.   Discontinue bladder scan when residual <150 ml/bladder
	Straight Catheter
		T+1;0001, Straight, Insert, Q4H, if PVR > ...
			Comment: PRN
	Foley Catheter
		T+1;0000, Foley, Insert, Pt. undergoing abdominal/pelvic surgery, 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
		T;N+1440, Regarding: Self catheterization, Instructions: Teach patient to perform self-catheterization  if more than 3 straight catheterizations required, see comment
		T;N, Instructions: Teach patient to perform self-cath if voiding trial failed.
	Voiding Trial
		T;N, Fill bladder retrograde with 300ml sterile H2O/NACL.  Remove catheter.  Have patient void over next 5-10 minutes.  Measure output and perform post void residual via straight cath.  If void is >/=150ml with <150ml on PVR, trial is passed.
			Comment: If > 150ml on PVR, trial is failed
	Notify MD
		T;N, Notify MD with results of voiding trial.
		Note: Outpatient Voiding Trial(NOTE)*
	Patient Education
		T;N, Regarding: Self catheterization, Instructions: Teach patient to perform self-cath if voiding trial failed x 2
	Voiding Trial
		T;N, Allow pt to void when feeling the urge. Measure output and perform post void residual via bladder scan.  If > 150ml on PVR, trial is failed. Attempt x 2.
	Notify MD
		T;N, Notify MD with results of voiding trial.

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

PCA hydromorphone (Dilaudid)
IV Solutions
	Sodium Chloride 0.9%
		500 mL, IV, 20 ml/hr
			Comment: If no current IV fluid order.
Medications
		Standard protocol w/basal(NOTE)*
	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 30mL 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, Nurse Admin Bolus (mg) 0.2 mg breakthrough pain, Nurse Admin Bolus Freq 1 hr, 30 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.
		6 mg, EVERY BAG
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
		Standard protocol NO basal(NOTE)*
	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 30mL 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, 30 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.
		6 mg, EVERY BAG
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
		High risk(NOTE)*
	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 30mL 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, 30 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.
		6 mg, EVERY BAG
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
		Opiate tolerant(NOTE)*
	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 30mL 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, 30 mL, PCA IV
			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.
		6 mg, EVERY BAG, 0.3 mg/hr
	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

Pain Constipation Nausea Protocol </= to 65 EKM
Medications
		Select only one medication in each category(NOTE)*
Mild Pain
	Tylenol
		650 mg, Tab, By Mouth, Q4H, PRN, see comment
			Comment: discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient
		650 mg, Suppository, RECTALLY, Q6H, PRN, see comment
			Comment: discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient
	ibuprofen
		600 mg, Tab, By Mouth, Q6H, PRN, pain-mild
			Comment: pain rating 1-3
		800 mg, Tab, By Mouth, Q8H, PRN, pain-mild
			Comment: pain rating 1-3
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-mild
			Comment: pain rating 1-3
	Percocet 5 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-mild
			Comment: pain rating 1-3
	Dilaudid Injectable
		0.2 mg, Injection, IV Push, Q2H, PRN, pain-mild
			Comment: for pain rating 1-3 and if NPO
	morphine  IV
		2 mg, Syringe, IV Push, Q2H, PRN, 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, 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, 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, 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.
	Percocet 5 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, 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.
	Percocet 7.5 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, 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.
	Percocet 10 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, 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.
	Roxicodone
		5 mg, Tab, By Mouth, Q4H, PRN, 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, pain-moderate
			Comment: Pain rating 4-6
	Dilaudid Injectable
		0.2 mg, Injection, IV Push, Q2H, PRN, 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, 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, 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, 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, pain-moderate, 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, pain-severe
			Comment: Pain rating 7-10
	acetaminophen-hydrocodone 325 mg-7.5 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Percocet 5 mg-325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Percocet 7.5 mg-325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Percocet 10 mg-325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Roxicodone
		10 mg, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	morphine  oral immediate release
		30 mg, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Dilaudid 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, 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, pain-severe
			Comment: For pain rating 7-10 if NPO
		0.8 mg, Injection, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10 if NPO
		1 mg, Injection, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10 if NPO
	morphine  IV
		4 mg, Syringe, IV Push, Q2H, PRN, 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, 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, IV Push, Q6H, 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)
		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.
	Reglan
		10 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron and phenothiazine ineffective; avoid in patients > 65 y/o.
		10 mg, Injection, IM-Intramuscular, Q6H, PRN, 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 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 pain-moderate
			Comment: For pain rating 4-6
	traMADol
		25 mg, Tab, By Mouth, Q6H, PRN 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.
	Dilaudid Injectable
		0.2 mg, Injection, IV Push, Q4H, PRN 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 pain-severe
			Comment: For pain rating 7-10.
	traMADol
		50 mg, Tab, By Mouth, Q6H, PRN 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.
	Dilaudid Injectable
		0.4 mg, Injection, IV Push, Q2H, PRN 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 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 discomfort
			Comment: Apply to affected area.
	menthol-methyl salicylate topical
		1 appl, Cream, TOPICAL, TID, PRN 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 constipation
			Comment: If other agents ineffective or if patient NPO.
	Fleet Enema 19 gm-7 gm rectal enema
		1 EA, Enema, RECTALLY, Q12H, PRN 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 nausea and/or vomiting
		4 mg, Injection, IV Push, Q6H, PRN nausea and/or vomiting
			Comment: If unable to take by mouth.

*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