SUR COLON Colo-Rectal POST OP ADULT [ ] Version: 18-Sep-2013 ( )

Transcription

1 SUR COLON Colo-Rectal POST OP ADULT [ ] Version: 18-Sep-2013 ( ) PATIENT CARE Admission [ ] Admit to Inpatient [ADT1] Admitting Physician: Level of Care: Diagnosis/Reason for Visit: Bed request comments: Attending Provider: Resuscitation Status (Single Response) [ ] MD Progress Note is required for all but Full Code ( ) Full Code [COD2] ( ) DNI [COD3] ( ) DNR [COD1] ( ) DNR/DNI [COD4] ( ) Special Code [COD5] NURSING Vital Signs [ ] Vital signs [NUR490] Routine, EVERY 30 MIN, Notify MD SBP less than: 100 Notify MD SBP greater than: 180 Notify MD DBP less than: Notify MD DBP greater than: Notify MD Pulse/HR less than: 50 Notify MD Pulse/HR greater than: 110 Notify MD MAP less than: Notify MD MAP greater than: Notify MD RR less than: Notify MD RR greater than: Notify MD Temp less than: Notify MD Temp greater than: 101 x 2, then every 1 hour x 2, then every 4 hours x 2, then every shift., [ ] CMS checks [NUR439] Routine, EVERY 30 MIN, x 2, then every 1 hour x 2, then every 4 hours x 2, then every shift., Activity [ ] Activity [NUR6] Type: Dangle at bedside Out of bed night of surgery, may dangle feet at bedside, Sep-2013 Orders Page 1 of 21

2 Activity: Ambulate with assist [NUR6] Routine, 4 TIMES DAILY, Type: Ambulate with assist Starting POD 1: Ambulate with or without assistance QID, [ ] Head of bed [NUR71] Elevate head of bed 30 degrees, Hygiene [ ] [ ] Bath [NUR21] Routine, PRN, Bath / shower as tolerated, [ ] Shower [NUR102] at 6:30 AM Shower POD # 2, Skin / Dressing / Wound Care [ ] [ ] Remove dressing [NUR543] [ ] Remove dressing [NUR543] Remove dressing POD 1 - change if leaking. Remove and redress using sterile technique, at 6:30 AM Remove dressing POD 2 - change if leaking, remove and redress using sterile technique, [ ] Dressing [NUR400] Routine, PER UNIT ROUTINE, Change if leaking, remove and redress using sterile technique. Dressing change *** site *** frequency, [ ] Ice to affected area Routine, PER UNIT ROUTINE, [NUR302] Ice to operative site, [ ] Elastic Stockings for Dependent Edema [ ] Apply anti-embolism stockings [NUR1111] Anti-embolism stockings (Equipment) [SUP1300] Routine, Qty-1, ONE TIME, Size: Surgical Drain [ ] [ ] Drain care [NUR856] Routine, EVERY SHIFT, #: Type: Location: Drain to: Vent: at mm Hg: at cm H20: Per nursing protocol, record output every shift, [ ] Rectal tube [NUR76] Starting S To straight gravity drainage. Flush with 10cc normal saline QID. Do not replace if it comes out., Urinary Catheter Management [ ] Fairview Urinary Catheter Management Guidelines URL: " Sep-2013 Orders Page 2 of 21

3 Indwelling urinary catheter (Foley) [55567] Indwelling urinary catheter (Foley) [NUR380] Reason: o. Anesthesia Discontinue catheter when no longer needed per Fairview Urinary Catheter Management Guidelines., Discontinue indwelling urinary catheter (Foley) [NUR378] Bladder scan and straight cath for urine [NUR374] Nasogastric Tube [ ] [ ] Nasogastric tube to low intermittent suction [NUR327] [ ] Nasogastric tube decompression, low intermittent suction - no irrigation [NUR327] [ ] Nasogastric tube decompression, low continuous suction [NUR327] Discontinue foley catheter: POD 2 Discontinue catheter when no longer needed per Fairview Urinary Catheter Management Guidelines., Bladder scan IF unable to void by 4 hours post-op or post-foley removal. Bladder scan every 4-8 hours if no voiding. Straight cath if bladder scan is greater than 300 ml OR use bladder scanner and intermittent straight catheterization per unit / population specific criteria or specific provider order. IF straight catheterization is required for greater than 48 hours, notify provider., Routine, PRN, Suction: Low intermittent Irrigate with 30 ml Sodium Chloride or air PRN, record output every shift post procedure, Suction: Low intermittent Do not irrigate, Suction: Low continuous Peripheral IV Catheter: Saline VAD Protocol [ ] Peripheral IV: Standard [NUR1122] sodium chloride 0.9 % flush [19722] sodium chloride 0.9 % flush [19722] sodium chloride 0.9 % flush [19722] Type: Standard Site care and add-on device change per FV Vascular Access Device Guidelines. Not used for blood draws, 3 ml, Intravenous, EVERY 1 HOUR PRN, line flush, post meds or blood draw for peripheral IV line flush post IV meds 3 ml, Intravenous, EVERY 8 HOURS to lock peripheral IV dormant line. Also Ordered Q1H PRN 3 ml, Intravenous, EVERY 1 HOUR PRN, line flush, to lock peripheral IV dormant line. Also Ordered EVERY 8 HOURS Sep-2013 Orders Page 3 of 21

4 Glucose Screen for Post Operative Hyperglycemia [ ] Glucose monitor nursing POCT [NUR1149] Notify Physician [ ] Notify Physician [NUR184] Notify Physician [NUR184] Notify Physician [NUR184] Notify Physician [NUR184] NUTRITION Nutrition [ ] Routine, DAILY, at 6:00 AM 0600 POD 1 and POD 2. Notify MD if blood glucose is greater than 180 NOTE: If early morning LAB DRAW includes glucose, may use that value, but ONLY IF lab drawn between If early morning LAB DRAW between does not include glucose may add glucose in lieu of POCT. Routine, PRN, IF critical or unexpected lab values, Routine, PRN, IF presence of abdominal distention, Routine, PRN, IF severe pain, Routine, PRN, IF increased nausea and vomiting, [ ] NPO [DIET41] DIET EFFECTIVE NOW, Except for: Other - Specify in Comments NPO day of surgery, clear liquids POD 1, [ ] IP Diet as tolerated [DIET108] [ ] NPO [DIET41] DIET EFFECTIVE NOW, Except for: [ ] Full Liquid Diet [DIET21] DIET EFFECTIVE NOW, Liquid Consistency?: Food Preferences: [ ] Low Residue Diet [DIET36] [ ] Clear Liquid Diet [DIET13] DIET EFFECTIVE NOW, Diet?: Clear Liquid Diet Food Preferences: Diet as tolerated when alert. Advance diet as tolerated., DIET EFFECTIVE NOW, Food Preferences: DIET EFFECTIVE NOW, Liquid Consistency?: Food Preferences: Sep-2013 Orders Page 4 of 21

5 [ ] Combination Diet [DIET111] [ ] Snacks/Supplements Adult [DNS1] DIET EFFECTIVE NOW, Adult Basic Diets: Pediatric Diets: Calorie Controlled?: Renal/Dialysis?: Consistent Carbohydrate?: Modified Texture/Chewing?: Modified Digestive/GI?: Low Na/Mineral Controlled: Low Fat/Cardiac Diet/Caffeine?: Food Preferences: Liquid Consistency?: CONTINUOUS, Select Supplement: Frequency?: RESPIRATORY THERAPY Respiratory [ ] Turn cough deep breathe [NUR371] Incentive spirometry nursing [NUR352] Oxygen [RT109] [ ] Respiratory Care IP Consult [CON21] LABORATORY Laboratory - PACU [ ] [ ] Basic metabolic panel STAT, Blood, PACU [LAB15] [ ] CBC with platelets STAT, Blood, PACU [LAB294] [ ] Comprehensive STAT, Blood, PACU metabolic panel [LAB17] [ ] Magnesium [LAB103] STAT, Blood, PACU [ ] Potassium [LAB114] STAT, Blood, PACU [ ] Hemoglobin [LAB291] STAT, Blood, PACU [ ] PT/INR [LAB3572] STAT, Blood, PACU Routine, EVERY 2 HOURS WHILE AWAKE, And PRN, Routine, PER UNIT ROUTINE, For 5 minutes, Every 1 hours while awake, Routine, PRN, Oxygen device: Nasal cannula Keep SaO2 above: 92% Liters per minute: 2 FIO2: Wean as tol Nasal cannula/ mask, Reason for Consult: Set up BIPAP or CPAP Set up BIPAP or CPAP, Laboratory [ ] [ ] Basic metabolic panel [LAB15] AM DRAW, Blood, Sep-2013 Orders Page 5 of 21

6 [ ] CBC with platelets AM DRAW, Blood, [LAB294] [ ] Comprehensive AM DRAW, Blood, metabolic panel [LAB17] [ ] Magnesium [LAB103] AM DRAW, Blood, [ ] Potassium [LAB114] AM DRAW, Blood, [ ] Phosphorus [LAB113] AM DRAW, Blood, [ ] INR [LAB3572] AM DRAW, Blood, [ ] Hemoglobin [LAB291] DAILY, Blood, CONSULTS Consults [ ] [ ] Hospitalist IP Consult [CON25] Wound Ostomy Continence Nurse IP Consult [CON161] [ ] Nutrition Services Adult IP Consult [CON206] [ ] Occupational Therapy Adult IP Consult [CON162] [ ] Physical Therapy Adult IP Consult [CON164] [ ] Pharmacy IP Consult [CON100] [ ] Social Work IP Consult [CON65] Reason for Consult: For medical management of comorbidities Type of Consult: Referring MD will Contact Consulting MD directly?: Requested Clinic or Group: Requested MD: Reason for Consult: For stoma or illeostomy take down Course of Action: Eval & Treat Fistula Location: Reason for Consult: Reason for Consult: Eval & treat Course of Action: Eval & Treat as indicated Treatment Prescription: Reason for Consult: Course of Action: Treatment Prescription: Other request?: Reason for Consult: Evaluation and treatment, Surgical VTE Prophylaxis POST-OP (Pharmacological recommended UNLESS contraindicated) Surgical VTE PHARMACOLOGICAL prophylaxis POST-OP (Single Response) [ ] Sep-2013 Orders Page 6 of 21

7 Recommendations Pharmacological alone or in combination with mechanical - unless a contraindication. Mechanical alone, only if pharmacological contraindicated ( ) enoxaparin (dosing for wt Kg with CrCl > 30 is prechecked) [ ] If CrCl > 30 ml/min and wt kg: recommend Enoxaparin (LOVENOX) 40 mg 40 mg, Subcutaneous, EVERY 24 HOURS, Check to make sure start date/time is hours post op unless documented complication, AND no sooner than 22 hours post op if spinal anesthesia used. Continue until discharge to home. HOLD if platelet count falls below 50% of baseline or <100,000/µL and notify MD. Sub-Q Q24H [920041] [ ] If CrCl > 30 ml/min 40 mg, Subcutaneous, EVERY 12 HOURS, and wt > 150kg or BMI Check to make sure start date/time is hours post op unless documented > 40: recommend Enoxaparin (LOVENOX) 40 mg complication, AND no sooner than 22 hours post op if spinal anesthesia used. Continue until discharge to home. HOLD if platelet count falls below 50% of baseline or <100,000/µL and notify MD. Sub-Q Q12H [920041] [ ] If CrCl ml/min or 30 mg, Subcutaneous, EVERY 24 HOURS, wt < 40 kg: recommend Enoxaparin (LOVENOX) 30 mg Check to make sure start date/time is hours post op unless documented complication, AND no sooner than 22 hours post op if spinal anesthesia used. Continue until discharge to home. HOLD if platelet count falls below 50% of baseline or <100,000/µL and notify MD. Sub-Q Q24H [920041] Platelet count [LAB301] ROUTINE, Blood Baseline. If no result is listed, this lab has not been done the past 365 days. LATEST LAB Platelet count [LAB301] EVERY THREE DAYS, at 6:00 AM For 24 Occurrences, Blood Repeat every 3 days while on VTE prophylaxis. If no result is listed, this lab has not been done the past 365 days. LATEST LAB Creatinine [LAB66] ROUTINE, Blood If no result is listed, this lab has not been done the past 365 days. LATEST LAB Notify Physician [NUR184] Routine, PRN, If platelet count falls below 50% of baseline or <100,000/µL and Hold Enoxaparin, ( ) enoxaparin (dosing for wt < 40 Kg OR CrCl ml/min) *enoxaparin NOT recommended if CrCl < 15 [ ] If CrCl ml/min or 30 mg, Subcutaneous, EVERY 24 HOURS, wt < 40 kg: recommend Enoxaparin (LOVENOX) 30 mg Check to make sure start date/time is hours post op unless documented complication, AND no sooner than 22 hours post op if spinal anesthesia used. Continue until discharge to home. HOLD if platelet count falls below 50% of baseline or <100,000/µL and notify MD. Sub-Q Q24H [920041] Platelet count [LAB301] ROUTINE, Blood Baseline. If no result is listed, this lab has not been done the past 365 days. LATEST LAB Platelet count [LAB301] EVERY THREE DAYS, at 6:00 AM For 24 Occurrences, Blood Repeat every 3 days while on VTE prophylaxis. If no result is listed, this lab has not been done the past 365 days. LATEST LAB Sep-2013 Orders Page 7 of 21

8 Creatinine [LAB66] ROUTINE, Blood If no result is listed, this lab has not been done the past 365 days. LATEST LAB RESULT: Notify Physician [NUR184] Routine, PRN, If platelet count falls below 50% of baseline or <100,000/µL and Hold Enoxaparin, ( ) enoxaparin (dosing for wt > 150 Kg and CrCl > 30) [ ] If CrCl > 30 ml/min 40 mg, Subcutaneous, EVERY 12 HOURS, and wt > 150kg or BMI Check to make sure start date/time is hours post op unless documented > 40: recommend Enoxaparin (LOVENOX) 40 mg complication, AND no sooner than 22 hours post op if spinal anesthesia used. Continue until discharge to home. HOLD if platelet count falls below 50% of baseline or <100,000/µL and notify MD. Sub-Q Q12H [920041] Platelet count [LAB301] ROUTINE, Blood Baseline. If no result is listed, this lab has not been done the past 365 days. LATEST LAB Platelet count [LAB301] EVERY THREE DAYS, at 6:00 AM For 24 Occurrences, Blood Repeat every 3 days while on VTE prophylaxis. If no result is listed, this lab has not been done the past 365 days. LATEST LAB Creatinine [LAB66] ROUTINE, Blood If no result is listed, this lab has not been done the past 365 days. LATEST LAB Notify Physician [NUR184] Routine, PRN, If platelet count falls below 50% of baseline or <100,000/µL and Hold Enoxaparin, ( ) HEParin (except HI) [ ] Note: Every 8 hour HEParin frequency is defaulted. There is also an every 12 hour option. HEParin injection 5,000 Units, Subcutaneous, EVERY 8 HOURS, (Recommend hrs Check to make sure start date/time is hours post op unless documented post op unless documented complication) [27763] complication. Continue until discharge to home. HOLD if platelet count falls below 50% of baseline or <100,000/µL and notify MD. [ ] HEParin injection 5,000 Units, Subcutaneous, EVERY 12 HOURS, (Recommend hrs Check to make sure start date/time is hours post op unless documented post op unless documented complication) [27763] complication. Continue until discharge to home. HOLD if platelet count falls below 50% of baseline or <100,000/µL and notify MD. Platelet count [LAB301] ROUTINE, Blood Baseline. If no result is listed, this lab has not been done the past 365 days. LATEST LAB Platelet count [LAB301] EVERY THREE DAYS, at 6:00 AM For 24 Occurrences, Blood Repeat every 3 days while on VTE prophylaxis. If no result is listed, this lab has not been done the past 365 days. LATEST LAB Sep-2013 Orders Page 8 of 21

9 Notify Physician [NUR184] IF platelet count falls below 50% of baseline or <100,000/µL, and hold SQ HEParin, ( ) HEParin (HI) [ ] Note: Every 8 hour HEParin frequency is defaulted. There is also an every 12 hour option. HEParin injection 5,000 Units, Subcutaneous, EVERY 8 HOURS, (Recommend hrs Check to make sure start date/time is hours post op unless documented post op unless documented complication) [27770] complication. Continue until discharge to home. HOLD if platelet count falls below 50% of baseline or <100,000/µL and notify MD. [ ] HEParin injection 5,000 Units, Subcutaneous, EVERY 12 HOURS, (Recommend hrs Check to make sure start date/time is hours post op unless documented post op unless documented complication) [27770] complication. Continue until discharge to home. HOLD if platelet count falls below 50% of baseline or <100,000/µL and notify MD. Platelet count [LAB301] ROUTINE, Blood Baseline. If no result is listed, this lab has not been done the past 365 days. LATEST LAB Platelet count [LAB301] EVERY THREE DAYS, at 6:00 AM For 24 Occurrences, Blood Repeat every 3 days while on VTE prophylaxis. If no result is listed, this lab has not been done the past 365 days. LATEST LAB Notify Physician [NUR184] ( ) No Pharmacological VTE Prophylaxis Post-Op [NUR1168] IF platelet count falls below 50% of baseline or <100,000/µL, and hold SQ HEParin, Reason: Surgical VTE MECHANICAL Prophylaxis POST-OP (Single Response) [ ] (X) Apply pneumatic compression device (PCD) [NUR1114] ( ) Using only Pharmacological Prophylaxis [NUR1032] ( ) Patient low risk & no surgical VTE prophylaxis needed post-op [NUR1032] ( ) Mechanical VTE Prophylaxis Contraindicated [NUR1032] Remove for 30 minutes BID. Calf-length sleeve is preferred. Foot sleeve may be used if calf-length sleeve cannot be applied, or if specified by Provider. Nursing must document PCD as applied, bilateral amputee, bilateral lower extremity trauma or refused by patient within 24 hours per CMS/SCIP measure. May discontinue PCDs when patient ambulating independently., No VTE Prophylaxis Post-op: Reason: Sep-2013 Orders Page 9 of 21

10 PHARMACY SUR COLON Colo-Rectal POST OP ADULT Post Op BETA BLOCKER for Patients on Chronic Therapy [ ] If patient is ON BETA BLOCKER PRIOR TO ADMISSION, it should be continued throughout hospital stay per evidence & CMS/SCIP measure. NPO is not a criteria for holding a beta blocker. Options: May order patient's HOME beta blocker using MED RECONCILIATION process May order IV beta blocker below [ ] metoprolol (LOPRESSOR) injection [13446] 5 mg, Intravenous, EVERY 6 HOURS, at 8:00 AM HOLD IF HR < 65 or SBP < 110 mmhg, bronchospasm, on inotropic continuous infusions or being paced. Start POD #1. ADMINISTRATION: By slow IV push over at least 2 mins or give by piggyback over mins if patient not appropriate for IV push administration. ASSESSMENT: Blood pressure and heart rate BEFORE and 10 mins AFTER each dose x first 2 doses. Sodium Chloride 0.9% bolus [ ] Normal Saline Bolus [ ] sodium chloride 0.9 % BOLUS [115217] IV Fluids (Single Response) [ ] ( ) lactated ringers infusion [11708] ( ) 0.9 % sodium chloride IV solution [40261] ( ) dextrose 5 % in lactated ringers infusion [26764] ( ) dextrose 5 %-0.9 % sodium chloride infusion [41985] ( ) dextrose 5 % and 0.9 % NaCl + KCl 20 meq/l [26771] ( ) dextrose 5 % and 0.45% NaCl solution [41922] ( ) dextrose 5 % and 0.45 % NaCl + KCl 20 meq/l [26777] Intravenous, 500 ml, EVERY 4 HOURS PRN, other, Give for urine output < 80 ml/4 hours., For 2 Doses Intravenous, CONTINUOUS Change to saline lock when well tolerated. Intravenous, CONTINUOUS Change to saline lock when well tolerated. Intravenous, CONTINUOUS Change to saline lock when well tolerated. Intravenous, CONTINUOUS Change to saline lock when well tolerated. Intravenous, CONTINUOUS Change to saline lock when well tolerated. Intravenous, CONTINUOUS Change to saline lock when well tolerated. Intravenous, CONTINUOUS Change to saline lock when well tolerated Sep-2013 Orders Page 10 of 21

11 Pain - Severe - IV (Single Response) [ ] For Severe Pain Choose appropriate order based on whether the patient is Opioid Naive or Tolerant. (Opioid Tolerant patients have taken the equivalent of 30 mg oral morphine/day or more in the last week) ( ) Opioid Naive (Single Response) [ ] Select LOWER dose of either opioid medication for Opioid Sensitive patient based on history, age, or creatinine clearance. Morphine NOT recommended IF patient is > 65 years old or has a Creatinine Clearance < 40 ml/minute. ( ) morphine injection [920030] ( ) morphine injection [920030] ( ) HYDROmorphone (DILAUDID) injection SOLN [115359] ( ) HYDROmorphone (DILAUDID) injection SOLN [115359] 1 mg, Intravenous, EVERY 2 HOURS PRN, severe pain, or if patient unable to take PO Hold while on PCA. 2-4 mg, Intravenous, EVERY 2 HOURS PRN, severe pain, or if patient unable to take PO Hold while on PCA. 0.2 mg, Intravenous, EVERY 2 HOURS PRN, severe pain, or if patient unable to take PO, Hold while on PCA mg, Intravenous, EVERY 2 HOURS PRN, severe pain, or if patient unable to take PO, Hold while on PCA. ( ) Opioid Tolerant (Single Response) [ ] ( ) morphine injection [920030] Intravenous, EVERY 2 HOURS PRN, severe pain, or patient unable to take PO Hold while on PCA. ( ) HYDROmorphone (DILAUDID) injection SOLN [115359] PCA - respiratory monitoring by nursing [ ] Pulse oximetry nursing [NUR585] Intravenous, EVERY 2 HOURS PRN, severe pain, or patient unable to take PO, Hold while on PCA. Routine, CONTINUOUS, Monitoring with IV PCA: -Continuously x 24 hours postoperatively. May discontinue after 24 hours if vital signs are stable and the dose of opioid has not been increased. -Continuous for patients with risk factors for opioid-induced respiratory depression who are not on supplemental oxygen. Risk factors include obesity (BMI 35 or greater), sleep apnea, COPD or CHF. Intermittent monitoring with vital signs for patients on supplemental oxygen. -Notify MD if SpO2 is less than 92%, Capnography Monitor - PH/WY [ ] Capnography Monitor [EQ1281] Routine, Qty-1, ONE TIME, Starting S, x 24 hours then reevaluate. May stop after 24 hours if vital signs are stable and the dose of opioid has not been increased. Consider Capnography monitoring beyond 24 hours if risk factors are present: Obesity (BMI 35 or greater ), Sleep Apnea, COPD or CHF. Notify MD if: ~Sedation level of 2 or higher on sedation scale ~ CO2 levels greater than 55 mm Hg and trends showing consistently elevated CO2 levels ~Integrated Pulmonary Index (IPI) level of less than 5, Sep-2013 Orders Page 11 of 21

12 Capnography Monitor - HI [ ] Capnography Monitor [EQ1281] [ ] Consult Pain Service - RH/SH [ ] [ ] Pain Management IP Consult [CON32] Routine, Qty-1, ONE TIME, x 24 hours then reevaluate. May stop after 24 hours if vital signs are stable and the dose of opioid has not been increased. Consider Capnography monitoring beyond 24 hours if risk factors are present: Obesity (BMI 35 or greater), Sleep Apnea, COPD or CHF. Notify MD if: ~Sedation level of 2 or higher on sedation scale ~ CO2 levels greater than 55 mm Hg and trends showing consistently elevated CO2 levels ~Integrated Pulmonary Index (IPI) level of less than 5, Routine, CONDITIONAL X 1, Reason for Consult: uncontrolled severe pain or anticipated pain control complexity Type of Consult: Referring Provider will contact Consulting Provider directly?: IV PCA OPIOID NAIVE PCA (patients have taken less than the equivalent of 30 mg oral morphine/day in the last week.) post-op (Single Response) [ ] Continuous infusions should NOT BE USED in opioid naive patients. * All orders below are for opioid naive patients (patients have taken less than the equivalent of 30 mg oral morphine/day in the last week.) URL: " " ( ) HYDROmorphone (DILAUDID) mg PCA dose (with mg Loading Dose Order) (except HI) [ ] * Loading dose order AND PCA order below: HYDROmorphone LOADING DOSE FROM PCA [122738] HYDROmorphone (DILAUDID) PCA dose 0.1 to 0.2 mg, Lockout 10 min, Hour limit 1.2 mg [114702] mg, Intravenous, PCA LOADING DOSE, For 1 Doses HYDROmorphone loading dose (bolus) with start of PCA. DO NOT GIVE IF A LOADING BOLUS DOSE HAS ALREADY BEEN GIVEN. (If dose not given from PCA, bar code scan must be overridden to chart dose) PCA dose (mg): 0.1 Max PCA dose (mg): 0.2 PCA Continuous Rate (mg/hr): CONTINUOUS RATE IS NOT RECOMMENDED FOR OPIOID NAIVE PATIENTS Hour Limit (mg): 1.2 Intravenous, ( ) HYDROmorphone (DILAUDID) mg PCA dose (with mg Loading Dose order) (except HI) [ ] * Loading dose order AND PCA order below HYDROmorphone LOADING DOSE ADMINISTERD FROM PCA [122738] mg, Intravenous, PCA LOADING DOSE, For 1 Doses DOSE HAS ALREADY BEEN GIVEN. (If loading dose not given from PCA, bar code scan must be overridden to chart dose) Sep-2013 Orders Page 12 of 21

13 HYDROmorphone PCA dose (mg): 0.2 (DILAUDID) PCA dose Max PCA dose (mg): to 0.3 mg, Lockout 10 minutes, Hour Limit PCA Continuous Rate (mg/hr): CONTINUOUS RATE IS NOT RECOMMENDED 1.8 mg [114702] FOR OPIOID NAIVE PATIENTS Hour Limit (mg): 1.8 Intravenous, ( ) HYDROmorphone (DILAUDID) mg PCA dose (with 0.25 mg Loading Dose order) (HI) [ ] * Loading dose order AND PCA order below: HYDROmorphone LOADING DOSE FROM PCA [122738] HYDROmorphone (DILAUDID) PCA dose 0.1 to 0.2 mg, Lockout 10 min, Hour limit 1.2 mg [ ] 0.25 mg, Intravenous, PCA LOADING DOSE, For 1 Doses HYDROmorphone loading dose (bolus) with start of PCA. DO NOT GIVE IF A LOADING BOLUS DOSE HAS ALREADY BEEN GIVEN. (If dose not given from PCA, bar code scan must be overridden to chart dose) PCA Dose (mg): 0.1 mg PCA Continuous Rate (mg/hr): CONTINUOUS RATE NOT RECOMMENDED FOR OPIOID NAIVE PATIENTS PCA One Hour Limit (mg): 0.6 mg Intravenous, ( ) Morphine PCA mg dose (with 1-2 mg Loading Dose Order) (except HI) [ ] **Morphine NOT recommended if the patient is >65 years or has a Creatinine Clearance < 40 ml/minute** * Loading dose order AND PCA order below: MORPHINE LOADING DOSE FROM PCA (ADULT) [122762] morphine ADULT PCA dose mg, Lockout 10 minutes, Hour Limit 6 mg [114700] 1-2 mg, Intravenous, PCA LOADING DOSE, For 1 Doses must be overridden to chart dose) PCA dose (mg): 0.5 Max PCA dose (mg): 1 PCA Continuous Rate (mg/hr): CONTINUOUS RATE SHOULD NOT BE USED IN OPIOID NAIVE PATIENTS Hour Limit (mg): 6 Intravenous, ( ) Morphine PCA mg dose (with 1-2 mg Loading Dose Order) (except HI) [ ] **Morphine NOT recommended if the patient is >65 years or has a Creatinine Clearance < 40 ml/minute** * Loading dose order AND PCA order below: MORPHINE LOADING DOSE FROM PCA (ADULT) [122762] 1-2 mg, Intravenous, PCA LOADING DOSE, For 1 Doses must be overridden to chart dose) Sep-2013 Orders Page 13 of 21

14 morphine ADULT PCA dose mg, Lockout 10 minutes, Hour Limit 9 mg [114700] PCA dose (mg): 1 Max PCA dose (mg): 1.5 PCA Continuous Rate (mg/hr): CONTINUOUS OPIOID DOSE SHOULD NOT BE GIVEN TO OPIOID NAIVE PATIENTS Hour Limit (mg): 9 Intravenous, ( ) Morphine mg PCA dose (with 2 mg Loading Dose order) (HI) [ ] **Morphine NOT recommended if the patient is >65 years or has a Creatinine Clearance < 40 ml/minute** * Loading dose order AND PCA order below: MORPHINE LOADING DOSE FROM PCA [122764] morphine ADULT PCA dose mg, Lockout 10 minutes, Hour Limit 6 [114696] 2 mg, Intravenous, PCA LOADING DOSE, For 1 Doses must be overridden to chart dose). PCA Dose (mg): 0.5 mg PCA Continuous Rate (mg/hr): CONTINUOUS RATE NOT RECOMMENDED FOR OPIOID NAIVE PATIENTS PCA One Hour Limit (mg): 3 mg Intravenous, ( ) Fentanyl mcg PCA dose (with 25 mcg Loading Dose order) (except HI) [ ] * Loading dose order AND PCA order below: FENTANYL LOADING DOSE FROM PCA [122766] fentanyl mcg PCA dose, Lockout 10 min, Hour Limit 120 mcg (with 25 mcg Loading Dose order) [114703] 25 mcg, Intravenous, PCA LOADING DOSE, For 1 Doses must be overridden to chart dose) Minimum PCA dose (mcg): 10 Max PCA dose (mcg): 20 PCA Continuous Rate (mcg/hr): CONTINUOUS RATE NOT RECOMMENDED FOR OPIOID NAIVE PATIENTS Hour Limit (mcg): 120 Intravenous, ( ) Fentanyl 12.5 mcg/0.5 ml PCA dose (with 25 mcg/1 ml Loading Dose order) (HI) [ ] * Loading dose order AND PCA order below: FENTANYL LOADING DOSE FROM PCA [ ] 1 ml, Intravenous, PCA LOADING DOSE, For 1 Doses must be overridden to chart dose) **For fentanyl concentration = 25 mcg/1 ml ONLY** Sep-2013 Orders Page 14 of 21

15 fentanyl 12.5mcg/ 0.5 PCA Dose ml (mcg): 0.5 ml (12.5 mcg) ml PCA dose, Lockout 10 min, Hour Limit 75 mcg/3 ml (with 25 mcg/1 ml Loading PCA Continuous Rate (mcg/hr): CONTINUOUS RATE NOT RECOMMENDED FOR OPIOID NAIVE PATIENTS PCA One Hour Limit ml (mcg): 3 ml (75 mcg) Dose order) [ ] Intravenous, OPIOID TOLERANT PCA (Single Response) [ ] FOR OPIOID TOLERANT PATIENTS ONLY - (those who have taken the equivalent of 30 mg oral morphine/day or more in the last week) ( ) HYDROmorphone (DILAUDID) Load and PCA dose (except HI) [59961] CHECK LOADING DOSE ORDER BELOW IF APPROPRIATE [ ] HYDROMORPHONE LOADING DOSE FROM PCA [122738] HYDROmorphone (DILAUDID) PCA [114702] Intravenous, ONCE, For 1 Doses must be overridden to chart dose) PCA dose (mg): Max PCA dose (mg): PCA Continuous Rate (mg/hr): MAX Continuous Rate (mg/hr): Hour Limit (mg): Intravenous, ( ) HYDROmorphone (DILAUDID) Load and PCA dose (HI) [ ] CHECK LOADING DOSE ORDER BELOW IF APPROPRIATE [ ] HYDROMORPHONE LOADING DOSE FROM PCA [122738] HYDROmorphone (DILAUDID) PCA [ ] ( ) Morphine Load and PCA doses (except HI) [ ] CHECK LOADING DOSE ORDER BELOW IF APPROPRIATE [ ] MORPHINE LOADING DOSE FROM PCA (ADULT) [122762] Intravenous, ONCE, For 1 Doses must be overridden to chart dose). PCA dose (mg): PCA Continuous Rate (mg/hr): PCA One Hour Limit (mg): Intravenous, Intravenous, PCA LOADING DOSE, For 1 Doses must be overridden to chart dose) Sep-2013 Orders Page 15 of 21

16 morphine ADULT PCA dose [114700] ( ) Morphine Load and PCA doses (HI) [ ] CHECK LOADING DOSE ORDER BELOW IF APPROPRIATE [ ] MORPHINE LOADING DOSE FROM PCA [122764] morphine PCA dose [114696] ( ) Fentanyl Load and PCA doses (except HI) [ ] CHECK LOADING DOSE ORDER BELOW IF APPROPRIATE [ ] FENTANYL LOADING DOSE FROM PCA [122766] fentanyl (SUBLIMAZE) PCA 1500 mcg/30ml [114703] ( ) Fentanyl Load and PCA doses (HI) [ ] CHECK LOADING DOSE ORDER BELOW IF APPROPRIATE [ ] FENTANYL LOADING DOSE FROM PCA [ ] fentanyl (SUBLIMAZE) PCA 25 mcg/ml [ ] PCA dose (mg): Max PCA dose (mg): PCA Continuous Rate (mg/hr): MAX Continuous Rate (mg/hr): Hour Limit (mg): Intravenous, Intravenous, PCA LOADING DOSE, For 1 Doses must be overridden to chart dose). PCA dose (mg): PCA Continuous Rate (mg/hr): Hour Limit (mg): Intravenous, Intravenous, PCA LOADING DOSE, For 1 Doses LOADING dose (bolus) with start of PCA. DO NOT GIVE IF A LOADING BOLUS must be overridden to chart dose) Minimum PCA dose (mcg): Max PCA dose (mcg): PCA Continuous Rate (mcg/hr): MAX Continuous Rate (mcg/hr): Hour Limit (mcg): Intravenous, Intravenous, PCA LOADING DOSE, For 1 Doses must be overridden to chart dose). **Fentanyl concentration = 25 mcg/1 ml ONLY** PCA Dose ml (mcg): PCA Continuous Rate (ml/hr): PCA One Hour Limit ml (mcg): Intravenous, Sep-2013 Orders Page 16 of 21

17 Moderate to severe pain - Oral opioids (short acting - immediate release) select one (Single Response) [ ] ( ) Pain Meds for > 65 years old with low urine output or low GFR (Single Response) [ ] ( ) oxycodone (ROXICODONE) immediate release tablet [29298] 5 mg, Oral, EVERY 3 HOURS PRN, moderate to severe pain ( ) oxycodoneacetaminophen (PERCOCET) MG per tablet [15990] ( ) hydrocodoneacetaminophen (NORCO) MG per tablet [50237] ( ) HYDROcodoneacetaminophen (LORTAB) MG/15ML solution [53241] ( ) HYDROmorphone (DILAUDID) tablet [114629] 1 tablet, Oral, EVERY 4 HOURS PRN, moderate to severe pain 1 tablet, Oral, EVERY 4 HOURS PRN, moderate to severe pain 10 ml, Oral, EVERY 4 HOURS PRN, moderate to severe pain 1-2 mg, Oral, EVERY 3 HOURS PRN, moderate to severe pain ( ) Pain Meds (NOT for elderly patients with poor renal function) (Single Response) [ ] Dose may need to be modified for Opioid Tolerant patients. (Opioid Tolerant patients have taken the equivalent of 30mg oral morphine/day or more in the last week) ( ) oxycodone (ROXICODONE) immediate release tablet [29298] ( ) oxycodoneacetaminophen (PERCOCET) MG per tablet [15990] ( ) hydrocodoneacetaminophen (NORCO) MG per tablet [50237] ( ) HYDROcodoneacetaminophen (LORTAB) MG/15ML solution [53241] ( ) HYDROmorphone (DILAUDID) tablet [114629] ( ) tramadol (ULTRAM) tablet [114686] 5-10 mg, Oral, EVERY 3 HOURS PRN, moderate to severe pain 1-2 tablet, Oral, EVERY 4 HOURS PRN, moderate to severe pain 1-2 tablet, Oral, EVERY 4 HOURS PRN, moderate to severe pain ml, Oral, EVERY 4 HOURS PRN, moderate to severe pain 2-4 mg, Oral, EVERY 3 HOURS PRN, moderate to severe pain mg, Oral, EVERY 6 HOURS PRN, moderate to severe pain Sep-2013 Orders Page 17 of 21

18 ( ) ONLY FOR OPIOID 1-2 tablet, Oral, EVERY 4 HOURS PRN, moderate to severe pain TOLERANT PATIENTS : hydrocodoneacetaminophen (NORCO ) MG per tablet [42714] ( ) ONLY FOR OPIOID 1-2 tablet, Oral, EVERY 4 HOURS PRN, moderate to severe pain TOLERANT PATIENTS : oxycodoneacetaminophen (PERCOCET ) MG per tablet [47483] ( ) ONLY FOR OPIOID TOLERANT mg, Oral, EVERY 3 HOURS PRN, moderate to severe pain PATIENTS: oxycodone (ROXICODONE) immediate release tablet [29298] Non-Steroidal Anti-inflammatory Agents (NSAIDS) [ ] [ ] Ketorolac (TORADOL) (Single Response) [ ] ( ) ketorolac (TORADOL) injection (For patients less than 65 years of age and Crcl Greater than 50 ml/minute) [801059] 30 mg, Intravenous, EVERY 6 HOURS, For 4 Doses For patients less than 65 years of age and Crcl Greater than 50 ml/minute. May continue use for up to 5 days MAX if order renewed. IF celecoxib was given pre-operatively, start ketorolac 12 hours after celecoxib given. ( ) ketorolac (TORADOL) injection (For patients equal to or greater than 65 years of age OR Crcl ml/minute) [801059] [ ] ibuprofen (ADVIL,MOTRIN) tablet [10519] Adjuvant Pain Medications [ ] 15 mg, Intravenous, EVERY 6 HOURS, For 4 Doses For patients equal to or greater than 65 years of age OR Crcl 30-50mL/minute. May continue use for up to 5 days MAX if order renewed. IF celecoxib was given pre-operatively, start ketorolac 12 hours after celecoxib given. 600 mg, Oral, EVERY 6 HOURS PRN, other, inflammatory pain Start when Ketorolac is discontinued. [ ] HydrOXYzine (VISTARIL, ATARAX) (Single Response) [ ] ( ) hydroxyzine 10 mg, Oral, EVERY 6 HOURS PRN, other, adjuvant pain, (ATARAX) tablet (For age equal or greater than 65 years) [10336] ( ) hydroxyzine (ATARAX) tablet: for < 65 years [10336] mg, Oral, EVERY 6 HOURS PRN, other, adjuvant pain, Sep-2013 Orders Page 18 of 21

19 [ ] acetaminophen (TYLENOL) tablet (Do not use if patient has an active opioid/acetaminophen analgesic order for pain.) [283] 650 mg, Oral, EVERY 6 HOURS PRN, mild pain Do not use if patient has an active opioid/acetaminophen analgesic order for pain. Naloxone (NARCAN) [ ] naloxone (NARCAN) injection [14380] mg, Intravenous, EVERY 2 MIN PRN, opioid reversal, Nausea and Vomiting [ ] This is a 3 step protocol. Choose all 3 steps unless contraindicated. Step 1: Ondansetron IV [ ] ondansetron (ZOFRAN) injection [108210] Step 2: prochlorperazine IV - {this section should only display for patients under 65 years old} [ ] prochlorperazine "Or" Linked Panel 4 mg, Intravenous, EVERY 6 HOURS PRN, nausea, vomiting, for 2-5 Minutes This is Step 1 of nausea and vomiting protocol. If nausea not resolved in 15 minutes, go to Step 2 (Prochlorperazine). "Or" Linked Panel 5-10 mg, Intravenous, EVERY 6 HOURS PRN, nausea, vomiting (COMPAZINE) injection This is Step 2 of the nausea and vomiting protocol. *Dose 5-10 mg if age < If nausea not resolved in 15 minutes, give Metoclopramide if ordered (step 3 of 65, 5 mg if 65 and nausea and vomiting protocol) above [17777] Step 2: Prochlorperazine IV - {this section should only display for patients greater than or equal to 65 years old} [ ] prochlorperazine "Or" Linked Panel 5 mg, Intravenous, EVERY 6 HOURS PRN, nausea, vomiting (COMPAZINE) injection This is Step 2 of the nausea and vomiting protocol. *Dose 5-10 mg if age < 65, 5 mg if 65 and above [17777] Step 3, Metoclopramide "Or" Linked Panel IV [ ] Avoid Metoclopramide in the presence of bowel obstruction or perforation. If nausea not resolved in 15 minutes, give Metoclopramide if ordered (step 3 of nausea and vomiting protocol) metoclopramide (REGLAN) injection *Dose 10 mg if age < 65, 5 mg if 65 and above [13439] 10 mg, Intravenous, EVERY 6 HOURS PRN, nausea and vomiting This is Step 3 of nausea and vomiting protocol. Give if nausea not resolve 15 minutes after giving prochlorperazine Sep-2013 Orders Page 19 of 21

20 Sleep/Hypnotic (Single Response) [ ] ( ) temazepam (RESTORIL) capsule Dose default is 15 mg if <65 years and 7.5 mg if 65 and above. [21096] ( ) zolpidem (AMBIEN) tablet [114690] ( ) trazodone (DESYREL) half tablet [114687] ( ) trazodone (DESYREL) tablet [114687] ( ) No Medication Sleep Aids for this Patient [ ] GI Protectants [ ] 15 mg, Oral, AT BEDTIME PRN, sleep, at 8:00 PM POD #1. May repeat x 1 if initial dose was 7.5mg. Do not repeat 15 mg dose. Do not give unless at least 6 hours of uninterrupted sleep is expected. 5 mg, Oral, AT BEDTIME PRN, at 8:00 PM, sleep POD #1. Do not give unless at least 6 hours of uninterrupted sleep is expected. 25 mg, Oral, AT BEDTIME PRN, sleep, at 8:00 PM POD #1. May repeat x 1. Do not give unless at least 6 hours of uninterrupted sleep is expected. 50 mg, Oral, AT BEDTIME PRN, sleep, at 8:00 PM POD #1. May repeat x 1. Do not give unless at least 6 hours of uninterrupted sleep is expected. CONTINUOUS PRN, [ ] Calcium Carbonate - Aluminum/Magnesium Hydroxide/Simethicone (Single Response) [ ] ( ) calcium carbonate 500-1,000 mg, Oral, 4 TIMES DAILY PRN, heartburn, (TUMS) chewable tablet [13958] ( ) alum and mag ml, Oral, EVERY 4 HOURS PRN, indigestion, hydroxide-simethicone (MYLANTA ES/MAALOX ES) suspension [24518] [ ] ranitidine (ZANTAC) PO or IV [ ] [ ] ranitidine (ZANTAC) tablet [1366] 150 mg, Oral, 2 TIMES DAILY May also be given IV [ ] ranitidine (ZANTAC) injection [30563] 50 mg, Intravenous, EVERY 8 HOURS May also be given PO alvimopan (ENTEREG)-SH/RH only [ ] Hospital pharmacy must be enrolled in the EASE (Entereg Access Support and Education) program Pre Op Criteria: Laparoscopic or open colon resection Post Op Criteria: Open or converted colon resection [ ] alvimopan (ENTEREG)-SH/RH only [ ] [ ] alvimopan (ENTEREG) 12 mg, Oral, 2 TIMES DAILY, For 14 Doses capsule [105916] Start POD 1. Discontinue after first bowel movement, or at hospital discharge. Maximum length of treatment: 14 doses post op. [ ] Pharmacy IP Consult [CON100] Other request?: Pharmacy to review criteria for post op alvimopan (ENTEREG), and to verify that requirements of EASE program have been met Sep-2013 Orders Page 20 of 21

21 IV Steroids - ONLY if patients on steroids pre-operatively or during the past 6 months [ ] [ ] Hydrocortisone [ ] [ ] hydrocortisone sodium succinate (SOLU-CORTEF) injection [10239] [ ] hydrocortisone sodium succinate (SOLU-CORTEF) injection [10239] [ ] hydrocortisone sodium succinate (SOLU-CORTEF) injection [10239] "Followed by" Linked Panel 75 mg, Intravenous, For 3 Doses, 50 mg, Intravenous, EVERY 8 HOURS, For 3 Doses, Intravenous, Cepastat [ ] [ ] phenol-menthol (CEPASTAT) lozenge [89400] 1-2 lozenge, Buccal, EVERY 1 HOUR PRN, sore throat, without fever, Postprocedure post procedure order set identifier [899222] Required post-op order set marker (used as alert trigger) [PHA30] Details PROVIDER SIGNATURE: DATE: TIME: PROVIDER NAME (print): PAGER #: Sep-2013 Orders Page 21 of 21