Unique Plan Description: Bari Surg Bariatric Major (MH), Post op EKM
Plan Selection Display: Bari Surg Bariatric Major (MH), Post op
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2014-03-28 09:09:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2021-04-21 08:01:25
Available at all facilities: Yes

Bari Surg Bariatric Major (MH), Post op EKM
Vital Signs
	Vital Signs
		Routine Post op Bariatric surgery
Activity
	Dangle
		Once
			Comment: and Ambulate 500 ft evening of surgery
	Ambulate
		T+1;0600, BID, 1, Day(s)
		T+1;0600, With assistance, TID, must ambulate at least 3 times per day
	Up in Chair
		T+1;0600, TID
	Elevate head of bed
		Elevate head of bed 30 degrees
			Comment: Continuously
Diet
	NPO
		T;N
			Comment: may have 1 cup ice chips every 8 hours
Laboratory
Today's Lab
	Blood Gases Arterial (ABG) - MH/WH/JE
		Stat, spec type = Blood
	CBC with Diff
		Stat, spec type = Blood
	CK
		Stat, spec type = Blood
	Comprehensive Metabolic Panel
		Stat, spec type = Blood
	Glucose POC - RN
		T;N, Q6H-Sch
Tomorrow's Lab
	CBC with Diff
		T+1;0400, Routine, Q24H 3 Dose(s)/Time(s), spec type = Blood
	CK
		T+1;0400, Routine, Q24H 3 Dose(s)/Time(s), spec type = Blood
	Comprehensive Metabolic Panel
		T+1;0400, Routine, Q24H 3 Dose(s)/Time(s), spec type = Blood
Diagnostic Tests

	Chest 1 View
		At Bedside, Central line, NG placement, Stat, Post Op F/U
			Comment: Patient in PACU
	Upper GI Series
		T+1;0600, Routine, Abnormal Findings
			Comment: Status post bariatric surgery
IV Solutions
	Dextrose 5% with 0.45% NaCl w/KCl 20 mEq
		1,000 mL, IV, 125 ml/hr
	Sodium Chloride 0.9%
		1,000 mL, IV, 125 ml/hr
Medications
	Chloraseptic Menthol 1.4% topical spray
		2 spray, Spray, By Mouth, Q2H, PRN, see comment
			Comment: hold for 15 seconds and spit
	pantoprazole IV
		40 mg, Injection, IV Push, DAILY, 3 Day(s)
			Comment: Dilute each 40mg vial with 10ml NS.
	Transderm-Scop 1 mg patch
		1 mg, Patch, TOPICAL, Q72H, T+3;0900
	Mefoxin IVPB
		2,000 mg, INT, IVPB, Q6H, Surgical prophylaxis, 3 Dose(s)/Time(s)
	Flagyl IVPB (NMH/WH/FH)
		500 mg, Injection-Premix, IVPB, Q8H, Surgical prophylaxis, 2 Dose(s)/Time(s), 100 ml/hr
			Comment: if allergic to cephalosporins or history of anaphylactic reaction to penicillin
	Levaquin IVPB
		750 mg, Injection-Premix, IVPB, Q24H, Surgical prophylaxis, 1 Day(s)
	Tylenol
		650 mg, Tab, By Mouth, Q6H, T;N+360, 48 hr
			Comment: Please be advised that the nonnarcotic pain meds are scheduled and not PRN.  Please give to the patients even if not in pain, do not give both oral and IV APAP, start 6 hr after any pre-op/intra-op dose.
		650 mg, Elixir, By Mouth, Q4H, T;N+360, 48 hr
			Comment: Please be advised that the nonnarcotic pain meds are scheduled and not PRN.  Please give to the patients even if not in pain, do not give both oral and IV APAP, start 6 hr after any pre-op/intra-op dose.
	Ofirmev
		1,000 mg, Solution-Injection, IVPB, Q6H, PRN, see comment, T;N+360, 48 hr
			Comment: Administer only if unable to take oral or rectal formulation; convert to oral medication as soon as possible and discontinue IV order, start 6 hours after any pre-op/intra-op dose.
		NSAIDs cannot be used (ARE CONTRAINDICATED) in the following cases:  Allergy to aspirin or any NSAID, During pregnancy, During breast feeding, On blood thinning agents (anticoagulants), Suffering from a defect of the blood clotting system (coagulation), A(NOTE)*
	ibuprofen
		600 mg, Tab, By Mouth, Q8H, see comment, T;N+1440, 24 hr
			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.  Please be advised that the nonnarcotic pain meds are scheduled and not PRN.  Please give to the patients even if not in pain. Please give on scheduled basis. Start 6 hours after IV ketorolac ends.
		600 mg, Suspension, By Mouth, Q8H, see comment, T;N+1440, 24 hr
			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. Please be advised that the nonnarcotic pain meds are scheduled and not PRN.  Please give to the patients even if not in pain. Please give on scheduled basis. Start 6 hours after IV ketorolac ends
	ketorolac injectable
		30 mg, Injection, IV Push, Q6H, T;N+720, 2 Dose(s)/Time(s)
			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.   Please be advised that the nonnarcotic pain meds are scheduled and not PRN.  Please give to the patients even if not in pain. Begin 6 hrs after preop NSAID; modify dose to 15mg for patients <50kg or >65 years old.
		For patients <50kg or >65 years old.(NOTE)*
		15 mg, Injection, IV Push, Q6H, T;N+720, 2 Dose(s)/Time(s)
			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 Comment: Please be advised that the nonnarcotic pain meds are scheduled and not PRN.  Please give to the patients even if not in pain. Begin 6 hrs after preop NSAID
	traMADol
		50 mg, Tab, By Mouth, Q6H, PRN, pain-mild
		If the patient has received an intrathecal/epidural anesthesia will order PO/IV opiods for the first 24hrs.(NOTE)*
	oxyCODONE
		5 mg, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: for pain rated 4 or greater and greater than patient stated comfort goal after scheduled medications given. Give for pain rated 4-6. For patients who received intrathecal analgesia start 24 hours after intrathecal dose given. Note pain score before and after administration; may cause drowsiness.  Goal of ERAS order set is to limit opiates as they have a deleterious effect on return of bowel function.  Please limit the administration of opiates unless the pain score is more than 5.
		10 mg, Tab, BY MOUTH, Q4H, PRN, pain-severe
			Comment: for pain rated 4 or greater and greater than pateint stated comfort goal after scheduled medications given. Give for pain rated 7-10. For patients who received intrathecal analgesia start 24 hours after intrathecal dose given. Note pain score before and after administration; may cause drowsiness.  Goal of ERAS order set is to limit opiates as they have a deleterious effect on return of bowel function.  Please limit the administration of opiates unless the pain score is more than 5.
	Dilaudid Injectable
		0.2 mg, Injection, IV PUSH, Q2H, PRN, pain-moderate
		0.5 mg, Injection, IV PUSH, Q2H, PRN, pain-severe
			Comment: for pain rating 7-10, use 0.4mg if age over 70
Antiemetics
	Zofran
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN, nausea and/or vomiting
		4 mg, Injection, IV Push, Q24H, nausea and/or vomiting
		4 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
	Reglan
		10 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron, phenothiazine or other anti-nausea medications ineffective
		10 mg, Injection, IM-Intramuscular, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron, phenothiazine or other anti-nausea medications ineffective
	Benadryl
		12.5 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron, ineffective; avoid in patients > 65yo
	Phenergan (JE)
		25 mg, Tab, By Mouth, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron, ineffective; avoid in patients > 65yo
	Phenergan (MH/WH)
		25 mg, Tab, By Mouth, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron, ineffective; avoid in patients > 65yo
	prochlorperazine
		10 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron, ineffective; avoid in patients > 65yo
Patient Care

	Resuscitation Status
		Full Code
		No Code
	VTE Advisor
		Bariatric surgery
	GI Tube
		NG, Connect to low continuous suction
		NG, Irrigate with normal saline, to maintain patency
		J-tube, Connect to gravity drainage
		J-tube, Irrigate with normal saline, 60ml, Q12H-Start of Shift
	Notify MD
		urine output <150 ml in 4 hours
		sustained pulse >120, temp >102
		CPK >1000
		Dr. Anthone results of PACU labs.
		Dr. Anthone for blood sugars greater than 300.
	Wound Drain
		T;N, Connect to compressed suction
	Shower
		T+3;0600
			Comment: When Epidural Removed
	Do not give medication
		T;N, Do not give heparin in abdomen
	Incentive Spirometer
		Q1HAWAKE, 10x per hour
	Patient to Chew Gum
		To increase GI motility
Therapies
	Consult Physical Therapy, Evaluate and Treat
		T+1;0600, For: Evaluation and treatment, Order Dx: post op bariatric surgery
	Consult Occupational Therapy, Evaluate and Treat
		Order Dx: Post Op Bariatric Surgery, Reason to See: Assistive Device
	Consult Social Work
		T+2;0600, Evaluation
	Respiratory Care Patient Education
		T;N
			Comment: Give patient CPAP/BiPAP safety tips sheet
	Respiratory Care Protocol Order
		T;N
			Comment: Do not use home CPAP/BiPAP until ordered by MD
Consults/Follow-up
	Consult Dietitian
		T;N, Regarding: Diet instructions
			Comment: oral supplement: impact TID
	Discharge Instructions Other
		To see Jackie Bertelsen 2 weeks post-op for dietary follow-up.       Diabetes Center, 402-354-8797.
	Consult Anesthesiologist
		Reason for Referral: Goal Directed therapy non-invasive cardiac output monitor

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

*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