Unique Plan Description: HN Onc and Surgery Gastric Tube Placement
Plan Selection Display: HN Onc and Surgery Gastric Tube Placement
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2024-05-14 09:24:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-05-14 09:24:00
Available at all facilities: Yes

HN Onc and Surgery Gastric Tube Placement
Vital Signs
	Vital Signs
		Routine Post Op
Activity
	Up in Chair
		TIDWM
			Comment: start evening of surgery.
	Ambulate
		TID Between Meals
			Comment: May start evening of surgery.
	Elevate head of bed
		Elevate head of bed 30 degrees
	Discharge Activity
		Avoid lifting more than 20 pounds for the first week then gradually increase to normal activity.  Resume full activities at 2-3 weeks. Very important to ambulate (walk around) same day as surgery and routinely thereafter., Bathing Activities: May shower 2
Diet
	NPO
		
	Clear Liquid Diet
		Advance as Tolerated
			Comment: to General Diet
		
	General  Diet
		
	Pureed 4 Diet
		T;N
	Advance Diet as Tolerated
		T;N
Tube Feeding
	Tube Feeding
		T;N, Isosource 1.5, Initial Rate: 10 ml/hr, Continuous
	Tube Feeding Rate Change
		T;N, Increase to goal rate per dietitian recommendations. Discontinue TF Rate Change order once goal is reached
	Tube Feeding - Instill
		Tap water, 30 ml, Q4HR
	Gastrostomy Tube
		T;N, May use gastrostomy tube immediately for medication administration.
IV Solutions

	Dextrose 5% with 0.45% NaCl w/KCl 20 mEq
		1,000 mL, IV, 125 ml/hr
			Comment: Total tube feeding and IV fluid to be 125ml/hr (independent of free water) Convert to peripheral lock when at goal.
		1,000 mL, IV, 100 ml/hr
			Comment: Total tube feeding and IV fluid to be 125ml/hr (independent of free water) Convert to peripheral lock when at goal.
		1,000 mL, IV, 75 ml/hr
			Comment: Total tube feeding and IV fluid to be 125ml/hr (independent of free water) Convert to peripheral lock when at goal.
		1,000 mL, IV, 150 ml/hr
			Comment: Total tube feeding and IV fluid to be 125ml/hr (independent of free water) Convert to peripheral lock when at goal.
Medications
	ondansetron
		4 mg, Tablet-Disintegrating, By Mouth, Q4H, PRN nausea
	morphine  IV
		2 mg, Syringe, IV Push, Q2H, PRN pain-breakthrough
	ibuprofen
		800 mg, Tab, By Mouth, Q8H, PRN pain-mild
	acetaminophen
		650 mg, Tab, By Mouth, Q4H
	pantoprazole IV
		40 mg, Injection, IV Push, DAILY
			Comment: Dilute each 40mg vial with 10ml NS.
Patient Care
	Gastrostomy Tube
		T;N, If gravity bag present, remove once patient is to floor
	Resuscitation Status
		Full Code
		No Code
	Notify MD
		T;N, Head and Neck Surgery House Officer for bleeding, temp >101.5 or <96.0, SBP >160 or <90, DBP >110 or <50, RR >30 or < 10, Oxygen sat <92%, UO <100ml/4hr
	Incision/Dressing Care
		T;N
			Comment: Cleanse around gastric tube and apply petroleum jelly prior to discharge.
		T;N
			Comment: Remove abdominal dressing prior to discharge
	VTE Advisor
		General surgery
	Non Invasive Cardiac Monitoring Device
		Q1H, 48, hr
	Patient Education
		T;N, Instructions: Teach patient to attach tube feed syringe and flush tube with 30ml water
	Abdominal Binder
		T;N, in place while in patient
		T;N, Send patient home with abdominal binder
	Obtain supplies/equipment
		Please send patient home with 2 tube feed syringes, graduate and 14 split gauzes.
	Discharge Symptoms to Report
		Instructions: Call the doctor for signs of an infection including temperature at or greater than 100.5, and or redness swelling or foul smelling drainage from incision or drain site.
		Instructions: If the skin becomes too red or sensitive, call the clinic to have it assessed.
		Instructions: If your gastric tube become hard to use or becomes dislodged, do not try and replace it. Please stop using it and call the Head & Neck Oncology clinic or the afterhours on call phone for assistance.
	Discharge Incisional, Wound, Stoma Care
		You may get thin drainage from around your gastric tube site. Please cleanse the surrounding skin daily and as needed. Apply petroleum jelly und gastrostomy tube utilizing a Q-tip. May apply split gauze under bumper if able.
		Incisional Care: Cleanse wound with soap and water and apply petroleum jelly twice a day
	Discharge Lines, Tubes and Drains
		Instructions: Flush gastric tube two times daily with 30ml of tap water to keep tube patent.
Therapies
Social Work
	Consult Social Work
		T;N
			Comment: Infusion Company for supplies
Consults/Follow-up

	Consult Dietitian
		T;N, Regarding: Nutrition Assessment
			Comment: Please make recommendation and or adjustments to current TF order.
	Consult MECC Dietitian
		T;N, Reason for MECC Diet Ref Tube Feeding
	Pharmacy Consult
		Recommendations for crushing meds

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

HN Onc Refeeding Syndrome
Laboratory
	Comprehensive Metabolic Panel
		T;N, Timed, Q12H, 5, Day(s), spec type = Blood
	Magnesium Level
		T;N, Timed, Q12H, 5, Day(s), spec type = Blood
	Phosphorus
		T;N, Timed, Q12H, 5, Day(s), spec type = Blood
Medications
	thiamine
		100 mg, Tab, Gastric Tube, DAILY, duration: 7 Day(s)
Patient Care
	Cardiac Telemetry Monitoring

*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