Unique Plan Description: HN Onc Laryngectomy (no flap) (MH) Post-Op EKM
Plan Selection Display: HN Onc Laryngectomy (no flap) (MH) Post-Op
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2016-09-13 11:20:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2022-12-13 09:52:28
Available at all facilities: Yes

HN Onc Laryngectomy (no flap) (MH) Post-Op EKM
Vital Signs
	Vital Signs
		Q1H, 24, hr, then routine
Activity
	Elevate head of bed
		Elevate head of bed 30 degrees
	Bedrest
		T;N
			Comment: Day of surgery
	Up in Chair
		T+1;0600, TIDWM
	Ambulate
		T+1;0600, TID
	Activity-Position
		T;N
			Comment: To keep head position at:
Diet
	NPO
		T;N
	Tube Feeding
		T+1;0600, Impact Peptide 1.5 (MH only), Continuous
			Comment: Begin at 20ml/hr, Increase rate by 10ml q4hr to dietary recommendations for goal determined by dietitian. No need to check residuals unless patient using PEG or G tube.
	Consult Dietitian
		T+1;0600, Regarding: Nutrition Assessment
			Comment: recommendations for tube feeding goal, and free water
Laboratory
Today's Lab
	CBC with Diff
		Stat, spec type = Blood
			Comment: IN PACU
	Basic Metabolic Panel
		Stat, spec type = Blood
			Comment: IN PACU
	Magnesium Level
		Stat, spec type = Blood
			Comment: IN PACU
	Phosphorus
		Stat, spec type = Blood
			Comment: IN PACU
Tomorrow's Lab
	CBC with Diff
		T+1;0400, Routine, Q24H, 2 Dose(s)/Time(s), spec type = Blood
	Basic Metabolic Panel
		T+1;0400, Routine, Q24H, 2 Dose(s)/Time(s), spec type = Blood
	Phosphorus
		T+1;0400, Routine, Q24H, 2 Dose(s)/Time(s), spec type = Blood
	Magnesium Level
		T+1;0400, Routine, Q24H, 2 Dose(s)/Time(s), spec type = Blood
Diagnostic Tests
Radiology
	Chest 1 View
		Stat, Post Op F/U
	Barium Swallow
		T;N, Routine
			Comment: Leak test with SLP present
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
	Unasyn IVPB
		3,000 mg, Injection-Premix, IVPB, Q6H, Surgical prophylaxis, 24 hr
		1,500 mg, Injection-Premix, IVPB, Q6H, Surgical prophylaxis, 24 hr
	bacitracin ointment
		1 appl, Packet, TOPICAL, BID
			Comment: Apply to neck/facial incision
	Peridex 0.12% oral rinse
		15 mL, Solution, Mouthwash, Q6H
			Comment: Swish and spit
	Senokot 8.6 mg oral tablet
		1 TAB, Tab, NASOGASTRIC, BID, T+1;N
			Comment: Hold if loose stools
	Dulcolax
		10 mg, Suppository, RECTALLY, DAILY, PRN, constipation
			Comment: If no stools in previous 3 days
	ondansetron
		4 mg, Injection, IV Push, Q4H, PRN for nausea and/or vomiting
	promethazine oral syrup
		25 mg, Syrup, NASOGASTRIC, Q4H, PRN, nausea
	morphine  IV
		2 mg, Syringe, IV Push, Q2H, PRN, pain-breakthrough
	acetaminophen-hydrocodone 325 mg-7.5 mg/15 mL oral solution
		15 mL, Elixir, NASOGASTRIC, Q4H, PRN, pain-moderate
		30 mL, Elixir, NASOGASTRIC, Q4H, PRN, pain-severe
	acetaminophen-hydrocodone 108 mg-2.5 mg/5 mL oral liquid
		15 mL, Elixir, NASOGASTRIC, Q4H, PRN, pain-moderate
		30 mL, Elixir, NASOGASTRIC, Q4H, PRN, pain-severe
	Motrin oral suspension
		800 mg, Suspension, NASOGASTRIC, Q8H
			Comment: Please be advised that the nonnarcotic pain meds are scheduled and not PRN.  Please give to the patients even if not in pain.
	acetaminophen 325 mg/10.15 mL elixir
		650 mg, Elixir, NASOGASTRIC, Q4H
			Comment: Please be advised that the nonnarcotic pain meds are scheduled and not PRN.  Please give to the patients even if not in pain.
	VTE Advisor
		General surgery
	pantoprazole IV
		40 mg, Injection, IV Push, DAILY
			Comment: Dilute each 40mg vial with 10ml NS.
Patient Care
	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, O2 sat < 90%, UO <100ml in 4HR, increase in blood in JP's, numbness/tingling in lips or fingers, any vomiting
	Foley Catheter
		T;N, To dependent drainage, Strict Immobilization for trauma/surgery
	Cardiac Telemetry Monitoring
		T;N, 48, hr, Telemetry Indications: Other
	Wound Drain
		T;N, Bulb Suction
			Comment: Strip JP and record output
	Record Output
		T;N, Bulb suction, Q4H, 48, hr
			Comment: Strip JP and record output
	Incision/Dressing Care
		Cleanse with normal saline, BID
			Comment: plus PRN apply antibiotic ointment and change dressings. plus PRN
	Oral Care
		Q2H-Sch, While awake. Q2H if NPO, May change to Q4H if taking oral intake.
	Obtain supplies/equipment
		T;N, Bayonett forceps and flashlight at bedside at all times
	Non Invasive Cardiac Monitoring Device
		Q1H, 48, hr
		T;N+2880, Q4H, 24, hr
Therapies
	Respiratory Care Patient Education
		T;N
			Comment: Laryngectomy Care and Supplies
	Consult Physical Therapy, Evaluate and Treat
		Reason to See: Evaluate and Treat
			Comment: Evaluate for ADL and shoulder strength. Post Op Laryngectomy
	Consult Speech Language (MH), Evaluate and Treat
		T+1;0600, Electrolarynx Training
			Comment: to keep at bedside
	Consult Occupational Therapy, Evaluate and Treat
		T+1;0600, Reason to See: Evaluate and Treat
			Comment: Evaluate for ADLs
	Consult Social Work
		Home Health Care
			Comment: Home suction and humidifier
	Oxygen Therapy
		T;N
	Pulse Oximetry Spot Check RT
		T;N, BID
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
Consults/Follow-up
	Pharmacy Consult
		Recommendations for crushing meds
	zzConsult Geriatric Medicine
		Reason for Referral: Patients 65 and older if appropriate

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

Insulin Sliding Scale - NovoLOG
Laboratory
	Glucose POC - RN
		T;N, QIDACHS
		T;N, 15 minutes after carbohydrate source or medication administered
	Hemoglobin A1C
		T+1;0400, Routine, spec type = Blood
	Order Lab
		T;N
			Comment: Blood Glucose (POC) as needed for signs and symptoms of hypoglycemia for patients with diabetic medication orders or known diabetic.
Medications
	Standard Dose NovoLOG
		2 - 12 units, Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale, Routine
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 2 units,200 - 249 = 4 units,250 - 299 = 6 units,300 - 349 = 8 units,350 - 399 = 10 units.Over 399 = 12 units,<< Sliding Scale Comments >> Check  POC in 3 hours; notify physician if repeat POC  greater than or equal to 400mg or less than or equal to 100.  Do not give insulin based on repeat POC value.  RN may change sliding scale insulin order and POC glucose order to every 6 hours if patient is NPO or not on oral diet (tube/enteral feedings, TPN, etc).  Enter as Q6H-SCH  PRN
	Moderate Dose NovoLOG
		4 - 24 units, Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 4 units,200 - 249 = 8 units,250 - 299 = 12 units,300 - 349 = 16 units,350 - 399 = 20 units.Over 399 = 24 units,<< Sliding Scale Comments >> Check  POC in 3 hours; notify physician if repeat POC  greater than or equal to 400mg or less than or equal to 100.  Do not give insulin based on repeat POC value.  RN may change sliding scale insulin order and POC glucose order to every 6hours if patient is NPO or not on oral diet (tube/enteral feedings,TPN, etc). Enter as Q6H-SCH PRN
	High Dose NovoLOG
		5 - 30 units, Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 5 units,200 - 249 = 10 units,250 - 299 = 15 units,300 - 349 = 20 units,350 - 399 = 25 units.Over 399 = 30 units, << Sliding Scale Comments >>Check  POC in 3 hours; notify physician if repeat POC  greater than or equal to 400mg or less than or equal to 100.  Do not give insulin based on repeat POC value.  RN may change sliding scale insulin order and POC glucose order to every 6hours if patient is NPO or not on oral diet (tube/enteral feedings, TPN, etc).  Enter as Q6H-SCH  PRN
	glucose oral gel (JE)
		15 gm, Gel, By Mouth, Once, PRN, low blood sugar
			Comment: For blood glucose is 60-70mg/dL as an alternative to apple juice. Notify provider if given with corresponding POC glucose recheck value
	Dextrose 50%
		25 mL, Injection, IV PUSH, Q15MIN, PRN for low blood sugar, Routine
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
	Dextrose 10% in Water (FH)
		250 mL, Injection, IVPB, Q30MIN, PRN for low blood sugar, infuse over 30 min(s)
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
	glucagon
		1 mg, Injection, IV Push, Q15MIN, PRN for low blood sugar, T;N
			Comment: Give if blood glucose < 70mg/dL AND if dextrose 50% injectable unavailable OR inadequate response to IV dextrose 50%. May give SubQ or IM if patient does not have IV access. Notify provider if given with corresponding POC glucose recheck value.
Patient Care
	Order Lab
		T;N, RN may change schedule of point of care glucose and sliding scale insulin order to every 6 hours if patient is NPO or not on oral diet (tube/enteral feedings, TPN, etc).. Enter POC order as Q6H-SCH, TIMED and medication order as Q6H-SCH PRN.
	Diabetic Snack
		T;N, Give snack (1 complex carb (15g), 1 protein snack (7g) ) anytime insulin is administered after the evening meal is complete and POC glucose is <150mg/dL.
	IV-Maintain
		T;N
			Comment: Patient should have IV site while on hypoglycemia protocol
	Hypoglycemia Treatment Parameters
		T;N, Hypoglycemia protocol initiated for patients with glucose <70mg/dl. Patient should have an IV while in Hypoglycemia protocol.
		T;N, glucose <60 mg/dL treat with Dextrose 50% 25 mL OR glucagon 1mg as per medication orders. Notify provider as per critical result protocol.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy
		T;N, glucose 60-70 mg/dL, administer 4 oz apple juice, 4 oz non-diet soda, or glucose gel (MJE/MFH).  If patient NPO or unable to tolerate oral intake, give Dextrose 50% 25 mL OR glucagon 1mg as per medication orders.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, After initial treatment of any glucose value </= 70 mg/dL, repeat POC glucose in 15 min; if result </= 70mg/dL continue treating as per protocol and rechecking glucose 15 min after treatment until glucose >70mg/dL.
			Comment: Notify provider of all treatments given and corresponding POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, Once glucose is within normal limits, give 1 complex carb and 1 protein source (such as ½ sandwich OR 1 individual container of peanut butter and 3 packs of crackers) or patient meal if patient able to take orals to prevent recurrent hypoglycemia.
			Comment: When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.

*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