Unique Plan Description: Hospitalist Follow Up
Plan Selection Display: Hospitalist Follow Up
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-03-05 15:25:17
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-05-13 15:40:20
Available at all facilities: No

Hospitalist Follow Up
Admit/Discharge/Transfer
	Transfer to Critical Care (WH JE)
		T;N
	Transfer to Med-Surg
		T;N
Activity
	Bedside Commode
		T;N
	Activity-As Tolerated
		T;N
Diet
	Diabetic Diet
		T;N, Calorie Level 1800 kcal
	NPO
		After Midnight
	Oral Supplement
		
Laboratory
Today's Lab
	Basic Metabolic Panel
		Stat, spec type = Blood
	CBC with Diff
		Stat, spec type = Blood
	Hepatic Function Panel
		Stat, spec type = Blood
	Hemoglobin and Hematocrit
		Stat, spec type = Blood
	Magnesium Level
		Stat, spec type = Blood
	Phosphorus
		Stat, spec type = Blood
	ProBNP
		Stat, spec type = Blood
	hs Troponin T - MH/WH/JE
		Stat, spec type = Blood
	TSH
		Stat, spec type = Blood
	UA (Culture if Positive)
		Stat, Stat, spec type = Urine
	Glucose POC - RN
		QIDACHS
Tomorrow's Lab
	Basic Metabolic Panel
		T+1;0400, Routine, spec type = Blood
	CBC with Diff
		T+1;0400, Routine, spec type = Blood
	Hepatic Function Panel
		T+1;0400, Routine, spec type = Blood
	Hemoglobin and Hematocrit
		T+1;0400, Routine, spec type = Blood
	Hemoglobin A1C
		T+1;0400, Routine, spec type = Blood
	hsCRP
		T+1;0400, Routine, spec type = Blood
	INR - MH/WH/JE
		T+1;0400, Routine, spec type = Blood
	Sed Rate
		T+1;0400, Routine, spec type = Blood
	Thyroid Panel
		T+1;0400, Routine, spec type = Blood
	Glucose POC - RN
		T+1;0300, Once
		T+1;0300, DAILY
	Lipid Panel
		T+1;0400, Routine, spec type = Blood
Diagnostic Tests

	Abd & Upright
		Routine
	Abd & Upright w Chest
		Routine
	Chest 1 View
		T+1;0001, Routine
		Routine
	Chest 2 View
		T+1;0001, Routine
	CT Head w/o Contrast
		
	CTA Chest Pulmonary Arteries
		T;N
	ECG
		Stat, Indication: ACS Rule Out
	Echo w Doppler resting
		Stat, Indication: Congestive heart failure
		T;N, Routine, Indication: Congestive heart failure
	Venous Duplex Bil Upper or Lower
		Indication: Pain, Location Upper Bilateral
		Indication: Pain, Location Lower Bilateral
	Venous Duplex Unilat Upper or Lower
		Indication: Pain, Location Left Upper
		Indication: Pain, Location Left Lower
		Indication: Pain, Location Right Upper
		Indication: Pain, Location Right Lower
IV Solutions
Medications
	Lovenox
		1.5 mg/kg, Syringe, SUBCUTANEOUS, Q24H
		40 mg, Syringe, SUBCUTANEOUS, Q12H
Patient Care
	Discontinue Hospital Protocol
		T;N, Insulin Sliding Scale
		T;N, TPN protocol
	IV-Decrease Rate
		T;N+60
	Discontinue IV
		T;N
	Foley Catheter
		T;N, Foley, Insert, Once
	Discontinue Urinary Catheter
		T;N
			Comment: and initiate voiding trial
		T;N
	zzNicotine Replacement Therapy FollowUP
		T;N
Cardiac Telemetry Monitoring
	Cardiac Telemetry Monitoring
		
	Discontinue Cardiac Telemetry Monitoring
		
Therapies

	Consult Occupational Therapy, Evaluate and Treat
		Reason to See: Evaluate and Treat
			Comment: weakness
	Consult Physical Therapy, Evaluate and Treat
		For: Evaluation and treatment
			Comment: weakness
	Consult Speech Therapy (JE)
		order MBS as indicated, and order appropriate diet
	Evaluate for home BiPAP
		
Consults/Follow-up
	Consult Wound Care
		
	Consult Physical Medicine (Rehab)
		
	Consult Diabetes Educator
		
	Consult Dietitian
		Regarding: Nutrition Assessment
	Pharmacy Consult - Warfarin (Coumadin) Therapy
		Pharmacy to dose coumadin while in hospital.
	Consult Primary Care Provider
		Reason for Referral: To manage Coumadin as an outpatient, Requested Time Frame Today
	Consult Social Work
		Facility Placement
		Evaluation
			Comment: Select Specialty Evaluation

Heparin Non DVT/PE (Low dose) Xa Monitoring
Admit/Discharge/Transfer
		This plan is to be used for patients with the following diagnoses: atrial fibrillation, chest pain, stroke, MI(NOTE)*
		MH/WH/JE only: Consider using PTT monitoring if enoxaparin/apixaban/rivaroxaban received in previous 48hr.(NOTE)*
Laboratory
	INR - MH/WH/JE
		Stat, spec type = Blood
	PTT - MH/WH/JE
		Stat, spec type = Blood
		T+2;0400, Timed, Q48H, spec type = Blood
	Heparin Anti-Xa Heparin
		Stat, spec type = Blood
		T;N+360, Timed, Q6H, spec type = Blood
IV Solutions
	HEParin 25,000 units/premixed diluent 250 mL
		250 mL, IV
			Comment: conc: 100 units/mL. Titrate according to Low Dose Weight Based Heparin Protocol.  Maximum weight for dosing 110kg.  MAXIMUM INITIAL rate is 1000unit/hr.1)  Anti-factor Xa UFH <than 0.2 units/mL, bolus 60 units/kg & increase rate by 4 units/kg/hr.2)  Anti-factor Xa UFH = 0.2-0.29 units/mL, bolus 30 units/kg & increase rate by 2 units/kg/hr.3)  Anti-factor Xa UFH = 0.3-0.7 units/mL, (therapeutic range) Do not give bolus & do not change rate.4)  Anti-factor Xa UFH = 0.71-0.95 units/mL, do not bolus. Decrease rate by 2 units/kg/hr.5)  Anti-factor Xa UFH = 0.96 units/mL or more, do not give bolus. Stop infusion for 60 mins & decrease rate by 3 units/kg/hr.Upper hard limits for weight based and non-weight based infusions are as follows: 40 units/kg/hour and 3000 units/hour, respectively; if patient needs require exceeding these limits, contact pharmacy and prescriber.MH/WH/JE only: Consider using PTT monitoring if enoxaparin/apixaban/rivaroxaban received in previous 48hr.
		25,000 units, EVERY BAG, 12 unit/kg/hr
Medications
		No IM injections while on anticoagulants(NOTE)*
	HEParin 1000 units/mL injectable soln
		60 units/kg, Injection, IV Push, Once, STAT
			Comment: Dose = 60 units/kg Bolus.  Patient on Low Dose Heparin Protocol.  Pharmacy to calculate dose. Begin heparin bolus and infusion immediately after initial stat labs are drawn.  (MAXIMUM INITIAL bolus = 4000 units)
		60 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 60 units/kg Bolus.  Anti-factor Xa UFH level < 0.2 units/mL, Patient on Low Dose Heparin Protocol.  Pharmacy to calculate dose. (MAXIMUM bolus = 6600 units)
		30 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 30 units/kg Bolus.  Anti-factor Xa UFH level between 0.2-0.29 units/mL.  Patient on Low Dose Heparin Protocol.  Pharmacy to calculate dose.  (MAXIMUM bolus = 3300 units)
Patient Care
	Notify MD
		T;N, For surgical patients, contact surgeon for approval to start heparin protocol if ordered post surgery
		T;N, if 2 consecutive 60 unit/kg boluses of heparin given and the resulting anti-factor-Xa UFH is not in therapeutic range within 12 hours
		T;N, if 2 consecutive anti-factor-Xa UFHs are greater or equal to 0.96 units/ml
		T;N, if initial stat anti-factor-Xa UFH comes back elevated.
		T;N, If baseline PTT is >42 seconds (5 seconds above upper normal limit of 22-37 seconds).
		T;N, if critical PTT >135.
		T;N, MH/WH/JE only: If patient has received enoxaparin/apixaban/rivaroxaban in previous 48hr and/or has an elevated baseline UFH antiXa level, please contact prescriber/pharmacy to consider switching to PTT monitoring protocol.
	Order Lab
		T;N, Enter orders for anti-factor-Xa UFH Q6Hr timed after initiation of therapy or any dosage change until 2 consecutive anti-factor-Xa UFH in therapeutic range, then q24h in am.
	Avoid IM Injections if possible while on anticoagulants

Heparin Non DVT/PE (Low dose) PTT Monitoring
Admit/Discharge/Transfer
		This plan is to be used for patients with the following diagnoses: atrial fibrillation, chest pain, stroke, MI(NOTE)*
Laboratory
	INR - MH/WH/JE
		Stat, spec type = Blood
	PTT - MH/WH/JE
		Stat, spec type = Blood
		T;N+360, Timed, Q6H, spec type = Blood
IV Solutions
	HEParin 25,000 units/premixed diluent 250 mL
		250 mL, IV
			Comment: conc: 100 units/mL. Titrate according to Low Dose Weight Based Heparin Protocol.  Maximum weight for dosing 110kg.  MAXIMUM INITIAL rate is 1000 units per hr.1)  PTT < 52 seconds, bolus 60 units/kg & increase rate by 4 units/kg/hr.2)  PTT = 52-64 seconds, bolus 30 units/kg & increase rate by 2 units/kg/hr.3)  PTT = 65-110 seconds, (therapeutic range) Do not give bolus & do not change rate.4)  PTT = 111-135 seconds, do not bolus. Decrease rate by 2 units/kg/hr.5)  PTT = 136 seconds or more, do not give bolus. Stop infusion for 60 mins & decrease rate by 3 units/kg/hr.Upper hard limits for weight based and non-weight based infusions are as follows: 40 units/kg/hour and 3000 units/hour, respectively; if patient needs require exceeding these limits, contact pharmacy and prescriber
		25,000 units, EVERY BAG, 12 unit/kg/hr
Medications
	HEParin 1000 units/mL injectable soln
		60 units/kg, Injection, IV Push, Once, STAT
			Comment: Dose = 60 units/kg Bolus.  Patient on Low Dose Heparin Protocol.  Pharmacy to calculate dose.  Begin heparin bolus and infusion immediately after initial stat labs are drawn.  (MAXIMUM INITIAL bolus = 4000 units)
		60 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 60 units/kg Bolus. PTT level < 52 seconds, Patient on Low Dose heparin Protocol.  Pharmacy to calculate dose.  (MAXIMUM bolus = 6600 units)
		30 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 30 units/kg Bolus. PTT level between 52-64 seconds.  Patient on Low Dose Heparin Protocol.  Pharmacy to calculate dose.  (MAXIMUM bolus = 3300 units)
Patient Care
	Notify MD
		T;N, For surgical patients, contact surgeon for approval to start heparin protocol if ordered post surgery
		T;N, if PTT is not in therapeutic range within 24 hours
		T;N, if 2 consecutive 60 unit boluses of heparin given and the resulting PTT value is not in therapeutic range within 12 hours
		T;N, For any critical PTT >135 AND with any 2 consecutive PTTs >135
		T;N, If baseline PTT is >42 seconds (5 seconds above upper normal
	Order Lab
		T;N, Enter orders for PTT Q6Hr timed after initiation of therapy or any dosage change until 2 consecutive PTT in therapeutic range, then q24h in am.
	Avoid IM Injections if possible while on anticoagulants
		T;N

Hypercalcemia
Laboratory
Today's Lab
	Ionized Calcium
		Routine, spec type = Blood
	Magnesium Level
		Routine, spec type = Blood
	Phosphorus
		Routine, spec type = Blood
	Basic Metabolic Panel
		Routine, spec type = Blood
	Parathyroid Hormone
		Routine, spec type = Blood
	Parathyroid Hormone-Related Peptide LC-MS/MS
		Routine, spec type = Blood
	Vitamin D 25-Hydroxy Level (preferred for deficiency)
		Routine, spec type = Blood
	Vitamin D Level (renal/hypercalcemia)
		Routine, spec type = Blood
	TSH
		Routine, spec type = Blood
	Albumin
		Routine, spec type = Blood
	Cortisol Level
		Routine, spec type = Blood
	Vitamin A Level
		Routine, spec type = Blood
	Protein Electrophoresis Serum
		Routine, spec type = Blood
	Bence Jones Urine (Immunofixation).
		Routine, Routine, spec type = Urine
Diagnostic Tests
Radiology
	Chest 1 View
		Routine, Cancer
IV Solutions

	Sodium Chloride 0.9%
		1,000 mL, IV, 1 Dose(s)/Time(s), Bolus
			Comment: for treatment of symptomatic or severe (>14mg/dL) hypercalcemia
		1,000 mL, IV, 200 ml/hr
			Comment: for treatment of symptomatic or severe (>14mg/dL) hypercalcemia
Medications
	Lasix Injection
		40 mg, IV PUSH, Once
			Comment: for treatment of symptomatic or severe (>14mg/dL) hypercalcemia
		80 mg, IV PUSH, Once
			Comment: for treatment of symptomatic or severe (>14mg/dL) hypercalcemia
		After failure of IVF and Lasix, may choose 1 of below (effective in 2+ days):(NOTE)*
	Aredia IVPB
		60 mg, Injection, IVPB, Once
			Comment: Pharmacy to adjust for renal function. For Albumin-corrected serum calcium 12-13.5 mg/dL
		90 mg, Injection, IVPB, Once
			Comment: Pharmacy to adjust for renal function. for Albumin-corrected serum calcium >=13.5 mg/dL
	zoledronic acid
		4 mg, Injection-Premix, IVPB, Once, T;N, Infuse Over 15 min(s)
			Comment: Preferred for hypercalcemia of malignancy. Pharmacy to adjust for renal function.
		For effect within 6-12 hours:(NOTE)*
	Miacalcin
		4 IU/kg, Injection, SUBCUTANEOUS, Once, NOW
		Discontinue all MVI, Calcium and Vitamin D(NOTE)*
Consults/Follow-up
	Pharmacy Consult
		Pharmacy to review meds for cause of hypercalcemia, especially (thiazides, lithium and theophylline). Verify all MVI, calcium, and Vitamin D have been discontinued.
	Consult Endocrinologist
		Reason for Referral: Hypercalcemia
	Consult Oncologist
		Reason for Referral: Hypercalcemia

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

Tube Feeding Orders
Diet

	Tube Feeding
		T;N, Continuous
			Comment: Change the enteral feed tubing every 24 hours or as ordered.
	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
Laboratory
	Basic Metabolic Panel
		T+1;0400, Routine, Q24H, 5, Day(s), spec type = Blood
			Comment: (Tube Feeding Orders)
		T;N, Routine, spec type = Blood
			Comment: (Tube Feeding Orders)
		T+10;0400, Routine, Q7D-Lab, spec type = Blood
			Comment: (Tube Feeding Orders)
	Magnesium Level
		T;N, Routine, spec type = Blood
			Comment: (Tube Feeding Orders)
		T+1;0400, Routine, Q24H, 5, Day(s), spec type = Blood
			Comment: (Tube Feeding Orders)
		T+10;0400, Routine, Q7D-Lab, spec type = Blood
			Comment: (Tube Feeding Orders)
	Phosphorus
		T;N, Routine, spec type = Blood
			Comment: (Tube Feeding Orders)
		T+1;0400, Routine, Q24H, 5, Day(s), spec type = Blood
			Comment: (Tube Feeding Orders)
		T+10;0400, Routine, Q7D-Lab, spec type = Blood
			Comment: (Tube Feeding Orders)
Diagnostic Tests
	Chest 1 View
		T;N, Routine, Tube Placement F/U
			Comment: Before initial feeding
Medications
	Dulcolax
		10 mg, Suppository, RECTALLY, DAILY, PRN, if no BM, T;N
			Comment: if no BM for 3 days.
	Reglan
		10 mg, Injection, IV Push, Q6H, PRN, see comment, T;N
			Comment: if holding tube feeding for residual.
		10 mg, Injection, IV Push, Q8H, see comment, T;N
			Comment: if holding tube feeding for residual.
	thiamine
		100 mg, Tab, NASOGASTRIC, DAILY, duration: 7 Day(s)
Patient Care
	Tube Feeding Residual Check
		T;N, hold feeding if gastric residual is greater than 500 ml
			Comment: After 4 hours, restart at previous rate if residual is acceptable. If the problem is not resolved, continue to hold for 4 hours and recheck. Residuals will not be checked for post pyloric feeding tube, or feeding tubes.
	Notify MD
		T;N, If residuals continue to be unacceptable after 8 hours of holding tube feeding.
	Discontinue IV Fluids
		T;N
			Comment: When tube feeding reaches goal rate
Consults/Follow-up
	Consult Dietitian
		T;N, Regarding: Tube feeding

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

Blood Culture Set
Laboratory
		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 11.00.10570.1001(NOTE)*
		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 11.00.10570.1001(NOTE)*
		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 11.00.10570.1001(NOTE)*
		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 11.00.10570.1001(NOTE)*
		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 11.00.10570.1001(NOTE)*
		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 11.00.10570.1001(NOTE)*
	.Blood Culture.
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
		Timed, spec type = Blood
		T+1;0400, Routine, spec type = Blood
	.Blood Culture
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
		Timed, spec type = Blood
		T+1;0400, Routine, spec type = Blood

PICC line Access
Diagnostic Tests
	IV Team US Guidance
		T;N, PICC Line Insertion
Medications
	sodium chloride 0.9% flush injectable soln
		10 mL, Syringe, IV Push, BID
		10 mL, Syringe, IV Push, Q5MIN, PRN, IV line flush
		20 mL, Syringe, IV Push, Q5MIN, PRN, IV line flush
		30 mL, Syringe, IV Push, Q5MIN, PRN, IV line flush
	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.
	lidocaine 1% injectable solution (MH/WH/FH)
		5 mL, SUBCUTANEOUS, Q1H, PRN, see comment
			Comment: For PICC line insert
	sodium chloride bacteriostatic 0.9% injectable soln
		5 mL, Injection, SUBCUTANEOUS, Q1H, PRN, see comment
			Comment: For PICC line insert, use if patient has lidocaine allergy.
Patient Care
	PICC Line Insert (MH/WH)
		T;N
	PICC Line Insert (JE)
		T;N
	PICC line insert (FH)
		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, Q15MIN, 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.

Adult TPN Protocol
Laboratory
		For critically ill adult patients, consider enteral nutrition when possible. Total Parenteral Nutrition (TPN) should be considered for patients who are unable to meet nutritional requirements with enteral nutrition and are expected to require it for great(NOTE)*
	Basic Metabolic Panel
		T+1;0400, Routine, Q24H, 5, Day(s), spec type = Blood
			Comment: (TPN Protocol)
		T;N, Routine, spec type = Blood
			Comment: (TPN Protocol)
		T+10;0400, Routine, spec type = Blood
			Comment: (TPN Protocol)
	CBC with Diff
		T;N, Routine, spec type = Blood
			Comment: (TPN Protocol)
		T+7;0400, Routine, Q7D-Lab, spec type = Blood
			Comment: (TPN Protocol)
	Chromium Level
		T+14;0400, Routine, Q14D-Lab, spec type = Blood
			Comment: (TPN Protocol)
	Comprehensive Metabolic Panel
		T;N, Routine, spec type = Blood
			Comment: (TPN Protocol)
		T+7;0400, Routine, Mon, spec type = Blood
			Comment: (TPN Protocol)
	Copper Level
		T+14;0400, Routine, Q14D-Lab, spec type = Blood
			Comment: (TPN Protocol)
	Magnesium Level
		T;N, Routine, spec type = Blood
			Comment: (TPN Protocol)
		T+1;0400, Routine, Q24H, 5, Day(s), spec type = Blood
			Comment: (TPN Protocol)
		T+10;0400, Routine, Q7D-Lab, spec type = Blood
			Comment: (TPN Protocol)
	Manganese Level
		T+14;0400, Routine, Q14D-Lab, spec type = Blood
			Comment: (TPN Protocol)
	Phosphorus
		T;N, Routine, spec type = Blood
			Comment: (TPN Protocol)
		T+1;0400, Routine, Q24H, 5, Day(s), spec type = Blood
			Comment: (TPN Protocol)
		T+10;0400, Routine, Q7D-Lab, spec type = Blood
			Comment: (TPN Protocol)
		If patient is on warfarin, select BOTH Protime orders below:(NOTE)*
	INR - MH/WH/JE
		T;N, Routine, spec type = Blood
			Comment: (TPN Protocol)
	Prothrombin Time (PT) - FH
		T;N, Stat, spec type = Diagnostic Blood
			Comment: (TPN Protocol)
		T;N, Stat, spec type = Therapeutic Blood
			Comment: (TPN Protocol)
	INR - MH/WH/JE
		T+7;0400, Routine, Q7D-Lab, spec type = Blood
			Comment: (TPN Protocol)
	Prothrombin Time (PT) - FH
		T+7;0400, spec type = Diagnostic Blood
			Comment: (TPN Protocol)
		T+7;0400, spec type = Therapeutic Blood
			Comment: (TPN Protocol)
	Selenium Level
		T+14;0400, Routine, Q14D-Lab, spec type = Blood
			Comment: (TPN Protocol)
	Triglycerides
		T;N, Routine, spec type = Blood
			Comment: (TPN Protocol)
		T+7;0400, Routine, Q7D-Lab, spec type = Blood
			Comment: (TPN Protocol)
	Zinc Level
		T+14;0400, Routine, Q14D-Lab, spec type = Blood
			Comment: (TPN Protocol)
Diagnostic Tests
	Indirect calorimetry
		T;N
			Comment: TPN Protocol.
IV Solutions
	TPN with Electrolytes - TPN Protocol
		1,800 mL, IV, T;2100, 75 ml/hr, 5 % Amino Acids, 15 % Dextrose, 40 mEq/L Sodium Chloride, 20 mEq/L Sodium Acetate, 15 mEq/L Potassium Chloride, 14 mMol/L Potassium Phosphat, 8 mEq/L Magnesium Sulfate, 4.8 mEq/L Calcium Gluconate, 10mL M W F mL/Bag MVI-Adu
			Comment: Infuse via central line only. TPN rate changes should occur with next bag unless specifically ordered by prescriber.
Patient Care
	Glucose POC - RN
		T;2100, Q6H
	Discontinue IV Fluids
		T;2100
			Comment: Upon TPN initiation (TPN Protocol)
	Central Line-Insert
		T;N
Consults/Follow-up
	Consult Dietitian
		T;N, Regarding: TPN, Dietitian Assess and Treat
			Comment: Pharmacy/Nutrition to order TPN solution, labs and make necessary adjustments.
	Pharmacy Consult - TPN
		T;N, Regarding: TPN | Pharmacy/nutrition to order TPN solution and monitor/adjust electrolytes. Add 100mg Thiamine IV Push daily for 7 days order if patient is at risk for refeeding syndrome. Discontinue Thiamine after 7 days.
			Comment: Pharmacy/nutrition to order TPN solution and monitor/adjust electrolytes. Add 100mg Thiamine IV Push daily x7 days order if patient is at risk for refeeding syndrome. Discontinue Thiamine after 7 days

*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