Unique Plan Description: Neuro Endovascular Intervention Post op
Plan Selection Display: Neuro Endovascular Intervention Post op
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2022-05-31 12:43:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2022-07-13 00:37:59
Available at all facilities: Yes

Neuro Endovascular Intervention Post op
Vital Signs
	Vital Signs
		Routine: Post op
Activity
	Bedrest
		
	Activity-Restrictions
		T;N
			Comment: Immobilize arm: limit motion in extremity for 2 hours post procedure. Patient must keep affect wrist straight (do not bend) for that time. Wrist board may be used to limit extremity movement. NO venipuncture or blood pressure on affect limb for 24 hours post procedure (radial device post procedure).
	Activity-As Tolerated
		
	Elevate head of bed
		Elevate head of bed 30 degrees
			Comment: continuously
Diet
	Regular Diet
		T;N, Advance as Tolerated
			Comment: Ok to place in Reverse Trendelenburg position to eat
Medications
	ondansetron
		4 mg, Injection, IV PUSH, Q6H, PRN for nausea and/or vomiting
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN for nausea and/or vomiting
	Senokot S 50 mg-8.6 mg oral tablet
		1 TAB, Tab, By Mouth, BID, PRN constipation
			Comment: Hold for diarrhea or loose stool
	acetaminophen
		1,000 mg, Tab, By Mouth, Q8H, T;2200
	labetalol  injection
		10 mg 2 mL, Injection, IV Push, Q1H, PRN, systolic blood pressure > (see comment), Duration: 30 Dose(s)/Time(s)
			Comment: sbp > 140.  Hold for HR < 60. If sbp greater than 140, 15min after dose, initiate Cardene Protocol.  Notify provider if approaching 300mg max dose limit.
	aspirin
		325 mg, Tablet-Enteric-Coated, By Mouth, DAILY
	Plavix
		75 mg, Tab, By Mouth, DAILY, T+1;0900
	aluminum hydroxide/magnesium hydroxide/simethicone 200 mg-200 mg-20 mg/5 mL oral susp
		15 mL, Suspension-Oral, By Mouth, Q4H, PRN indigestion
	Milk of Magnesia 8% oral suspension
		30 mL, Suspension, By Mouth, DAILY, PRN constipation
	Tylenol
		650 mg, Tab, By Mouth, Q4H, PRN for temperature >  (see comment)
			Comment: 100.6; Total acetaminophen not to exceed 4,000 mg in 24 hours.
	morphine  IV
		4 mg, Syringe, IV Push, Q30MIN, PRN pain-moderate
	Xanax
		0.25 mg, Tab, By Mouth, TID, PRN anxiety
			Comment: hold if too sedated
	Ambien
		5 mg, Tab, By Mouth, QHS, PRN insomnia
	sodium chloride 0.9% flush injectable soln
		10 mL, Syringe, IV Push, BID, for IV line flush
		10 mL, Syringe, IV Push, Q5MIN, PRN IV line flush
Patient Care
	Resuscitation Status
		Full Code
		No Code
	VTE Advisor
		Medical
	Incision/Drain Assessment-Focused
		T;N, Q15MIN, 4, Dose(s)/Time(s)
		T;N, Q30MIN, 4, Dose(s)/Time(s)
		T;N, Q1H, 6, Dose(s)/Time(s)
			Comment: (Femoral Sheath Post Procedure)
	Vascular Assessment-Focused
		T;N, Q15MIN, 2, Dose(s)/Time(s)
			Comment: Assess the circulation (including Doppler pulses), movement and sensation (CMS) to bilateral extremities distal to the site of the sheath removal. (Femoral/Radial Sheath Post Procedure
		T;N, Q30MIN, 4, Dose(s)/Time(s)
			Comment: Assess the circulation (including Doppler pulses), movement and sensation (CMS) to bilateral extremities distal to the site of the sheath removal. (Femoral/Radial Sheath Post Procedure
		T;N, Q1H, 6, Dose(s)/Time(s)
			Comment: Assess the circulation (including Doppler pulses), movement and sensation (CMS) to bilateral extremities distal to the site of the sheath removal. (Femoral/Radial Sheath Post Procedure
	Intake and Output
		Q1H
			Comment: Renal Protocol if GFR<60
	Neurological Assessment-Focused
		T;N, Q1H
	Sequential Compression Device
		T;N, Wear, Both legs
	Notify MD
		T;N, if SBP persistent > 160 despite treatment. Pulse less than or equal to 50 bpm, resp rate greater than or equal to 25/min, resp rate less than or equal to 12/min, temp greater than or equal to 38.5, SpO2 less than or equal to 92%
			Comment: Urine output less than or equal to 30ml/hr, hematoma formation, increased oxygen requirement, neurological deficit or loss of signals LE ,of any new or worsening chest pain/angina, bleeding or hematoma, loss of distal pulses or extremity ischemia, new neurologic deficit (radial device post procedure)
	Patient Education
		T;N, Instructions: Educate patient on limb and weight restrictions (radial device post procedure)
	Obtain supplies/equipment
		T;N, Doppler with gel to remain at bedside at all times (radial device post procedure)
	No Venipunctures
		NO venipuncture or blood pressure on affected limb for 24 hours post procedure (radial device post procedure).
	Hemostatic Compression Device
		T;N
			Comment: Start deflation of radial band 2 hours after radial band applied. Remove 3ml of air every 10 minutes until air is removed. If bleeding occurs when 2ml is remove, reinflate with 2 ml of air. Wait 20 minutes then restart deflation. If site is free of complications after 1 hour, remove radial again and apply sterile dressing. Keep compression device at bedside in case of bleeding complications.
	Foley Catheter
		T;N
Therapies

nicardipine (Cardene) Protocol EKM
IV Solutions
	niCARdipine 25 mg/NS 250 mL
		25 mg, EVERY BAG, 5 mg/hr, T;N
		250 mL, IV, Routine, Start: T;N, Increment Increase: 2.5 mg/hr, Increment Decrease: 2.5 mg/hr, Increment Freq: 5 min(s), Max Dose: 15 mg/hr
			Comment: Begin to taper off nicardipine 1 hour after initiation of oral anti-hypertensive therapy.  If hypotension or tachycardia occurs, discontinue the infusion and notify provider.  IV may be re-initiated after weaning within 12hours, re-initiate at the dosing rate that maintained Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation.
	niCARdipine 20mg/NS 200mL
		200 mL, IV, STAT, Increment Increase: 2.5 mg/hr, Increment Decrease: 2.5 mg/hr, Increment Freq: 5 min(s), Max Dose: 15 mg/hr
			Comment: Begin to taper off nicardipine 1 hour after initiation of oral anti-hypertensive therapy. Reduce by 2.5mg/hr every 15 minutes.   If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached.  IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that maintained Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation.
		20 mg, EVERY BAG, 5 mg/hr, T;N
	nicardipine 20mg/NS 200mL premix
		200 mL, IV, STAT, Increment Increase: 2.5 mg/hr, Increment Decrease: 2.5 mg/hr, Increment Freq: 5 min(s), Max Dose: 15 mg/hr
			Comment: Begin to taper off nicardipine 1 hour after initiation of oral anti-hypertensive therapy. Reduce by 2.5mg/hr every 15 minutes.   If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached.  IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that maintained Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation.
		20 mg, EVERY BAG, 5 mg/hr
Patient Care
	IV-Restart
		T;N, Q12H
			Comment: if peripheral site is used while on nicardipine

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

Pain Constipation Nausea Protocol </= to 65 EKM
Medications

		Select only one medication in each category(NOTE)*
Mild Pain
	Tylenol
		650 mg, Tab, By Mouth, Q4H, PRN, see comment
			Comment: discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient
		650 mg, Suppository, RECTALLY, Q6H, PRN, see comment
			Comment: discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient
	ibuprofen
		600 mg, Tab, By Mouth, Q6H, PRN, pain-mild
			Comment: pain rating 1-3
		800 mg, Tab, By Mouth, Q8H, PRN, pain-mild
			Comment: pain rating 1-3
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-mild
			Comment: pain rating 1-3
	Percocet 5 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-mild
			Comment: pain rating 1-3
	Dilaudid Injectable
		0.2 mg, Injection, IV Push, Q2H, PRN, pain-mild
			Comment: for pain rating 1-3 and if NPO
	morphine  IV
		2 mg, Syringe, IV Push, Q2H, PRN, pain-mild
			Comment: for pain rating 1-3 and if NPO
Moderate Pain
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	acetaminophen-hydrocodone 325 mg-7.5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	acetaminophen-hydrocodone 325 mg-10 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	Percocet 5 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	Percocet 7.5 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	Percocet 10 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	Roxicodone
		5 mg, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	morphine  oral immediate release
		15 mg, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: Pain rating 4-6
	Dilaudid Injectable
		0.2 mg, Injection, IV Push, Q2H, PRN, pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
		0.4 mg, Injection, IV Push, Q2H, PRN, pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
	morphine  IV
		2 mg, Syringe, IV Push, Q2H, PRN, pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
		4 mg, Syringe, IV Push, Q2H, PRN, pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
	ketorolac injectable
		15 mg, Injection, IV Push, Q6H, PRN, pain-moderate, 48 hr
			Comment: For pain rating 4-6.
Severe Pain
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	acetaminophen-hydrocodone 325 mg-7.5 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Percocet 5 mg-325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Percocet 7.5 mg-325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Percocet 10 mg-325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Roxicodone
		10 mg, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	morphine  oral immediate release
		30 mg, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Dilaudid Injectable
		0.4 mg, Injection, IV Push, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10 if NPO or for breakthrough pain if on oral analgesics. Use 0.4mg if over age 70.
		0.5 mg, Injection, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10 if NPO or for breakthrough pain if on oral analgesics. Use 0.4mg if over age 70.
		0.6 mg, Injection, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10 if NPO
		0.8 mg, Injection, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10 if NPO
		1 mg, Injection, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10 if NPO
	morphine  IV
		4 mg, Syringe, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10; may give if NPO or for breakthrough pain if on oral analgesics.
		6 mg, Syringe, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10; may give if NPO or for breakthrough pain if on oral analgesics.
		Opiate Reversal(NOTE)*
	Narcan
		0.2 mg, Injection, IV Push, Q2MIN, PRN for see comment
			Comment: if patient has received opiate agents in the past 24 hours and/or if patient becomes somnolent with minimal or no response to stimuli or respiratory rate is 10 or less per minute.  RN may administer naloxone prior to contacting MD.  Notify MD immediately upon administration of naloxone.  May give 0.2mg every 2 min up to 1mg total dose.
Constipation
	docusate
		100 mg, Capsule, By Mouth, DAILY
			Comment: Hold for diarrhea
	Senokot S 50 mg-8.6 mg oral tablet
		2 TAB, Tab, By Mouth, QHS
	MiraLax oral powder for reconstitution
		17 gm, Packet, By Mouth, Q12H, PRN, constipation
			Comment: Mix in 6 oz juice or water
		17 gm, Packet, By Mouth, DAILY, PRN, constipation
			Comment: Mix in 6 oz juice or water
	Milk of Magnesia 8% oral suspension
		30 mL, Suspension, By Mouth, DAILY, PRN for constipation
			Comment: If Miralax not effective; do not use if creatinine clearance or GFR < 30mL/min
		30 mL, Suspension, By Mouth, Q12H, PRN for constipation
			Comment: If Miralax not effective; do not use if creatinine clearance or GFR < 30mL/min
	Dulcolax
		10 mg, Suppository, RECTALLY, DAILY, PRN, constipation
			Comment: If MOM ineffective or if patient NPO
		10 mg, Suppository, RECTALLY, Q12H, PRN, constipation
			Comment: If MOM ineffective or if patient NPO
	Fleet Enema 19 gm-7 gm rectal enema
		1 EA, Enema, RECTALLY, Q12H, PRN, constipation
			Comment: If bisacodyl ineffective
	Enema-Administer
		Tap water, Q1H, constipation
			Comment: if suppository ineffective
Nausea Vomiting
	ondansetron
		4 mg, Injection, IV PUSH, Q6H, PRN for nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN for nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED
		Select either promethazine or prochlorperazine orders(NOTE)*
	prochlorperazine
		10 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures.
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures, give if IV access not available.
	Phenergan (MH/WH)
		25 mg, Tab, By Mouth, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures.
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
		6.25 mg, Injection, IM-Intramuscular, Q6H, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Phenergan (FH)
		12.5 mg, INT, IVPB, Once, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
		25 mg, INT, IVPB, Once, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Phenergan (JE)
		25 mg, Tab, By Mouth, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Reglan
		10 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron and phenothiazine ineffective; avoid in patients > 65 y/o.
		10 mg, Injection, IM-Intramuscular, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron and phenothiazine ineffective; avoid in patients > 65 y/o.
Patient Care

	Notify MD
		If patient develops itching
		if no results from enema.

Neuro Endovascular Post Sheath Removal
Activity
	Activity-Restrictions
		T;N, Immobilize affected extremity while on bedrest. (radial device post procedure)
		T;N
			Comment: Immobilize arm. Limit motion in extremity for 2 hours post procedure. Patient must keep affected wrist straight. (Do not bend) for that time. Wrist board may be used to limit extremity movement (radial device post procedure)
		T;N, Do not lift more than 10 pound for 5 days after the sheath has been removed (radial device post procedure)
		T;N
			Comment: : No push or pulling with affect arm for 24 hour. Patient should not lift more than 5 pounds with involved arm for 72 hours post procedure (radial device post procedure)(radial device post procedure)
	Elevate head of bed
		Elevate head of bed: Elevate head of bed 30 degrees (radial device post procedure)
			Comment: continuously
	Bedrest
		6, hr
			Comment: Strict bedrest for 6 hours post femoral arterial sheath removal (radial device post procedure)
Patient Care
	Notify MD
		T;N
			Comment: if any new or worsening chest pain/angina, bleeding or hematoma, loss of distal pulses or extremity ischemia, new neurologic deficit. Any new, severe back and/or groin pain, or emerging bruising or swelling over the abdomen, groin, or flank areas with low BP and increasing heart rate should be documented and reported immediately to the procedural physician. (Femoral/Radial Sheath Post Procedure)
	Obtain supplies/equipment
		T;N, Doppler with gel to remain at bedside at all times (radial device post procedure)
	Incision/Drain Assessment-Focused
		T;N
			Comment: Apply manual pressure and restart bedrest if bleeding or hematoma re-occurs. (radial device post procedure)
	Patient Education
		T;N, Instructions: Educate patient on limb and weight restrictions (radial device post procedure)

*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