Unique Plan Description: Vasc Surg Catheter Directed Thrombolysis, Post op EKM
Plan Selection Display: Vasc Surg Catheter Directed Thrombolysis, Post op
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-11-05 08:51:30
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2022-03-25 13:15:20
Available at all facilities: Yes

Vasc Surg Catheter Directed Thrombolysis, Post op
Admit/Discharge/Transfer
	Admit to Inpatient Status
		T;N, Anticipated LOS 2 midnight or more
	Admit to Critical Care Inpatient Status (MH)
		T;N, Anticipated LOS 2 midnight or more
Vital Signs
	Vital Signs
		Routine
		Q4H
Activity
	Bedrest
		
	Activity-Position
		T;N
			Comment: May bend waist:       Degrees
		Flat
	Bedrest with Bathroom Privileges
		
	Up with Assistance
		
Diet
	Regular Diet
		
	Low Cholesterol/No Added Salt Diet
		
	Renal Diet
		
	Cardiac Diet
		
	Diabetic Diet
		
	Clear Liquid Diet
		
	NPO
		NPO Except for: Medications
Laboratory
Today's Lab
	PTT - MH/WH/JE
		Timed, Q6H, 24 hr, spec type = Blood
	Hemoglobin and Hematocrit
		Timed, Q6H, 24 hr, spec type = Blood
	Fibrinogen Level - MH/WH/JE
		Timed, Q6H, 24 hr, spec type = Blood
Tomorrow's Lab
	Basic Metabolic Panel
		T+1;0400, Routine, spec type = Blood
	CBC with Diff
		T+1;0400, Routine, spec type = Blood
	INR - MH/WH/JE
		T+1;0400, Routine, spec type = Blood
IV Solutions

	Sodium Chloride 0.45% w/ KCl 20mEq
		1,000 mL, IV, 50 ml/hr
		1,000 mL, IV, 75 ml/hr
		1,000 mL, IV, 100 ml/hr
		1,000 mL, IV, 125 ml/hr
	Dextrose 5% in Lactated Ringers
		1,000 mL, IV, 50 ml/hr
		1,000 mL, IV, 75 ml/hr
		1,000 mL, IV, 100 ml/hr
		1,000 mL, IV, 125 ml/hr
	Sodium Chloride 0.9%
		1,000 mL, IV, 50 ml/hr
		1,000 mL, IV, 75 ml/hr
		1,000 mL, IV, 100 ml/hr
		1,000 mL, IV, 125 ml/hr
		1,000 mL, IV, 300 ml/hr
Medications
	sodium chloride 0.9% flush injectable soln
		10 mL, Syringe, IV PUSH, Once, PRN, IV line flush
			Comment: lysis catheter coolant line occlusion; call provider if additional doses are needed and/or attempt unsuccessful.
		10 mL, Syringe, IV PUSH, Once, PRN, IV line flush
			Comment: lysis catheter tpa line occlusion; call provider if additional doses are needed and/or attempt unsuccessful.
Patient Care
	Resuscitation Status
		Full Code
		No Code
	VTE Advisor
		Vascular surgery
	Foley Catheter
		Foley, Insert, Foley Removal Protocol
			Comment:  Indication: bedrest and enforced groin immobility.
	Incision/Drain Assessment-Focused
		T;N, Q1H
			Comment: monitor for excessive bleeding, and catheter placement
	Dressing Care
		Reinforce | Do not remove
	Discontinue
		Heparin protocol, no lab monitoring while lysis catheter in place
	Vascular Assessment-Focused
		T;N, Q1H
			Comment: While catheter in place
	No Venipunctures
		Avoid any unnecessary peripheral venous punctures for 24 hours post tpa infusion.
	Do Not
		No insertion of any IV, NG, central lines or arterial lines during tpa infusion and for 24 hours post tpa infusion
	Cardiac Telemetry Monitoring
		Telemetry Indications: Other

Vasc Surg Arterial Thrombolysis
IV Solutions
	HEParin 25,000 units/premixed diluent 250 mL
		25,000 units, EVERY BAG, 500 units/hr
		250 mL, IV, Routine, T;N
		EKOs:(NOTE)*
	alteplase 5 mg/NS 500 mL
		500 mL, Catheter, STAT, 1 Dose(s)/Time(s), 25 ml/hr
			Comment: conc: 0.01mg/mLInfuse via infusion catheter.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		5 mg, EVERY BAG, 0.25 mg/hr
	Sodium Chloride 0.9%
		1,000 mL, IV, 35 ml/hr
			Comment: via coolant port
		1,000 mL, IV, 30 ml/hr
			Comment: via sheath
	alteplase 5 mg/NS 250 mL
		250 mL, Catheter, STAT, 1 Dose(s)/Time(s), 12.5 ml/hr
			Comment: conc: 0.02mg/mLInfuse via infusion catheter.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		5 mg, EVERY BAG, 0.25 mg/hr
	Sodium Chloride 0.9%
		1,000 mL, IV, 35 ml/hr
			Comment: via coolant port
		1,000 mL, IV, 30 ml/hr
			Comment: via sheath
	alteplase 10 mg/ NS 250 mL
		250 mL, Catheter, STAT, T;N, 1 Dose(s)/Time(s), 12.5 ml/hr
			Comment: conc: 0.04mg/mLInfuse via infusion catheter.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		10 mg, EVERY BAG, 0.5 mg/hr, T;N
	Sodium Chloride 0.9%
		1,000 mL, IV, 35 ml/hr
			Comment: via coolant port
		1,000 mL, IV, 30 ml/hr
			Comment: via sheath
	alteplase 20mg/NS 250mL
		250 mL, Catheter, STAT, 1 Dose(s)/Time(s), 12.5 ml/hr
			Comment: conc: 0.08mg/mLInfuse via infusion catheter.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		20 mg, EVERY BAG, 1 mg/hr
	Sodium Chloride 0.9%
		1,000 mL, IV, 35 ml/hr
			Comment: via coolant port
		1,000 mL, IV, 30 ml/hr
			Comment: via sheath
		Catheter:(NOTE)*
	alteplase 5 mg/NS 500 mL
		500 mL, Catheter, STAT, 1 Dose(s)/Time(s), 25 ml/hr
			Comment: conc: 0.01mg/mLInfuse via infusion catheter.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		5 mg, EVERY BAG, 0.25 mg/hr
	alteplase 5 mg/NS 250 mL
		250 mL, Catheter, STAT, 1 Dose(s)/Time(s), 12.5 ml/hr
			Comment: conc: 0.02mg/mLInfuse via infusion catheter.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		5 mg, EVERY BAG, 0.25 mg/hr
	alteplase 10 mg/ NS 250 mL
		250 mL, Catheter, STAT, T;N, 1 Dose(s)/Time(s), 12.5 ml/hr
			Comment: conc: 0.04mg/mLInfuse via infusion catheter.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		10 mg, EVERY BAG, 0.5 mg/hr
	alteplase 20mg/NS 250mL
		250 mL, Catheter, STAT, T;N, 1 Dose(s)/Time(s), 12.5 ml/hr
			Comment: conc: 0.08mg/mLInfuse via infusion catheter.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		20 mg, EVERY BAG, 1 mg/hr
Consults/Follow-up
	Pharmacy Consult
		pharmacy to review tpa orders STAT. Please deliver to pt room within 30 minutes

Vasc Surg Venous Thrombolysis
IV Solutions
	HEParin 25,000 units/premixed diluent 250 mL
		25,000 units, EVERY BAG, 500 units/hr
		250 mL, IV
		EKOs:(NOTE)*
	alteplase 5 mg/NS 500 mL
		500 mL, Catheter, STAT, 1 Dose(s)/Time(s), 25 ml/hr
			Comment: conc: 0.01mg/mLInfuse via infusion catheter.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		5 mg, EVERY BAG, 0.25 mg/hr
	Sodium Chloride 0.9%
		1,000 mL, IV, 35 ml/hr
			Comment: via coolant port
		1,000 mL, IV, 30 ml/hr
			Comment: via sheath
	alteplase 5 mg/NS 250 mL
		250 mL, Catheter, STAT, 1 Dose(s)/Time(s), 12.5 ml/hr
			Comment: conc: 0.02mg/mLInfuse via infusion catheter.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		5 mg, EVERY BAG, 0.25 mg/hr
	Sodium Chloride 0.9%
		1,000 mL, IV, 35 ml/hr
			Comment: via coolant port
		1,000 mL, IV, 30 ml/hr
			Comment: via sheath
	alteplase 10 mg/ NS 250 mL
		250 mL, Catheter, STAT, T;N, 1 Dose(s)/Time(s), 12.5 ml/hr
			Comment: conc: 0.04mg/mLInfuse via infusion catheter.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		10 mg, EVERY BAG, 0.5 mg/hr
	Sodium Chloride 0.9%
		1,000 mL, IV, 35 ml/hr
			Comment: via coolant port
		1,000 mL, IV, 30 ml/hr
			Comment: via sheath
	alteplase 20mg/NS 250mL
		250 mL, Catheter, STAT, 1 Dose(s)/Time(s), 12.5 ml/hr
			Comment: conc: 0.08mg/mLInfuse via infusion catheter.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		20 mg, EVERY BAG, 1 mg/hr
	Sodium Chloride 0.9%
		1,000 mL, IV, 35 ml/hr
			Comment: via coolant port
		1,000 mL, IV, 30 ml/hr
			Comment: via sheath
		Catheter:(NOTE)*
	alteplase 5 mg/NS 500 mL
		500 mL, Catheter, STAT, 1 Dose(s)/Time(s), 25 ml/hr
			Comment: conc: 0.01mg/mLInfuse via infusion catheter.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		5 mg, EVERY BAG, 0.25 mg/hr
	alteplase 5 mg/NS 250 mL
		250 mL, Catheter, STAT, 1 Dose(s)/Time(s), 12.5 ml/hr
			Comment: conc: 0.02mg/mLInfuse via infusion catheter.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		5 mg, EVERY BAG, 0.25 mg/hr
	alteplase 10 mg/ NS 250 mL
		250 mL, Catheter, STAT, T;N, 1 Dose(s)/Time(s), 12.5 ml/hr
			Comment: conc: 0.04mg/mLInfuse via infusion catheter.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		10 mg, EVERY BAG, 0.5 mg/hr, T;N
	alteplase 20mg/NS 250mL
		250 mL, Catheter, STAT, T;N, 1 Dose(s)/Time(s), 12.5 ml/hr
			Comment: conc: 0.08mg/mLInfuse via infusion catheter.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		20 mg, EVERY BAG, 1 mg/hr
Consults/Follow-up
	Pharmacy Consult
		pharmacy to review tpa orders STAT. Please deliver to pt room within 30 minutes

Vasc Surg PE Thrombolysis
IV Solutions
	HEParin 25,000 units/premixed diluent 250 mL
		250 mL, IV, 12 hr
		25,000 units, EVERY BAG, 500 units/hr
		<!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 11.00.9600.20512(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 11.00.9600.20512(NOTE)*
	Alteplase 12mg/NS 250mL
		250 mL, Catheter, STAT, T;N, 1 Dose(s)/Time(s), 21 ml/hr
			Comment: Infusion rate: 21ml/hr (1mg/hr) Infuse via LEFT pulm artery infusion catheter, Total IV fluids at 125ml/hr while tpa infusing. Begin enoxaparin 1mg/kg SC q12h once tpa infusion is complete.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		12 mg, EVERY BAG
	Sodium Chloride 0.9%
		1,000 mL, IV, 12 hr, 35 ml/hr
			Comment: via LEFT coolant port
		1,000 mL, IV, 12 hr, 30 ml/hr
			Comment: via LEFT coolant sheath
		<!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 11.00.9600.20512(NOTE)*
	Alteplase 12mg/NS 250mL
		12 mg, EVERY BAG
		250 mL, Catheter, STAT, T;N, 1 Dose(s)/Time(s), 21 ml/hr
			Comment: Infusion rate: 21ml/hr (1mg/hr)  Infuse via RIGHT pulm artery infusion catheter, Total IV fluids at 125ml/hr while tpa infusing.  Begin enoxaparin 1mg/kg SC q12h once tpa infusion is complete.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
	Sodium Chloride 0.9%
		1,000 mL, IV, 12 hr, 35 ml/hr
			Comment: via RIGHT coolant port
		1,000 mL, IV, 12 hr, 30 ml/hr
			Comment: via RIGHT coolant sheath
		<!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 11.00.9600.20512(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 11.00.9600.20512(NOTE)*
	Alteplase 12mg/NS 250mL
		12 mg, EVERY BAG
		250 mL, Catheter, STAT, T;N, 1 Dose(s)/Time(s), 21 ml/hr
			Comment: Infusion rate: 21ml/hr (1mg/hr) Infuse via LEFT pulm artery infusion catheter, Total IV fluids at 125ml/hr while tpa infusing. Begin enoxaparin 1mg/kg SC q12h once tpa infusion is complete.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
	Sodium Chloride 0.9%
		1,000 mL, IV, 12 hr, 30 ml/hr
			Comment: via LEFT pulmonary artery sheath
		<!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 11.00.9600.20512(NOTE)*
	Alteplase 12mg/NS 250mL
		12 mg, EVERY BAG
		250 mL, Catheter, STAT, T;N, 1 Dose(s)/Time(s), 21 ml/hr
			Comment: Infusion rate: 21ml/hr (1mg/hr) Infuse via RIGHT pulm artery infusion catheter, Total IV fluids at 125ml/hr while tpa infusing. Begin enoxaparin 1mg/kg SC q12h once tpa infusion is complete.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
	Sodium Chloride 0.9%
		1,000 mL, IV, 12 hr, 30 ml/hr
			Comment: via RIGHT pulmonary artery sheath
Consults/Follow-up
	Pharmacy Consult
		pharmacy to review tpa orders STAT. Please deliver to pt room within 30 minutes of OR start time
		Follow up to insure enoxaparin 1mg/kg SC q12h is started once TPA finished

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.

Vasc Surg PE Thrombolysis - OPTALYSE
IV Solutions
	HEParin 25,000 units/premixed diluent 250 mL
		25,000 units, EVERY BAG, 500 units/hr
		250 mL, IV, Routine, 6 hr
			Comment: Infuse until Alteplase (TPA) infusion is complete and first dose of Enoxaparin 1mg/kg has been administered;
		<!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 11.00.9600.20512(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 11.00.9600.20512(NOTE)*
	alteplase 6mg/NS 100mL
		100 mL, Catheter, STAT, T;N, 1 Dose(s)/Time(s), 17 ml/hr
			Comment: Infusion rate: 17ml/hr (1mg/hr) Infuse via LEFT pulm artery infusion catheter, Total IV fluids at 125ml/hr while tpa infusing. Begin enoxaparin 1mg/kg SC q12h once tpa infusion is complete. Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		6 mg, EVERY BAG
	Sodium Chloride 0.9%
		1,000 mL, IV, 12 hr, 35 ml/hr
			Comment: via LEFT coolant port
		1,000 mL, IV, 12 hr, 30 ml/hr
			Comment: via LEFT coolant sheath
		<!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 11.00.9600.20512(NOTE)*
	alteplase 6mg/NS 100mL
		100 mL, Catheter, STAT, T;N, 1 Dose(s)/Time(s), 17 ml/hr
			Comment: Infusion rate: 17ml/hr (1mg/hr) Infuse via RIGHT pulm artery infusion catheter, Total IV fluids at 125ml/hr while tpa infusing. Begin enoxaparin 1mg/kg SC q12h once tpa infusion is complete. Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		6 mg, EVERY BAG
	Sodium Chloride 0.9%
		1,000 mL, IV, 12 hr, 35 ml/hr
			Comment: via RIGHT coolant port
		1,000 mL, IV, 12 hr, 30 ml/hr
			Comment: via RIGHT coolant sheath
Consults/Follow-up
	Pharmacy Consult
		pharmacy to review tpa orders STAT. Please deliver to pt room within 30 minutes of OR start time
		Follow up to insure enoxaparin 1mg/kg SC q12h is started once TPA finished

Vasc Surg PE Thrombolysis HI PEITHO trial
IV Solutions
	HEParin 25,000 units/premixed diluent 250 mL
		25,000 units, EVERY BAG, 500 units/hr
		250 mL, IV, 12 hr
			Comment: Infuse until Alteplase (TPA) infusion is complete and first dose of Enoxaparin 1mg/kg has been administered;
		<!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 11.00.9600.20512(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 11.00.9600.20512(NOTE)*
	alteplase 7 mg/NS 250 mL
		250 mL, Catheter, STAT, T;N, 1 Dose(s)/Time(s), 36 ml/hr
			Comment: Infusion rate: 36 ml/hr (1mg/hr) Infuse via LEFT pulm artery infusion catheter, Total IV fluids at 125ml/hr while tpa infusing. Begin enoxaparin 1mg/kg SC q12h once tpa infusion is complete.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		7 mg, EVERY BAG
	Sodium Chloride 0.9%
		1,000 mL, IV, 12 hr, 35 ml/hr
			Comment: via LEFT coolant port
		1,000 mL, IV, 12 hr, 30 ml/hr
			Comment: via LEFT coolant sheath
		Right pulmonary artery(NOTE)*
	alteplase 7 mg/NS 250 mL
		250 mL, Catheter, STAT, T;N, 1 Dose(s)/Time(s), 36 ml/hr
			Comment: Infusion rate: 36ml/hr (1mg/hr)  Infuse via RIGHT pulm artery infusion catheter, Total IV fluids at 125ml/hr while tpa infusing.  Begin enoxaparin 1mg/kg SC q12h once tpa infusion is complete.Pharmacy to inquire on procedure start time with Main OR to ensure proper tpa start time.
		7 mg, EVERY BAG
	Sodium Chloride 0.9%
		1,000 mL, IV, 12 hr, 35 ml/hr
			Comment: via RIGHT coolant port
		1,000 mL, IV, 12 hr, 30 ml/hr
			Comment: via RIGHT coolant sheath
Consults/Follow-up
	Pharmacy Consult
		pharmacy to review tpa orders STAT. Please deliver to pt room within 30 minutes of OR start time
		Follow up to insure enoxaparin 1mg/kg SC q12h is started once TPA finished

Pain Constipation Nausea Protocol > 65 Geriatric E
Medications
		Select only one medication in each category(NOTE)*
Mild Pain
	acetaminophen
		1,000 mg, Tab, By Mouth, Q8H-Sch, T;N
			Comment: For pain rating 1-3; Consider IV Acetaminophen (Ofirmev) if NPO.
		1,000 mg, Tab, By Mouth, Q8H, PRN pain-mild
			Comment: For pain rating 1-3; Consider IV Acetaminophen (Ofirmev) if NPO.
		1,000 mg, Tab, By Mouth, Q8H-Sch, T+1;N
			Comment: For pain rating 1-3; Consider IV Acetaminophen (Ofirmev) if NPO.
	acetaminophen 10 mg/mL intravenous solution
		1,000 mg, Solution-Injection, IVPB, Q8H, T;N, duration: 3 Dose(s)/Time(s)
			Comment: For pain rating 1-3.
Moderate Pain
	oxyCODONE
		2.5 mg, Tab, By Mouth, Q4H, PRN pain-moderate
			Comment: For pain rating 4-6
	traMADol
		25 mg, Tab, By Mouth, Q6H, PRN pain-moderate
			Comment: For pain rating 4-6; Screen for drug interactions (e.g.SSRI), and adjust dose for CrCl<30ml/min; avoid use if history of seizures.
	Dilaudid Injectable
		0.2 mg, Injection, IV Push, Q4H, PRN pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics.
Severe Pain
	oxyCODONE
		5 mg, Tab, By Mouth, Q4H, PRN pain-severe
			Comment: For pain rating 7-10.
	traMADol
		50 mg, Tab, By Mouth, Q6H, PRN pain-severe
			Comment: For pain rating 7-10; screen for drug interactions (e.g.SSRI), and adjust dose for CrCl<30ml/min; avoid use if history of seizures.
	Dilaudid Injectable
		0.4 mg, Injection, IV Push, Q2H, PRN pain-severe
			Comment: For pain rating 7-10 if NPO or for breakthrough pain if on oral analgesics.
		Opiate Reversal(NOTE)*
	Narcan
		0.2 mg, Injection, IV Push, Q2MIN, PRN 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.
PRN Discomfort
	trolamine salicylate 10% topical cream
		1 appl, Cream, TOPICAL, TID, PRN discomfort
			Comment: Apply to affected area.
	menthol-methyl salicylate topical
		1 appl, Cream, TOPICAL, TID, PRN discomfort
			Comment: Apply to affected area.
	lidocaine 4% topical patch
		1 patch, Patch, TransDERMAL, DAILY
	lidocaine Patch Removal
		Patch Removal, Patch, TransDERMAL, QHS
	Medication patch site check
		T;N+720, Q12H
Constipation
	Senokot S 50 mg-8.6 mg oral tablet
		1 TAB, Tab, By Mouth, BID, PRN for constipation
			Comment: Hold for loose stools
	MiraLax oral powder for reconstitution
		17 gm, Packet, By Mouth, BID
			Comment: Hold for loose stools.  Mix in 6oz juice or water.
	Dulcolax
		10 mg, Suppository, RECTALLY, Q12H, PRN constipation
			Comment: If other agents ineffective or if patient NPO.
	Fleet Enema 19 gm-7 gm rectal enema
		1 EA, Enema, RECTALLY, Q12H, PRN constipation
			Comment: If suppository ineffective.
	Enema-Administer
		Tap water, Q1H, see comment
			Comment: If suppository ineffective.
Nausea Vomiting
	ondansetron
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN nausea and/or vomiting
		4 mg, Injection, IV Push, Q6H, PRN nausea and/or vomiting
			Comment: If unable to take by mouth.

*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