OUTPATIENT ENDOSCOPY (PAIN) PROCEDURE PLAN WITH SEDATION - Phase: Diagnostic/Pre-Op Orders
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1 - Phase: Diagnostic/Pre-Op Orders PHYSICIAN S Diagnosis Weight Allergies Admit/Discharge/Transfer Request Endoscopy Services-GI Patient Care Obtain Consent Vital Signs Per Unit Standards Insert Peripheral Line POC by Nursing POC Blood Sugar Check POC Chem 8 POC Hemoglobin and Hematocrit POC Urine Pregnancy Communication Code Status Code Status: Full Code Code Status: DNR/AND (Allow Natural Death) Code Status: Care Limitation Dietary Outpatient Diet NPO NPO, except meds. IV Solutions NS IV, 25 ml/hr, x 1 dose DC IV fluid post procedure LR IV, 25 ml/hr, x 1 dose DC IV fluid post procedure ***Order 500 ml IV fluid below for patients with heart failure, COPD, or end stage renal disease*** NS IV, 25 ml/hr, x 1 dose DC IV fluid post procedure LR IV, 25 ml/hr, x 1 dose DC IV fluid post procedure Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. Antibiotics 1
2 - Phase: Diagnostic/Pre-Op Orders PHYSICIAN S Primary therapy cefazolin 1 g, IVPB, ivpb, OCTOR, Infuse over 30 min cefuroxime (Zinacef) 1.5 g, IVPB, ivpb, OCTOR, Infuse over 30 min cefoxitin 1 g, IVPB, ivpb, OCTOR, Infuse over 30 min 2 g, IVPB, ivpb, OCTOR, Infuse over 30 min cefotetan 2 g, IVPB, ivpb, OCTOR, Infuse over 30 min ampicillin-sulbactam 1.5 g, IVPB, ivpb, OCTOR, Infuse over 30 min 3 g, IVPB, ivpb, OCTOR, Infuse over 30 min May add ONE of the following: metronidazole 500 mg, IVPB, ivpb, OCTOR, Infuse over 1 hr Do not refrigerate. Do not give with drugs containing alcohol. vancomycin 1,000 mg, IVPB, ivpb, OCTOR, Infuse over 90 min Administer 1 hour before surgery. For penicillin and/or cephalosporin allergy: clindamycin 600 mg, IVPB, ivpb, OCTOR, Infuse over 30 min 900 mg, IVPB, ivpb, OCTOR, Infuse over 30 min vancomycin 1,000 mg, IVPB, ivpb, OCTOR, Infuse over 90 min Administer 1 hour before surgery May add ONE of the following: levofloxacin 500 mg, IVPB, ivpb, OCTOR, Infuse over 60 min 750 mg, IVPB, ivpb, OCTOR, Infuse over 90 min gentamicin 80 mg, IVPB, ivpb, OCTOR, Infuse over 1 hr Analgesics Only intended for use by Pain Management Center for endoscopy procedures ketamine (ketamine (Pain Management)) 50 mg, IVPB, ivpb, ONE TIME, Infuse over 150 min Only intended for use by Pain Management Center for endoscopy procedures 75 mg, IVPB, ivpb, ONE TIME, Infuse over 150 min Only intended for use by Pain Management Center for endoscopy procedures 100 mg, IVPB, ivpb, ONE TIME, Infuse over 150 min Only intended for use by Pain Management Center for endoscopy procedures 125 mg, IVPB, ivpb, ONE TIME, Infuse over 150 min Only intended for use by Pain Management Center for endoscopy procedures 2
3 - Phase: Diagnostic/Pre-Op Orders PHYSICIAN S Laboratory CBC CBC with Differential Platelet Count Prothrombin Time with INR PTT Basic Metabolic Panel Comprehensive Metabolic Panel Hepatic Function Panel BUN Creatinine Beta HCG Serum Qualitative Diagnostic Tests EKG-12 Lead Routine DX Chest Single View Routine Consults/Referrals Consult MD Service: Anesthesiology, Reason: Pre-Op Endo Procedure. 3
4 - Phase: History and Physical Documenation Orders PHYSICIAN S Patient Care Sedation History and Physical Update 4
5 - Phase: Intra-Procedure Documentation Orders PHYSICIAN S Patient Care Vital Signs T;N, Per Policy Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. Reversal Agent flumazenil 0.2 mg, IVPush, inj, q1min, PRN excess sedation naloxone 0.2 mg, IVPush, inj, q2min, PRN bradypnea 5
6 - Phase: Medication Documenation PHYSICIAN S...Additional Orders 6
7 - Phase: Post-Op Orders PHYSICIAN S Patient Care Convert IV to INT Discontinue Peripheral Line When vital signs stable and tolerating po fluids. POC by Nursing POC Blood Sugar Check Communication Notify Provider of VS Parameters Code Status Code Status: Full Code Code Status: DNR/AND (Allow Natural Death) Code Status: Care Limitation Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. Respiratory albuterol 2.5 mg, inhalation, soln, as needed, PRN wheezing ipratropium (ipratropium (Atrovent) 0.02% inhalation solution) 2.5 ml, inhalation, soln, as needed, PRN wheezing Gastrointestinal Agents loperamide 4 mg, PO, cap, ONE TIME Laboratory CBC CBC with Differential Prothrombin Time with INR PTT Comprehensive Metabolic Panel Diagnostic Tests DX Chest Single View 7
8 - Phase: Discharge Orders PHYSICIAN S Admit/Discharge/Transfer General Discharge Patient (Outpatient) Discharge Condition Discharge Condition: Stable Discharge Condition: Improved Discharge Condition: Fair Discharge Disposition Discharge To: Home Discharge To: Home with Home Health Discharge To: SNF Discharge To: Nursing Home - Intermediate Care Discharge To: Home with Hospice Discharge To: Long term care Discharge To: TDCJ or any other jail Discharge Instructions Diet Discharge Diet Diet: Resume pre-hospital diet Diet: ADA Diet: AHA Diet: Low sodium (Less than 2 grams) Diet: Regular Diet: Renal Activity Discharge Activity/Activity Precautions Activity: As tolerated No restrictions Activity: As tolerated Activity: Bed rest Activity: Do NOT lift arms above shoulders Activity: Exercise per OT/PT instructions Activity: Keep splint on at all times Activity: Knee precautions Activity: No restrictions Activity: No pushing or pulling with arms Activity: No straining or heavy lifting Activity: Posterior hip precautions Activity: Sternal precautions Activity: With assistance Discharge Lifting Instructions Discharge Bathing Instructions Discharge Driving Instructions Line, Drain, and Wound Care Discharge Wound Care Discharge Surgical Drain/Tube Care Follow Up Discharge Follow-up Appointment Discharge Follow-up Appointment Discharge Follow-up Lab Discharge Follow-up Diagnostic Procedure (Discharge Follow-up Diagnostic Procedures) Communication Patient May Return to Work/School 8
9 - Phase: SEDATION MEDICATION DOCUMENTATION PLAN PHYSICIAN S Communication Procedural Sedation Medications Guidelin (Procedural Sedation Medications Guidelines) Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. Analgesics: Opioids fentanyl 25 mcg, IVPush, inj, OCTOR 50 mcg, IVPush, inj, OCTOR 75 mcg, IVPush, inj, OCTOR 100 mcg, IVPush, inj, OCTOR HYDROmorphone 0.5 mg, IVPush, inj, OCTOR 1 mg, IVPush, inj, OCTOR 2 mg, IVPush, inj, OCTOR morphine 2 mg, IVPush, inj, OCTOR 4 mg, IVPush, inj, OCTOR 10 mg, IVPush, inj, OCTOR Sedatives LORazepam 0.5 mg, IVPush, inj, OCTOR 1 mg, IVPush, inj, OCTOR 2 mg, IVPush, inj, OCTOR midazolam 0.5 mg, IVPush, inj, OCTOR 2 mg, IVPush, inj, OCTOR 4 mg, IVPush, inj, OCTOR 5 mg, IVPush, inj, OCTOR 9
10 - Phase: SEDATION MEDICATION DOCUMENTATION PLAN PHYSICIAN S The Following Medications are for Deep Sedation Use Only dexmedetomidine (dexmedetomidine 20 mcg/10 ml) 25 mcg, Slow IVPush, inj, OCTOR 50 mcg, Slow IVPush, inj, OCTOR 100 mcg, Slow IVPush, inj, OCTOR etomidate 5 mg, IVPush, inj, OCTOR 10 mg, IVPush, inj, OCTOR 20 mg, IVPush, inj, OCTOR ketamine 50 mg, IVPush, inj, OCTOR 100 mg, IVPush, inj, OCTOR 200 mg, IVPush, inj, OCTOR propofol 10 mg, IVPush, inj, OCTOR 20 mg, IVPush, inj, OCTOR 50 mg, IVPush, inj, OCTOR 100 mg, IVPush, inj, OCTOR 10
11 - Phase: OUTPATIENT BB TYPE AND SCREEN PHYSICIAN S Laboratory BB Blood Type (ABO/Rh) Routine Outpatient/PACU, T;N, Vendor Bill No BB Antibody Screen Routine Outpatient/PACU, T;N, Vendor Bill No BB Clot to Hold Routine Outpatient/PACU, T;N, Vendor Bill No 11
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