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1 HENRY FORD MACOMB HOSPITALS. BARIATRIC PROTOCOL ORDERS. POST-OPERATIVE (Page 1 of 4). height : feet weight : pounds Date: Time: Inches (Actual on day of surgery ). Allergy/Sensitivities and Reactions: = Automatic Physician's option check off to order ADMIT TO: . ADMIT AS: Full Admission 23:59 Observation DIAGNOSIS: Morbid Obesity 1. CONSULT & PARTICIPATE: DR. (See Physician Consultation Form). SAMPLE. Nutrition Consult RE. Diet Education for hospital stay and at home Other: 2. LABORATORY: (To be completed on Post-Operative day one (1) in the morning). CBC LYTES BUN/CREAT MAGNESIUM/PHOSPHATE/CALCIUM. 3. ANCILLARY ORDERS: Continuous Telemetry and Pulse Oximetry Give Oxygen via nasal cannula to keep Oxygen Saturation (SPO2) greater than or equal to 92 percent, notify surgical resident if SPO2 less than 92 percent C-PAP/BIPAP if patient is currently on this therapy at home to bring in machine and fittings from home.

2 Must be approved by Clinical Engineering prior to use. Patient to wear in bed at all times if asleep or resting/napping. Connect Oxygen to C-PAP to keep SPO2 greater than or equal to 92 percent Glucometer on arrival to the unit, then every six (6) hours (Diabetic patient only). See Sliding Scale Insulin (SSI) orders for coverage diabetic flow sheet initiate diabetic teaching with insulin instruction Albuterol Inhalation Solution mg/3 ml Normal Saline every six (6) hours Aerosol treatment around the clock Respiratory Therapy to measure SPO2 on Room Air at night during sleep and document Respiratory to do Home Oxygen Assessment on Post-Operative day two (2) in the morning 4.

3 BARIATRIC DIET: Stage II Clear Liquid Bariatric Diet (dilute juices 1:1) (Start day of surgery). Oral Swabs as needed No carbonated or caffeinated beverages, No straws. Stage Ill Full Liquid Bariatric Diet - Instruct to start stage III diet (Upon Discharge). Physician Signature: Date: Time: Printed Physician: Transcriber's Signature: Date: Time: Noting Nurses Signature: Date: Time: Form #: HFBH-59-0613MR-1010rev Chart Tab: Physician Orders 1. HENRY FORD MACOMB HOSPITALS. BARIATRIC PROTOCOL ORDERS. POST-OPERATIVE (Page 2 of 4). = Automatic Physician's option check off to order 5. NURSING: Vital signs every 15 minutes times four (4), then every 30 minutes times two (2), then every four (4) hours Semi-Fowler's position while in bed (head of bed up 45 degrees) at all times Sequential Compression Devices on while in bed at all times, except when walking Incentive Spirometry ten (10) times per hour.

4 (Encourage frequent use). Instruct patient in coughing and deep breathing, laughing, yawning, & sighing Foley Catheter to gravity drainage (if present). Discontinue Foley at 0700 on Post-op day one (1) notify surgical resident if patient does not void within eight (8) hours Strict Intake and Output every eight (8) hours SAMPLE. Ensure proper Bariatric Equipment Change dressing if soaked or blood stained Enoxaparin (Lovenox ) Teaching initiate on Post-Operative day one (1). Assess pain management with pain scale, start oral pain meds on Post-Operative day one (1). Patient may shower on Post-Operative day two (2) (if Epidural has been removed). NOTIFY ATTENDING SURGEON IF: Temperature greater than 101 degrees Heart Rate greater than 120 or less than 50 beats per minute Systolic Blood pressure greater than 180 or Diastolic Blood pressure greater than 90 mmHg Respiratory rate less than eight (8) or greater than 24.

5 Urine output less than 240 ml in eight (8) hours or less than 30 ml per hour Oxygen Saturation less than 92 percent If pain level greater than eight (8) on the pain scale Any serious event or change in condition IF Epidural: IF Oxygen Saturation less than 92 percent or Blood Pressure (Systolic less than 100 or Diastolic less than 50) notify Anesthesia also Assess for signs and symptoms of bleeding if present hold Lovenox and notify surgeon 6. ACTIVITY. Walking with assistance (if tolerated) within two (2) hours of arrival to the unit (Or Sooner) and then every two (2) hours around the clock while awake at a minimum. Encourage ambulation day and night if awake. Physician Signature: Date: Time: Printed Physician: Transcriber's Signature: Date: Time: Noting Nurses Signature: Date: Time: Form #: HFBH-59-0613MR-1010rev Chart Tab: Physician Orders 2.

6 HENRY FORD MACOMB HOSPITALS. BARIATRIC PROTOCOL ORDERS. POST-OPERATIVE (Page 3 of 4). = Automatic Physician's option check off to order 7. RADIOLOGY: (To be completed on Post-Operative day one (1) in the morning). Upper GI with KUB (using 60 ml Gastrografin). 8. MEDICATIONS: A. IV Solutions: Normal Saline with KCL 20 meq/1000 ml bag at 150 ml/hr (Upon return to Bariatric Unit). Add one amp MVI, PLUS Thiamine 100 mg, PLUS Folate one (1) mg to first liter of IV fluid daily . Start on Post-Operative day one (1) at 0800. Decrease Intravenous fluids to 100 ml/hr on Post-op day one (1) at 0800. SAMPLE. B. GI Prophylaxis/Motility/Itching: Pantoprazole (Protonix ) 40 mg Intravenous push daily Ondansetron (Zofran ) four (4) mg Intravenous push every four (4) hours as needed nausea and vomiting Simethicone (Mylicon ) drops ml orally (40 mg) every six (6) hours as needed gas Bisacodyl (Dulcolax ) Tabs times three (3) orally at 0800, if no bowel movement on Post-Operative day two (2).

7 Diphenhydramine (Benadryl ) 25 mg Intravenous Push every six (6) hours as needed Itching (May repeat 25 mg Intravenous Push if ineffective for itching in one (1) hour). C. Pain Management: PCA Pump (if applicable) - See PCA order sheet Ketorolac (Toradol ) 15 mg Intravenous push every six (6) hours times eight (8) doses (total) around the clock, start on arrival Hydrocodone mg and Acetaminophen 500/15 ml (Lortab Elixir ) 15 ml orally every four (4) hours as needed Mild to Moderate pain. Dilute 1:1 with water/juice. Initiate first dose on Post-operative day one (1). Hydrocodone mg and Acetaminophen 500/15 ml (Lortab Elixir ) 30 ml orally every four (4) hours as needed Severe pain.

8 Dilute 1:1 with water/juice. Initiate first dose on Post-operative day one (1). Warning: No more than 4 GM of Acetaminophen in 24 hours from all sources Physician Signature: Date: Time: Printed Physician: Transcriber's Signature: Date: Time: Noting Nurses Signature: Date: Time: Form #: HFBH-59-0613MR-1010rev Chart Tab: Physician Orders 3. HENRY FORD MACOMB HOSPITALS. BARIATRIC PROTOCOL ORDERS. POST-OPERATIVE (Page 4 of 4). IF EPIDURAL: Anesthesia to manage epidural catheter (See epidural order sheet). IF NO EPIDURAL: Hydromorphone (Dilaudid ) one (1) mg Intravenous push every four (4) hours as needed for Mild to Moderate break through pain Hydromorphone (Dilaudid ) two (2) mg Intravenous push every four (4) hours as needed for Severe break through pain D.

9 Antibiotics: Cefazolin (Ancef ) two (2) grams Intravenous Piggyback every eight (8) hours times two (2). SAMPLE. (first dose given in PACU at_____ ). If Allergy to Cefazolin (Ancef ) or Penicillin then: Cleocin 600 mg Intravenous Piggyback every eight (8) hours times two (2). Start eight (8) hours after Pre-Operative dose. (Pre-Operative dose given at_ _____ ) and Gentamicin one (1) mg/kg Intravenous Piggyback every eight (8). hours times two (2), based on ADJUSTED BODY weight Pharmacy to dose start 12. hours after Pre-Operative dose (Pre-Operative dose given at_____ ). E. Deep Vein Thrombosis Prophylaxis: Enoxaparin (Lovenox ) 40 mg subcutaneous twice daily, Start first dose at 1800 Day of surgery, then every 12 hours at 1000 and 2200 daily (Hold and notify surgeon if signs and symptoms of bleeding).

10 Hold am Enoxaparin (Lovenox ) Dose on Post-Operative day two (2) in Epidural patients and wait two (2) hours after Epidural catheter removed to give morning dose (as approved by Anesthesia). Physician Signature: Date: Time: Printed Physician: Transcriber's Signature: Date: Time: Noting Nurses Signature: Date: Time: Form #: HFBH-59-0613MR-1010rev Chart Tab: Physician Orders 4.