Plastics

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===== Trangender Pathways =====

These pathways have been built into Agile MD and can be found in the pathway button. They allow you to add all the orders automatically with just a few clicks.\\

==== Inversion Vagionoplasty ====

**POD#0**\\
\\
Admission\\
Code status\\
Nursing assessment\\
Notify clinician for excessive bleeding or drainage at incision site\\
Vital signs Q4H\\
Heart Rate: Notify clinician for pulse >120 or <50 bpm\\
Respiratory Rate: Notify clinician for respiratory rate >24 or <8 breaths per minute\\
Respiratory: Notify clinician if change in respiratory status of oxygen delivery device\\
Blood Pressure: Notify clinician for SBP >160 mmHg or <90 mmHg\\
Temperature: Notify clinician for temperature >38 C or <35 C\\
Continuous Pulse oximetry for 24 hours\\
Notify clinician of oxygen saturation <90%\\
Sequential compression devices\\
I&Os Q8H\\
Insentive spirometry 10 times per hour while awake\\
Clear liquid diet\\
Wound Vac at 125mmHG continuous\\
Notify clinician for VAC machine alarm or malfunction\\
Activity:\\
Bedrest for first 48 hours\\
Turn Q4H x 48 hours\\
Consult Physical Therapy in preparation for supine to stand on POD3\\
Indwelling urinary catheter\\
Notify provider if urine output <30 mL/hr\\
Medication\\
IV Fluid: Lactated Ringers at 125 mL/hr continuous for 24 hours\\
Acetaminophen 1gm PO Q8H x 30 days (Do not exceed 4gm per day)\\
Lyrica 25mg PO BID x 7 days\\
Zosyn 3.375mg IV extended infusion Q8H x 5 days\\
Flomax 0.4mg PO QD x 14 days\\
(Hold if systolic <110 mmhg)\\
Sildenafil (Revatio) 20mg PO Q8H x 30 days\\
(Hold if systolic <110 mmhg)\\
Heparin 5,000 units SC TID x 30 days beginning POD0 evening\\
Ondansetrom 4mg IV Q6H PRN\\
Oxycodone (immediate release) 5mg PO Q4H PRN for 3 days\\
Oxycodone (immediate release) 10 mg PO Q4H PRN for 3 days\\
Phlebotomy and IV Starts: Lidocaine (LMX) 4% topical creat Q6H PRN\\
Indigestion/Bloating: Simethicone chewable tablet 80mg PO Q6H PRN\\
No enemas\\

**POD#1**\\
\\
CBC at 6:00AM\\
BMP at 6:00AM\\
Diet as tolerated\\
Consult Care Management for discharge planning\\
Confirm transportation for discharge\\
Medication\\
Celebrex 200mg PO BID with breakfast and at bedtime for 7 days (Do not crush)\\
Colace 100mg PO TID for 30 days (Do Not crush)\\
Senna 8.6mg PO HS for 30 days\\
Constipation:n Miralax 17g PO QD PRN\\
Discontinue IV fluids and buff cap IV when patient advances to regular diet\\

**POD#2**\\
\\
Advance Vital signs to Q8H\\
Discontinue pulse oximetry\\
Discontinue Bedrest\\

**POD#3**\\
\\
Physical Therapy: Supine to stand 4 times a day (First time must be with PT)\\

**POD#4**\\
\\
Ambulate with shuffle gait outside of room 4 times a day (First time must be with PT)\\
No sitting\\
Remove IUC at 10:00PM\\
Dulcolax suppository 10mg rectally PRN\\
**Discontinue wound vac in afternoon and foley at 10 PM**\\
Begin removing dressing from perineal and abdomen\\
**OF NOTE: Dr. K will sometimes discharge patients on POD#4. Perform the below on POD#4 if so.**

**POD#5**\\
\\
Discontinue Zosyn\\
**Void trial by 0400-0600 (MD to reinsert IUC if fail)**\\
Document Post Void Residual Volume with each void\\
Patient to shower\\
**Discontinue vaginal packing at 7:00am**\\
**Complete first dilation at 7:00am - assistance by MD**\\
Second dilation from 10:00am-11:00am\\

**Discharge**\\
\\
IF free flap: Discharge with\\
Aspirin 81mg PO QD x 28 days\\
Discharge patient before 11:00AM\\
Discharge with wound care supplies\\
Discharge with Red Robinson catheter for douching\\
Education - Ensure patient knows how to properly dilate\\
\\
Use dot phrase: .ckdcvaginoplasty\\
Activity\\
Balance activity with rest.\\
No lifting more than 5 pounds, pushing or pulling for the first 4 weeks\\
No sexual intercourse\\
(vaginal or anal) at least for the first 3 months, and until cleared by your surgeon\\
No strenuous activity for the first 4 weeks\\
Daily Care\\
Dilate 4 times per day as directed\\
Shower daily – wash with soap and water. Use Chlorhexidine wash for the first week when showering\\
Douche twice daily as directed with normal saline\\
Remember to wipe from front to back after urinating or defecating.\\
Discharge Medications\\
Take pain medication as directed as needed. Use Acetaminophen (Tylenol), Celecoxib (Celebrex), Pregabalin (Lyrica) as first line pain relief. Take narcotic medication ONLY as necessary\\
Continue bowel regimen – Docusate Sodium (Colace) two times daily, Senna once a day at bedtime.\\
You may also add Polyethylene Glycol (Miralax) or Milk of Magnesia if needed. Hold the medications if stool is loose.\\
NO SUPPOSITORIES OR ENEMAS\\
Metronidazole gel (Metrogel) – 1st, 2nd, and 3rd dilation of the day (about a quarter size on dilator on top of lube)\\
Collagenase (Santyl) – last dilation of the day (about a nickel size on dilator on top of lube).\\
IF blisters or skin tears only: Mupirocin (Bactroban)\\
Saline for the first week of douching\\
Resume home medications unless advised otherwise.\\
You may resume your hormones if you are walking daily without difficulty. Please see or speak with your hormone provider to adjust dose if necessary.\\
Diet - Resume preoperative diet\\
Drink lots of water – aim for 2 liters a day\\
Avoid alcohol\\
Do NOT restart any tobacco product as it can interfere with the healing process.\\