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.

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.