General Surgery Post-Op Orders

PLACE LABEL HERE GENERAL SURGERY POST-OP ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked. Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

Allergies: ______

1.  Status order was addressed pre-procedure and has NOT CHANGED

or  Status order was addressed pre-procedure and HAS CHANGED to  Admit as Inpatient, expected stay will cross two midnights  Place in Observation 2. Diagnosis: ______Level of Care:  Critical  Intermediate  Acute Care Location/Specialty Unit Preference: ______3.  Telemetry: If patient Medical/Surgical, must complete form # 36084 4.  Isolation:  Contact  Droplet  Airborne For: ______5.  Consult: Hospitalist for medical management  Notified  Consult Wound Ostomy Care Nurse (WOCN) for ostomy management and teaching  Other Consult: ______, Reason: ______ Notified 6. Vital signs per unit routine 7. Diagnostics in AM: H & H  CBC  Chem 7  Other: ______8. Incentive spirometry 10 inhalations q 1 hr while awake or  Other: ______9. Elevate HOB 30-45° or  Other: ______10.  Ice packs to: ______11. Dressing:  Reinforce prn (notify physician after 2 times)  Change: ______ Remove on POD # 2  Other: ______12. I & O per unit routine or  q 4 hrs x 24 hrs, then per unit routine or  Other: ______13. Mastectomy patients: Post sign: “No blood pressure, needle sticks, or IV’s in  Right  Left  Bilateral arm(s)” 14.  Foley catheter to bedside 15. Discontinue Foley catheter on post op day (POD) # 1 at 5 am  Other (document reason to maintain the Foley): ______16. Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620) 17. Drains:  NGT to LIS  JP to bulb suction  Hemovac  J-Vac  Other: ______18.  Clamp NGT 8-12 hrs post-op. Unclamp NGT for any signs/symptoms of distress 19. Activity: Progressive ambulation: Dangle @ 4 hrs post op with assist; Ambulate @ 6 hrs post-op with assist. Advance ambulation to 4-6 times a day starting POD # 1, then progressing to up ad lib OR  Bedrest  Other: ______20. Diet:  NPO  NPO except meds  NPO except ice chips  NPO except Sips of clear  NPO except gum/hard candy  NPO except hot team and/or coffee  Clear liquids  Full liquids   Advance as tolerated to:  Regular  Cardiac  Diabetic ______calorie  Renal Order writer’s initials ______

*3-18196* FORM 3-18196 REV. 07/2015 WHITE: Medical Record CANARY: Pharmacy Page 1 of 3 PLACE LABEL HERE GENERAL SURGERY POST-OP ORDERS

21. Oral Nutritional Supplement Standing Orders (form # 31417), initiate if patient meets criteria

Order writer’s initials ______

*3-18196* FORM 3-18196 REV. 07/2015 WHITE: Medical Record CANARY: Pharmacy Page 1 of 3 PLACE LABEL HERE GENERAL SURGERY POST-OP ORDERS

SCHEDULED MEDICATIONS 22. IVF:  D5½ NS with KCl 20 mEq /L at ______ml/hr IV  Other: ______ Discontinue IV fluids when po fluids tolerated 23. Antibiotic: Post-op antibiotic will be automatically stopped within 24 hrs unless indication is documented

 Ancef (cefazolin) 2 gm IV q 8 hrs x 2 doses or  continue > 24 hrs for ______(Reason REQUIRED)

or  Mefoxin (cefoxin) 2 gm IV q 8 hrs x 2 doses or  continue > 24 hrs for ______(Reason REQUIRED)

or  Zosyn (piperacillin/tazobactrim) Reason REQUIRED for Zosyn selection: ______

3.375 gm IV q 8 hrs x 2 doses or continue > 24 hrs for ______(Reason REQUIRED)

or  None needed, (i.e. colectomy patient received Invanz (ertapenem) 1 gm IV pre-op)

or  Other: ______

24. Stress Ulcer Prophylaxis:  Pepcid (famotidine) 20 mg bid  po or  IV DC Pepcid if PPI (i.e. esomeprazole, omeprazole) is ordered DC Pepcid, if ordered, when NG removed 25.  For Colectomy patients only:  Entereg (alvimopan) 12 mg po bid on POD 1 x 7 days max DC when tolerates a clear liquid diet and/or +flatus 26. Pain:  See PCA orders (form # 2119)  See Sleep Apnea PCA orders (form # 21261)

27. VTE prophylaxis, Initiate Venous Thromboembolism (VTE) Prophylaxis Orders (form # 33058)  Heparin 5,000 units SQ q 8 hrs (q 12 hrs if wt < 50 kg OR age > 75) or  Lovenox (enoxaparin) 40 mg SQ daily (30 mg if CrCl < 30 ml/min) begin in am on POD # 1 (if patient has an epidural, do not begin enoxaparin until epidural has been out for 12 hrs) and/or  Mechanical devices: SCDs 28. Betablockers: (must address, SCIP measure)  Patient is not on betablockers  Contraindication to Beta-Blocker (please indicate):  Systolic BP < 90  2nd or 3rd Degree AV Bloc  Inferior MI  Bradycardia  Severe COPD  Severe LV dysfunction with HF  Other: ______ If patient is npo and/or IV beta-blocker is needed: Lopressor (metoprolol)  1.25mg or  2.5mg or  5mg IV q 6 hrs. Hold for SBP < 90 or HR < 60  Lopressor (metoprolol) _____ mg po two times daily. Hold for SBP < 90 or HR < 60

Order writer’s initials ______

FORM 3-18196 REV. 07/2015 WHITE: Medical Record CANARY: Pharmacy Page 2 of 3 PLACE LABEL HERE GENERAL SURGERY POST-OP ORDERS

 Coreg (carvedilol) _____ mg po bid with meals. Hold for SBP < 90 or HR < 60  Other: ______

Order writer’s initials ______

FORM 3-18196 REV. 07/2015 WHITE: Medical Record CANARY: Pharmacy Page 2 of 3 PLACE LABEL HERE GENERAL SURGERY POST-OP ORDERS

PRN MEDICATIONS See policy 520-06 for range orders and pain intensity guidelines.

29.  Electrolyte Replacement Protocol (form # 21340)

30. Mild Pain, Temp >100.5F, HA:  Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn

31. Moderate Pain:  Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered. or  If patient can not take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po q 4 hrs prn intead of Norco. DC if Percocet ordered. or  Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Norco ordered.

and/or  Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (15 mg if CrCl 31-50, > 65 y/o old or < 50 k g) or 10 mg po q 6 hrs prn (max combined duration of IV and po ketorolac is 5 days). DC if CrCl < 30.

32. Severe Pain (Begin when Epidural or PCA has been discontinued)  Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered. or  Dilaudid (HYDROmorphone) 0.25-0.5 mg IV q 3 hrs prn. If CrCl < 30, dose at 0.25 mg. Hold for excessive sedation. DC if Morphine ordered.

33. Nausea/Vomiting:  Zofran (ondansetron) 4 mg IV or po q 6 hrs prn  If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)

34. Sleep:  Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn

35. Indigestion:  Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn

36. Stool Softener:  Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement

37. Constipation:  Milk of Magnesia (MOM) 30 ml po daily prn If no BM after 48 hrs  Dulcolax (biscodyl) 10 mg per rectum daily prn and/or  Senokot-S (docusate/senna) 2 tablets po at bedtime nightly

38. Cough:  Robitussin (guaifenesin) 15 ml po q 4 hrs prn

39. Sore Throat:  Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn

ADDITIONAL ORDERS: ______

______Date Time Physician Signature PID Number

FORM 3-18196 REV. 07/2015 WHITE: Medical Record CANARY: Pharmacy Page 3 of 3