Wake Tech Community College

Physician’s Orders Wake Tech Community College Simulation Suite

Date Hour Chart Copy of Order Phase 1 Hip Fracture: Pre-op Patient Status: Acute Inpatient Patient Location: Surgical Unit Date of Surgery: tomorrow Informed Consent to be obtained by MD. Place form on clipboard. Allergies: NKDA, strawberries- hives Consults: anesthesia consult pre-op Activity: Bedrest Vital Signs: Every 4 hours per unit protocol with neurovascular checks Pulse Oximetry: Every 4 hours Nutrition: NPO after midnight IV: Medlock Nursing: Intake and output every 8 hours. Notify MD if urinary output is less than 240 ml in 8 hours. Foley: placed in ED Labs: CMP, type and screen, PT, aPTT, INR, Albumin, Protein- done in ED Diagnostic Tests: Left hip x-ray- done in ED DVT prophylaxis: Send TED hose and SCD’s to OR with patient Medications: Oxycodone 5 mg PO every 4-6 hours PRN pain Resume Home Medications (on MAR)

Patient Name: Sara Tompkins Medication Record Number: 1231230 Physician’s Orders Wake Tech Community College Simulation Suite

Date Hour Chart Copy of Order Phase 1 Discontinue Diazepam and Naproxen. Second Institute Falls Precautions. Order Set Initiate K Protocol. Ondansetron (Zofran) 10 mg IV every four hours x 2 doses PRN for nausea/vomiting. Ketorolac (Toradol) 15 mg IV every 6 hours PRN pain. Percocet 1-2 tablets every 6 hours PRN pain.

Patient Name: Sara Tompkins Medication Record Number: 1231230 Physician’s Orders Wake Tech Community College Simulation Suite

Date Hour Chart Copy of Order Phase 2 Hip Surgery: Post-Op Orders Patient Status: Acute Inpatient Patient Location: Surgical Unit Diagnosis: Left Hip Repair Allergies: NKDA, strawberries-hives Vital Signs: every 4 hours with neurovascular checks Pulse oximetry every 4 hours IV of LR at 100 ml/hour. Medlock on POD #1 in evening. Consults: PT, OT, Rehab Nursing: Intake and Output every 8 hours. Call MD if urinary output is less than 240 ml in 8 hours. Discontinue foley on POD #2 at 0600. If patient unable to void after foley discontinued, scan bladder and reinsert foley if residual is greater than 500 ml. Dressing: Reinforce dressing PRN for saturation. Nutrition: Ice chips and meds allowed day of surgery. Then advance diet as tolerated on POD #1. Activity: Safety and Falls Precautions. Turn and position every 2 hours off affected extremity. Cough and deep breathe every two hours while awake. Basic post-op exercises per PT routine. Labs: CBC with diff daily x 3. BMP daily X3. IF K is less than or equal to 3.6 initiate Adult K Protocol. Medications: Morphine 1-2 mg IV every 2 hours PRN severe pain. Percocet 1-2 tablets PO every 6 hours PRN pain.

Patient Name: Sara Tompkins Medication Record Number: 1231230 Ondansetron (Zofran) 10 mg IV every 4 hours x 2 doses. Zolpidem (Ambien) 5 mg PO at bedtime PRN insomnia. Bisocodyl (Dulcolax) 10 mg supp PR daily PRN constipation start POD #2.

Physician’s Orders Wake Tech Community College Simulation Suite

Date Hour Chart Copy of Order Skip to Assign sitter to be with patient at all times until delirium clears. Phase 4 Discontinue Ambien. Discontinue Oxybutynin. Check blood glucose every 6 hours. IVF: D5 NS at 100 ml/hour Obtain Nutrition consult Keep sats greater than 92%. CBC now Obtain urine C&S and then d/c foley. Levofloxacin (Levaquin) 500 mg PO once a day for 14 days.

Patient Name: Sara Tompkins Medication Record Number: 1231230 Patient Name: Sara Tompkins Medication Record Number: 1231230