Eye Laser Retinal Photocoagulation Pre Op and Post Op Orders

PLACE LABEL HERE EYE LASER RETINAL PHOTOCOAGULATION PRE-OP and 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).

Diagnosis:  Retinopathy  Retinal Detachment  Retinal Tear  Right eye  Left eye  Both eyes

PRE-OP ORDERS

MEDICATIONS TO OPERATIVE EYE (Starting 30 minutes prior to procedure):

1.  Iopidine (apraclonidine) 1% 1 drop x 1 dose 2.  Mydriacyl (tropicamide) 1% 1 drop q 5 minutes x 2 doses 3.  Neosynephrine (phenylephrine) 2.5% 1 drop q 5 minutes x 2 doses 4.  Cyclogyl (cyclopentolate) 1% 1 drop q 5 minutes x 2 doses

ADDITIONAL ORDERS: ______

POST - OP ORDERS

1. Vital signs per unit routine 2. ❑ Iopidine (apraclonidine) 1% 1 drop x 1 dose to operative eye 3. Mild pain: ❑ Tylenol (acetaminophen) 650 mg po q 4 hrs prn

ADDITIONAL ORDERS: ______

______Date Time Physician Signature PID Number

Copy to pharmacy

*1-18108* FORM 1-18108 REV. 05/2015 Page 1 of 1