r*po1004*r PHYSICIAN S ORDERS Page 1 of 7 HOUR THORACOTOMY POSTOPERATIVE ORDERS General x Admit to Inpatient Status x Admitting Physician: Admit to:

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1 PHYSICIAN S ORDERS Page 1 of 7 General x Admit to Inpatient Status x Admitting Physician: Admit to: SICU Telemetry Med/Surg room x Resuscitation status: see Resuscitation Status Order Activity x Bed rest while intubated or if unstable. x Elevate head of bed 30 degrees in Semi Fowler s position, if SBP permits. x Up to Chair if extubated and if stable x Ambulate as tolerated with assistance Nursing Orders Assessments x Cardiac Monitor per Unit protocol x Pulse oximetry, continuous, while in SICU x Vital signs Q 1 H for 4 H, then per Unit routine. x Measure weight daily in AM x Measure intake and output x Measure Urine Output hourly, if Foley catheter present x Neuro checks Q 2 H X4, then once per shift x Turn, cough and deep breathe Q 2 H with assistance Chest tubes to PleurEvac on cm H2O suction. on water seal at (date/time) x Measure chest tube drainage every hour x Blood glucose testing bedside STAT ONCE on arrival in SICU/PACU Interventions Urinary Catheter Management Remove catheter on POD #1 x Leave catheter in place on POD #1 due to: Urologic, obstetric/gynecologic or perineal/rectal procedure requiring prolonged catheterization Suprapubic catheter or a history of intermittent catheterizations being required preoperatively Hourly urine output measurement required because of clinical instability Neurologic impairment with SIADH or inability to cooperate or neurogenic bladder Lower urinary tract obstruction requiring catheter Gross hematuria Open sacral or perineal wound or decubitus requiring urinary diversion x Bedrest post thoracotomy/chest tube Remove catheter on POD #2 PHY00049 r*hhphy *r

2 PHYSICIAN S ORDERS Page 2 of 7 x Leave catheter in place on POD #2 due to: Urologic, obstetric/gynecologic or perineal/rectal procedure requiring prolonged catheterization Suprapubic catheter or a history of intermittent catheterizations being required preoperatively Hourly urine output measurement required because of clinical instability Neurologic impairment with SIADH or inability to cooperate or neurogenic bladder Lower urinary tract obstruction requiring catheter Gross hematuria Open sacral or perineal wound or decubitus requiring urinary diversion Bedrest post thoracotomy/chest tube x Contact Physician on POD #3 for urinary catheter decision/order x Maintain strict I & O for 24 hours after urinary catheter is removed. For urinary catheter removal: If patient unable to void in 6 hours after catheter removal x Check for frequency x Check for distention x Perform bladder scan. If greater than 300 ml, perform in and out catheterization. May repeat process once in next 6 hours. Call MD if patient doesn t tolerate in and out catheterization or if reinsertion of catheter seems necessary. x Active patient warming if temperature less than 96.5 Fahrenheit (35.8 Celsius). x Sequential Compression Devices (SCDs) x Skin Care Bundle VTE addressed on separate form. Other: x Identify home meds and obtain order for meds to be continued, when patient may have PO intake. Contingency Notify provider for the following: x Systolic Blood Pressure greater than 140 or less than 90, Diastolic Blood Pressure greater than 100 or less than 50 x PVCs of 12 or more per minute or runs of V Tach x Temperature less than 95 F (35 C) or greater than F (38 C) x Heart rate less than 60 or greater than 120 x Respiratory rate greater than 25 x Hemoglobin less than 7.0 g per dl or hematocrit less than 21%. x Urine output less than 30 ml per H for 2 consecutive hours. Respiratory Oxygen via nasal cannula at L per minute. Oxygen via Venturi mask at %. x Airway suctioning as needed. x Incentive spirometry every 2 hours, while awake after extubation. x Supplemental oxygen titration to maintain O2 saturation at 90% or greater. x Wean O2 sats above 90%. PHY00049pg2 r*hhphy *r

3 Diet x PHYSICIAN S ORDERS Page 3 of 7 NPO until extubated Clear liquid after extubation and progress to low fat/low cholesterol diet as tolerated Clear liquid after extubation and, if patient is diabetic, progress to 1800 calorie ADA low fat/low cholesterol diet as tolerated. Clear liquids after extubation Advance to regular diet as tolerated Regular Diet Other: IV Fluids x Dextrose 5% + lactated ringers IV at 50 ml per H for 6 hours, then discontinue. Dextrose 5% + lactated ringers IV at ml per H for hours, then decrease to ml per H. Dextrose 5% + lactated ringers IV at ml per H Other: If Urine output is low (less than 30 ml per H) or unresponsive to previous volume expansion, may use normal saline or albumin. sodium chloride 0.9% 500 ml per H IV once for 1 hour as needed for volume replacement. May repeat once as necessary. albumin 5% 500 ml IV bolus for volume replacement. May repeat once. Radiology XRay, chest, AP Portable x stat on arrival on Unit. Reason: Post op Thoracotomy x TIMED ONCE in AM on POD #1 at 0500 hours. Reason: Post op Thoracotomy Cardiology 12 Lead ECG STAT once on arrival on Unit, if not already done in PACU. Reason: Post Op Thoracotomy Medications Analgesics/Antipyretics x Activate Epidural Analgesia per Anesthesia Epidural Protocol Orders. Activate PCA Pump Protocol The total dose of acetaminophen from all sources should not exceed 4000 mg per 24 hours. acetaminophen (TYLENOL) 650 mg PO Q 4 H PRN fever with temp greater than 101 F (38 C) acetaminophen (TYLENOL) 650 mg PR Q 4 H PRN fever with temp greater than 101 F (38 C) if intubated. Do not order NORCO 5, NORCO 7.5, morphine, or other individual pain meds until after Epidural or PCA orders are discontinued. HYDROcodone 5 mg and acetaminophen 325 mg (NORCO 5) 1 tablet PO Q 4 H PRN moderate pain after Epidural or PCA meds are discontinued. HYDROcodone 5 mg and acetaminophen 325 mg (NORCO 5) 2 tablets PO Q 4 H PRN moderate pain after Epidural or PCA meds are discontinued. PHY00049pg3 r*hhphy *r

4 PHYSICIAN S ORDERS Page 4 of 7 x HYDROcodone 7.5 mg and acetaminophen 325 mg (NORCO 7.5) 1 tablet PO Q 4 H PRN moderate pain after Epidural or PCA meds are discontinued. HYDROcodone 7.5 mg and acetaminophen 325 mg (NORCO 7.5) 2 tablets PO Q 4 H PRN moderate pain after Epidural or PCA meds are discontinued. morphine 2 mg to 4 mg IV Q 1 H PRN severe pain after Epidural or PCA meds are discontinued. morphine 4 mg to 8 mg IM Q 3 H PRN severe pain after Epidural or PCA meds are discontinued. HYDROmorphone (DILAUDID) 0.5 mg to 1 mg IV Q 3 H PRN severe pain after Epidural or PCA meds are discontinued. HYDROmorphone (DILAUDID) 1 mg to 2 mg IV Q 3 H PRN severe pain after Epidural or PCA meds are discontinued. (Use this dose for frail or elderly patients) Antibacterial Agents For patient weight below 80 kg cefazolin (ANCEF) 1 g IV Q 8 H for 2 doses cefazolin (ANCEF) 1 g IV Q 12 H for 2 doses. Complete dosing before 24 H of surgery end time cefazolin (ANCEF) 1 g IV once 24 H after pre op dose. Complete dosing within 24 H of For patient weight kg cefazolin (ANCEF) 1.5 g IV Q 8 H for 2 doses cefazolin (ANCEF) 1.5 g IV Q 12 H for 2 doses. Complete dosing before 24 H of surgery end time cefazolin (ANCEF) 1.5 g IV once 24 H after pre op dose. Complete dosing within 24 H of For patient weight kg cefazolin (ANCEF) 2 g IV Q 8 H for 2 doses cefazolin (ANCEF) 2 g IV Q 12 H for 2 doses. Complete dosing before 24 H of surgery end time cefazolin (ANCEF) 2 g IV once 24 H after pre op dose. Complete dosing within 24 H of For patient weight kg cefazolin (ANCEF) 2.5 g IV Q 8 H for 2 doses cefazolin (ANCEF) 2.5 g IV Q 12 H for 2 doses. Complete dosing before 24 H of surgery end time cefazolin (ANCEF) 2.5 g IV once 24 H after pre op dose. Complete dosing within 24 H of For patient weight 125 kg and above cefazolin (ANCEF) 3 g IV Q 8 H for 2 doses cefazolin (ANCEF) 3 g IV Q 12 H for 2 doses. Complete dosing before 24 H of cefazolin (ANCEF) 3 g IV once 24 H after pre op dose. Complete dosing within 24 H of ***If allergic to Beta Lactam Antibiotics (Cephalosporins, Penicillins)*** clindamycin (CLEOCIN) 900 mg IV Q 8 H for 2 doses. Complete final dose within 24 H of surgery time. PHY00049pg4

5 PHYSICIAN S ORDERS Page 5 of 7 For patient weight below 60 kg GFR 60 and above vancomycin (VANCOCIN) 500 mg IV once 12 H after pre op dose. GFR less than 60 vancomycin (VANCOCIN) 500 mg IV once 24 H after pre op dose. Complete dose within 24 hours of, allowing for prolonged infusion time. For patient weight kg GFR 60 and above vancomycin (VANCOCIN) 750 mg IV once 12 H after pre op dose. GFR less than 60 vancomycin (VANCOCIN) 750 mg IV once 24 H after pre op dose. Complete dose within 24 hours of, allowing for prolonged infusion time. For patient weight 80 kg and above GFR 60 and above vancomycin (VANCOCIN) 1000 mg IV once 12 H after pre op dose. GFR less than 60 vancomycin (VANCOCIN) 1000 mg IV once 24 H after pre op dose. Complete dose within 24 hours of, allowing for prolonged infusion time. Antiemetics x ondansetron (ZOFRAN) 4 mg IV Q 6 H PRN nausea/vomiting Anti ulcer Agents pantoprazole (PROTONIX) 40 mg IV daily while intubated. Discontinue once extubated. Beta Blockers For patients without contraindications who are undergoing non cardiac surgery and are currently on beta blocker therapy, a beta blocker should be used during the perioperative period. Beta Blockers: Reminders Patients undergoing non cardiac surgery who have been on a beta blocker prior to surgery should be maintained on a beta blocker in the peri operative period unless contraindicated. Qualifying patients should receive a beta blocker the day before or the day of surgery and a beta blocker on POD #1 or POD #2 and resume their pre operative beta blocker in the post op period. Beta Blockers: Exclusions The following do not require a beta blocker peri operatively: Patient is not on beta blocker preoperatively or at home. Patient is pregnant. Patient age is less than 18 yo. Beta Blocker received within the last 24 hours. PHY00049pg 5

6 PHYSICIAN S ORDERS Page 6 of 7 Beta Blockers: Day of surgery If patient qualifies and did not take a beta blocker the day before or morning of surgery and cannot take meds orally, give IV metoprolol tartrate (LOPRESSOR). metoprolol tartrate (LOPRESSOR) 5 mg IV over 5 minutes. May repeat every 5 minutes for a total of up to 3 doses if needed for control of hypertension or tachycardia. Repeat 5 mg dose Q 12 H until oral preop beta blocker is resumed. If patient qualifies and did not take a beta blocker the day before or morning of surgery and can take meds orally, resume preop beta blocker or one of the following choices. metoprolol tartrate (LOPRESSOR) 25 mg PO Q 12 H carvedilol (COREG) 6.25 mg PO Q 12 H Beta Blocker from Home Med List Provide an order for the beta blocker from Home Medication List Consult primary physician or hospitalist for beta blocker dosing. Patients who should receive post op beta blockers must have them ordered through POD #2 or the contraindication indicated on each of those days. Contraindications to giving beta blocker: Indicate any that apply to this patient. Reactive airway disease asthma or COPD Severe left ventricular dysfunction (EF less than 30%) Bradyarrhythmia with heart rate less than 50 bpm Sick Sinus Syndrome without a pacemaker 2nd or 3rd degree AV heartblock without a pacemaker Hypotension with Systolic BP less than 100 mm Hg Hemodynamic instability Patient on beta blocker monotherapy for migraine, benign essential tremors or pheochromocytoma Sedatives propofol (DIPRIVAN) mg per H (0.3 mg per kg per H) IV. Increase by 0.3 per kg per H every 5 minutes until desired sedation score. Target Richmond Agitation Sedation Scale (RASS) score of 1 to 2 (Suggested Maximum Dose: 4.8 mg per kg per H) Other Medications x magnesium hydroxide 400 mg/5 ml oral suspension (MILK OF MAGNESIA) 30 ml PO daily PRN constipation docusate sodium (COLACE) 100 mg capsule PO TID. Start when extubated. docusate sodium (COLACE) 100 mg capsule PO BID. Start when extubated. diphenhydramine (BENADRYL) 25 mg PO daily HS PRN insomnia temazepam (RESTORIL) 7.5 mg PO HS PRN insomnia. May repeat once enoxaparin (LOVENOX) 40 mg SUBQ Q 24 H. Start in AM of POD #1. Pharmacy to renally dose, if needed. Hold anticoagulation until further notice due to patient s potential bleeding risk. PHY00049pg6

7 PHYSICIAN S ORDERS Page 7 of 7 Laboratory ABGs with electrolytes (is7) STAT once on arrival in SICU x Routine in early AM BMP STAT once on arrival in SICU x Once on POD #1 Magnesium STAT once on arrival in SICU x Once on POD #1 CBC with differential STAT once on arrival in SICU x Once on POD #1 CBC x Routine in early AM once Consults Consult Primary Care Physician for Medical Management Consult to Dietitian, adult Reason: Consult to Diabetes Center Reason: Consult Physician: Reason: RN or PA Signature Date Time Physician Signature Date Time Developed: October 2003 Revised: January 2015 Revised: September 2016 PHY00049pg7

8 SCIP NOT PART OF PERMANENT RECORD AUDIT Tool Outside the OR SCIP Procedure Done VTE Prophylaxis What method of VTE prophylaxis has been used? Please choose one. VTE Ordered pharmacologic *1st dose MUST be given within 24 hrs of AET LOVENOX (enoxaparin) HEPARIN COUMADIN (warfarin) XARELTO (rivaroxaban) Yes No N/A Date / Time OR mechanical *must be applied within 24 hrs of AET VTE Admin SCD applied No Yes Date applied: Yes No N/A *If NO VTE prophylaxis used is there physician documentation? No Yes Foley Removal Foley Was Foley DC d by end of POD #2? N/A No DOS POD #1 POD #2 Yes No N/A Name of person completing Audit (please print): Created 1/2012 Revised 9/2015 Revised 1/2016 Sgy00021