ST. DOMINIC-JACKSON MEMORIAL HOSPITAL JACKSON, MISSISSIPPI

Transcription

1 Date & Time Post-Op Inpatient General Orthopedic Page 1 of 5 Pharmacy Mnemonic: POIGOP1 1. Admit as inpatient to Dr. 2.Diagnosis: 3.Admit to PACU and then to floor ICU 4.Radiology: AP Pelvis in PACU AP Right Shoulder AP Left Shoulder AP & Lateral Right Knee AP & Lateral Left Knee 5.Vital signs per routine 6.Check circulation q hr x 4; q 4 hrs x 6; then q shift. Call if decreased pulse, numbness, tingling, or cool to touch. 7.Activities: Up on side of bed day of surgery Extremity: Elevate May sit in bed as tolerated. May turn side to side. Elevate extremity 8. CM: SCIP Foley will be discontinued on Post-Op Day 1 unless MD or NP documents exception below: DO NOT discontinue foley since patient meets one of the following EXCEPTIONS: Urinary tract obstruction Patient unable to pass urine Neurogenic bladder dysfunction including urinary retention Urologic studies/procedures or surgery on contiguous structures ICU only Patient is intubated ICU only Patient requires strict I&O monitoring Stage III or IV sacral decubitus ulcer End of life/comfort care patient Other: Strict I and O. Record all drain output q 4 hrs. Foley catheter to gravity. Notify physician for urine output less than 60 ml over 2 hrs. If unable to void after foley discontinued, begin Urecholine (bethanechol chloride) 25 mg PO tid PRN May straight cath x 3; do not insert foley without contacting surgeon. 9. If catheter required after foley discontinued, obtain urinalysis If WBC greater than 5, obtain culture. Notify physician if culture positive. 10.Transfuse 2 units PRBC's, if Hb <= 7 gm/dl (Autologous if available) post-op day # 11.Bedside commode post-op day one. Walker in room post-op day two.

2 Date & Time Post-Op Inpatient General Orthopedic Page 2 of Begin daily dressing changes on post-op day 2 until no drainage. (Clean incision H2O2 - apply very light layer of Bactroban) 14. Consult Medical Doctor _ upon arrival to floor. 15. Notify Surgeon's office of room number on admission to floor. Pharmacy Mnemonic: 16. Begin Lovenox or Arixtra self-administration education post-op day one, if on Lovenox or Arixtra 17. If patient will be discharged on Lovenox or Arixtra, be sure prescription is obtained prior to discharge 18. CM: SCIP - Surgical Care Improvement Project (Nursing Order - Do Not Delete) 19. Diet: Ice chips, clear liquids only on night of surgery, then progress to pre-op diet as tolerated. Regular Ensure - 1 can twice daily 20. Lab: Draw all AM lab at IV: CBC - on POD one, two, and three BMP - on POD one, two, and three CMP - for 1/2/3 PODs 1500 Calories 1800 Calories NPO Pureed Clear Liquid General Healthful 60/60/60 CHO Counting Protime q am for days. Start date: ; keep anticoagulant sheet up to date Dextrose 5% in Lactated Ringer's 1000 ml at 125 ml per hr Dextrose 5% in Lactated Ringer's 1000 ml plus 20 meq KCl at 125 ml per hr Dextrose 5% in 0.45% Sodium Chloride 1000 ml at 125 ml per hr Dextrose 5% in 0.45% Sodium Chloride 1000 ml plus 20 meq KCl at 125 ml per hr 0.45% Sodium Chloride 1000 ml at 125 ml per hr 0.45% Sodium Chloride 1000 ml plus 20 meq KCl at 125 ml per hr 0.9% Sodium Chloride 1000 ml at 125 ml per hr 0.9% Sodium Chloride 1000 ml plus 20 meq KCl at 125 ml per hr Other: 22. Studies: 23. Respiratory Therapy - Hyperinflation Consult O2 via nasal cannula or face mask to keep SPO2 >= 92%. 24. Pharmacy to identify and list home meds 25. Therapy: POIGOP2 A. PT: Evaluate and treat: non weight bearing WBAT TTWB partial weight bearing B. OT eval and treat

3 Date & Time Post-Op Inpatient General Orthopedic Page 3 of Durable Medical Supplies (for home use): Bedside commode chair 27. Home Health Services: Walker Physical Therapy Aide Registered Nurse Occupational Therapy 28. Consults: A. Social Work: Evaluate for rehab vs home health and Discharge Planning B. Case Manager to arrange for TB skin test if needed for rehab placement (if no history of TB and no previous positive TB skin test reading) Pharmacy Mnemonic: POIGOP3 29. Additional Orders: 30. ANESTHESIA END TIME: Medication: Administer medication utilizing range order guideline. 31. Antibiotics: Antibiotics should not be administered more than 24 hrs after the documented Anesthesia End Time unless specifically and additionally ordered by a physician. Suspected infection should be clearly documented. Ancef (cefazolin) 2 gram IVPB q 8 hrs x 2 doses (If patient weighs > 120kg give 3 grams) If patient has beta-lactam allergy, substitute Cleocin (clindamycin): Cleocin (clindamycin) IVPB 300mg 600mg 900mg every 6 hrs x 3 doses Vancomycin 15 mg/kg IVPB q 12 hrs x 1 dose Select reason for use of Vancomycin below Significant penicillin allergy or allergy to cephalosporins Known prior colonization with MRSA High-risk due to inpatient hospitalization within the last year Patient has chronic wound care or on dialysis Increased MRSA rate either facility-wide or procedure-specific Hospital inpatient for >24 hrs prior to procedure High-risk due to residence in long-term care setting within the last year 32. VTE Prophylaxis: Any of the following - (Mechanical at minimum) Pharmacologic: Begin 22 hrs post surgery/procedure stop time. Discontinue when INR is >= 1.8 Lovenox (enoxaparin) 40 mg subcutaneous daily (Hold if platelet count <100,000)Pharmacy to renally adjust Arixtra (fondaparinux) 2.5 mg subcutaneous q 24 hrs (Hold if platelet count <100,000) Coumadin mg PO today, then mg PO tomorrow (If patient has epidural catheter, DO NOT give coumadin until >= 2 hrs after removal) Xarelto (rivaroxaban) 10mg PO daily to start (date) for days. Pharmacologic prophylaxis may be combined with the following: Mechanical: SCD Plus TED hose Begin immediately post-procedure.

4 Date & Time Post-Op Inpatient General Orthopedic Page 4 of 5 If no pharmacologic prophylaxis is ordered select the reason: Anticoagulation allergy Treatment not tolerated Heparin-induced thrombocytopenia Pharmacy Mnemonic: POIGOP4 Blood coagulation disorder due to liver disease Blood coagulation disorder Platelet count below reference range Hemorrhagic cerebral infarction Renal Impairment Anterior cerebral circulation hemorrhagic infarction Posterior cerebral circulation hemorrhagic infarction Bleeding Medication refused Patient non-compliant - refused support Refusal of treatment by patient Anticoagulation not tolerated 33. Pain: Patient has received intrathecal narcotics. Follow anesthesia intrathecal narcotic orders for 24 hrs and then give the following drugs (as ordered below) for symptom relief. Patient has an epidural catheter with a continuous infusion. Follow anesthesia epidural infusion orders until discontinued, and then give the following drugs (as ordered below) for symptom relief. PCA See PCA Orders If not on PCA: For the sections of mild, moderate and severe pain If more than one choice is selected in any of the sections, please write a numeric value (1,2,3 etc..) in front of the meds to indicate which med should be administered initially, and which should be administered in the event the first is ineffective. Severe Pain (6 10 on the numeric pain intensity scale) If patient becomes obtunded and respiratory rate is 10, administer Narcan (naloxone) 0.4 mg IV STAT and notify physician immediately (unless patient is considered terminal, comfort care only, or hospice). Morphine 2 mg 3 mg 4 mg IV q 3 hrs q 4 hrs q 6 hrs PRN severe pain (6-10 on the numeric pain intensity scale). Dilaudid (hydromorphone HCl) 0.5 mg 1 mg 1.5 mg IV q 3 hrs q 4 hrs q 6 hrs PRN severe pain (6-10 on the numeric pain intensity scale). Moderate Pain ( on the numeric pain intensity scale) Oxycontin (oxycodone) 10 mg 1 tab PO q 12 hrs for moderate pain x 24 hrs 48 hrs. Oxycontin (oxycodone) 20 mg 1 tab PO q 12 hrs for moderate pain x 24 hrs 48 hrs. Percocet-5 (oxycodone HCl/acetaminophen): one to two tabs PO q 6 hrs PRN moderate pain Percocet-10 (oxycodone HCl/acetaminophen): one to two tabs PO q 6 hrs PRN moderate pain Norco- (hydrocodone/acetaminophen 5/325) 1 OR 2 tabs PO q 6 hrs PRN moderate pain. Norco- (hydrocodone/acetaminophen 10/325) 1 OR 2 tabs PO q 6 hrs PRN moderate pain. Oxycodone 5 mg IR PO q 4 hrs PRN for moderate pain Oxycodone 10 mg IR PO q 4 hrs PRN for moderate pain Ultram (tramadol) 50 mg 1 to 2 tabs PO q 4 hrs PRN for moderate pain. Mild Pain (0.1 3 on the numeric pain intensity scale) If Tylenol and Ofirmev are both selected, do NOT give Tylenol while the patient is receiving Ofirmev. Dyloject (diclofenac) 37.5 mg IVP over 15 seconds q 6 hrs x 3 doses. If SCr > 1.8: Ofirmev (acetaminophen) 1 gram IVPB q 6 hrs x 3 doses. Next dose at Pt must be >=50kg (DO NOT administer any oral acetaminophen products while the patient is receiving Ofirmev) Tylenol ES (acetaminophen) 500 mg PO q 6 hrs PRN mild pain or temp > F. Tylenol (acetaminophen) 325 mg 2 tabs PO q 6 hrs PRN mild pain or temp > F. DO NOT EXCEED 3 grams of acetaminophen in 24 hrs. 34. Zofran (ondansetron) 4 mg IV (over 2 to 5 min) OR PO q 6 hrs PRN vomiting. (If both routes of administration are selected, give by the oral route when the patient is taking other oral meds. If not taking oral meds, give by the IV route of administration).

5 Date & Time Post-Op Inpatient General Orthopedic Page 5 of Constipation: A. Miralax (polyethylene glycol) 17g in 4-8 oz water or beverage PO daily. Pharmacy Mnemonic: POIGOP5 B. Senokot S (senna) two tabs PO hs (hold for diarrhea). C. Please write a 1, 2 or 3 in front of the meds to indicate which med should be administered initially and which should be administered in the event the first is ineffective: Laxative of choice Fleets enema PRN constipation Dulcolax Suppository PRN constipation 36. Other: Ecotrin (aspirin) 325 mg PO daily bid Celebrex (celecoxib) 200 mg PO daily. Reglan (metoclopramide HCl) 10mg IV q 8 hrs x 48 hrs (may change to PO if no IV access) Ambien (zolpidem) 5 mg hs PRN insomnia. Miralax (polyethylene glycol) 17g in 4-8 oz water or beverage PO daily. Benadryl (diphenhydramine) 25 mg PO q 4 hrs PRN itching Cyklokapron (tranexamic acid) 1 gram IV in 50ml NS over 20 today (3 hrs after initial dose was given in OR) / Date Time Physician Signature