Demographics Orthopaedic Hip Fracture Post-Op Orders
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1 Clinical der Set Page of 7 Admit to thopaedics MRP is Code Status: Full Code No-CPR see further written orders regarding CPR/DNR MRP to determine Consults Hospitalist Geriatric medicine Other Inpatient Rehab referral Physiotherapy/Occupational Therapy referral Dr aware Dr aware Dr aware Diet Universal Swallow Screen Clear fluids as tolerated If no nausea progress to full fluids If tolerating full fluids progress to: General Diabetic High Protein, High Calorie High Fibre Other Swallowing Assessment Referral Registered Dietitian Referral Activity Weight bear as tolerated Other Post-op day 0 (POD 0) dangle/stand/walk POD up for meals or walk/stand daily X 2 minimum Other Vitals Neurosensory assessments of affected limb(s) q2h q4h as per Unit Guideline Vital signs as per unit protocols Tubes/Respiratory Drains Remove drain when drainage less than ml in hours or POD Urinary Catheter Discontinue Foley Catheter POD at 0600 h or Use commode or toilet to promote effective bladder emptying. Avoid bedpans If unable to void: In and out catheterization X 2 PRN (if then unable to void, notify surgeon) If urine output less than 50 ml in 6 hours consult MRP (goal minimum output 25 ml/h) Peri-care BID and PRN Respiratory Titrate O2 to maintain SpO2 greater 92% or Incentive spirometer qh while awake Signature, Designation College License # Date Time Page / 7
2 Clinical der Set Page 2 of 7 Wound Management thopaedic dressing as per unit guidelines Remove clips/staples in days Investigations Hematology profile: Day and 3 Sodium, potassium, chloride, carbon dioxide total, creatinine, egfr: Day and 3 Phosphorus, magnesium Day INR Day Calcium, phosphorus, albumin, protein, alkaline phosphatase, TSH Other Medical Imaging X-ray POD IV Fluids Solution 0.9% sodium chloride 2/3 + /3 D5W % sodium chloride D5W and 0.9% sodium chloride Ringer s Lactate Additive KCl 20 mmol/l Rate 75 ml/h 25 ml/h 00 ml/h 50mL/h ml/h Bolus 500 ml Ringer s Lactate over 90 minutes X PRN when urine output less than 30mL/h for 2h and if no increase in urine output notify surgeon Bolus 500 ml 0.9% sodium chloride over 90 minutes X PRN when urine output less than 30mL/h for 2h and if no increase in urine output notify surgeon IV to infusor/saline lock when tolerating fluids; discontinue when IV access no longer required Antibiotic Prophylaxis cefazolin 2g IV q8h X 2 doses. Start 8h after pre-op dose For patients with severe beta-lactam (penicillin/cephalosporin) allergy eg. anaphylaxis, angioedema clindamycin 900 mg IV q8h x 2 doses. Start 8 hours after pre-op dose vancomycin g IV to be given 2h after pre-op dose. Infuse over h Signature, Designation College License # Date Time Page 2/ 7
3 Clinical der Set Page 3 of 7 Bowel Management Ensure fluids/adequate hydration within prescribed limits; frequent/encourage mobility within prescribed limits, regular bowel routine Acute care: Bowel Intervention Adult if NPO: RN, RPN and/or Pharmacist to complete thorough assessment of bowel function including review of Pre-Hospital Functional Screening Tool to determine if regularly scheduled laxatives are required Laxatives as indicated RN, RPN and/or Pharmacist based on assessment above and Best Possible Medication History Contact MRP to discuss docusate 00 mg PO BID; hold if patient develops diarrhea. Reassess need for docusate Delirium CAM assessment Q shift If CAM positive, notify MD to investigate/ address underlying cause within 2 hrs Medication orders only for persistent agitation with risk of harm or injury Notify MD if agitation medication given and document QUEtiapine 6.25 mg to 2.5 mg PO Q4h PRN to a maximum of 8.75 mg in 24h loxapine 2.5 to 5 mg q2h PO PRN to a maximum of 0 mg in 24h If unable to use oral route give loxapine 2.5 to 5 mg q2h subcutaneously PRN to a maximum of 0 mg in 24h Insomnia zopiclone 3.75 mg PO at bedtime as required for sleep If patient has been taking another sleeping pill regularly, continue the same: Diabetes Management Follow either IV or Subcut Insulin der Set MRP to complete Other Signature, Designation College License # Date Time Page 3/ 7
4 Clinical der Set Page 4 of 7 *** Systemic narcotics or other CNS depressants ordered by Anesthesiologist take precedence over those ordered by surgeon *** Pain and Nausea Management Pain acetaminophen 650 mg PO or RECTAL suppository QID to a max of 4,000 mg per 24 hours Other: ***Do not use IV/subcutaneous and PO simultaneously*** HYDROmorphone 0.5 mg PO q4h HYDROmorphone mg PO q4h For patients unable to tolerate oral route HYDROmorphone 0.25 mg subcutaneously q4h HYDROmorphone 0.5mg subcutaneously q4h Hold opioid dose if frequently drowsy (or per sedation scale) May hold opioid if sleeping Breakthrough pain HYDROmorphone 0.5 to mg PO Q2h PRN for patients unable to tolerate oral route HYDROmorphone 0.25 to 0.5 mg subcutaneously Q2h PRN Nausea and Vomiting ondansetron 4 mg IV/PO Q8h PRN metoclopramide 5 to 0 mg IV/PO Q6h PRN if ondansetron ineffective Other VTE Prophylaxis (See Page 6) Mechanical method can be combined with anticoagulant in very high risk patients used alone in patients with a high risk for bleeding Anticoagulation not to start any earlier than 8h post-operatively No Anticoagulation required (reason) dalteparin 5,000 units subcut q24h Patients less than 40 kg or age greater than 85 years dalteparin 2,500 units subcut q24h Other Mechanical: Specify Give first dose at (time/date) Signature, Designation College License # Date Time Page 4/ 7
5 Clinical der Set Page 5 of 7 Vitamin and Mineral Supplements cholecalciferol(vitamin D3) 2,000 units PO daily multivitamin PO daily: tablet 5 ml liquid(rn: Indicate which prep) calcium carbonate 250 mg PO daily ferrous fumarate 300 mg (99 mg elemental iron) PO daily starting POD 5 Increase ferrous fumarate 300 mg (99 mg elemental iron) to BID POD 0 ferrous sulphate liquid 300 mg (60 mg elemental iron) PO daily starting POD 5. Increase ferrous sulphate liquid 300 mg (60 mg elemental iron) to BID POD 0 Discharge Patient may be discharged when meets unit criteria or as per physicians order Follow up in weeks post-op with Surgeon s office or Fracture/Cast Clinic Follow-up out-patient physiotherapy as appropriate Follow-up Island Osteoporosis Clinic OT/PT to arrange home safety assessment PT to assess & prescribe home exercise program and fall prevention in the community Additional ders Signature, Designation College License # Date Time Page 5/ 7
6 VTE Risk Assessment Clinical Decision Support Step One assess all patients admitted to hospital for level of mobility (tick one box). All surgical patients and all medical patients with significantly reduced mobility, should be considered for further risk assessment Step Two review patient-related factors against thrombosis risk, ticking each box that applies (more than one box can be ticked) any tick for thrombosis risk should prompt thromboprophylaxis according to NICE guidance. Risk factors identified are not exhaustive. Clinicians may consider additional risks in individual patients and offer thromboprophylaxis as appropriate Step Three review the patient-related factors against bleeding risk and tick each box that applies (more than one box can be ticked) any tick should prompt clinical staff to consider if bleeding risk is sufficient to preclude pharmacological intervention Balancing risk/benefit is at the discretion of the ordering physician Mobility all patients (tick one box) Surgical patient Tick Tick Tick Medical patient expected to have ongoing reduced mobility relative to normal state Assess for thrombosis and bleeding risk below Medical patient NOT expected to have significantly reduced mobility relative to normal state Risk assessment now complete Thrombosis Risk Patient related Tick Admission related Tick Active cancer or cancer treatment Age greater than 60 Dehydration Known thrombophilias Obesity (BMI greater than 30 kg/m 2 ) One or more significant medical comorbidities (eg heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions) Personal history or first-degree relative with a history of VTE Use of hormone replacement therapy Use of estrogen-containing contraceptive therapy Varicose veins with phlebitis Pregnancy or less than 6 weeks post partum (see NICE guidance for specific risk factors) Significantly reduced mobility for 3 days or more Hip or knee replacement Hip fracture Total anaesthetic + surgical time greater than 90 min Surgery involving pelvis or lower limb with a total anaesthetic + surgical time greater than 60 minutes Acute surgical admission with inflammatory or intra-abdominal condition Critical care admission Surgery with significant reduction in mobility Bleeding Risk Patient related Tick Admission related Tick Active bleeding Acquired bleeding disorders (such as acute liver failure) Concurrent use of anticoagulants known to increase risk of bleeding (eg warfarin with INR greater than 2.0) Acute stroke Thrombocytopaenia (platelets less than 75) Uncontrolled systolic hypertension (230/20 mmhg or higher) Untreated inherited bleeding disorders (such as haemophilia and von Willebrand s disease) Neurosurgery, spinal surgery or eye surgery Other procedure with high bleeding risk Lumbar puncture/epidural/spinal anaesthesia expected within the next 2 hours Lumbar puncture/epidural/spinal anaesthesia within the previous 4 hours Reference: Risk Assessment for Venous Thromoboembolism (VTE). National Institute for Health and Clinical Excellence, London UK. March 200. See Page 6/7
7 ACUTE CARE: BOWEL INTERVENTION - ADULT Clinical Regimen Clinical Decision Support Note: not for use in patients who have had bowel surgery in the last year Newly-admitted patients experiencing constipation longer than 4 days or those unable to identify date of last bowel movement start at step 2 All other patients requiring bowel care per protocol including those where assessment not possible begin at baseline Notify physician if vomiting and abdominal pain develop Discontinue protocol and notify MRP if step 4 reached more than once in 0 days Intervention for Constipation Baseline Step 2: Last BM more than 48 hours ago Step 3: Last BM more than 72 hours ago Step 4: Last BM more than 96 hours ago Medication No medication lactulose 30 ml PO x today and If no results by next AM proceed to next step Increase lactulose to 30 ml PO BID today, and sennosides 24 mg PO after breakfast today, and If no results in 24 hours proceed to next step Continue with lactulose 30 ml PO BID AND sennosides 24 mg PO after breakfast today, and glycerine suppository (2.65 g) PR after breakfast today x If no results after 3 hours give sodium citrate enema (Microlax) 5 ml PR x today If no results from sodium citrate enema perform rectal examination for presence or absence of stool and inform physician Return to baseline once desired results are achieved RN s Signature College License # Date Time RN to sign. Send addressographed labelled order to pharmacy Page 7/7
IF YOU RECEIVED THIS FACSIMILE IN ERROR, PLEASE CALL IMMEDIATELY. ADMISSION INSTRUCTIONS: Admitted to Dr.
ADMISSION INSTRUCTIONS: Admitted to Dr. Procedure: Right Hip Left Hip CODE STATUS: Full DNR level of intervention DIET: Dysphagia screen consult SLP High protein, high energy Regular Nutrient dense Boost
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