ALL orders are active unless: 1. Order is manually lined through to inactivate 2. Orders with check boxes ( ) are unchecked DRUG AND TREATMENT ORDERS
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1 DRUG AND TREATMENT Available at: BMC-B BMC-D BMC-N BMC-S Diet Diet NPO After Midnight NPO except for meds with sip of water NPO NPO except for meds with sip of water Diet Message Clear liquids until 0800 if surgery after 1400 (except for CV Surgery patients which are ALL NPO after midnight Nursing Orders Pre-Operative Anesthesia Reference Text See Reference Text Patient Education Instruct patient not to eat or drink anything after midnight the day of surgery OR if surgery is scheduled after 1400 may have clear liquids until 0800 (except for CV Surgical patients which are ALL NPO after midnight) Comments: Patient is to continue all usual daily AM medications and take with sip of water the morning of surgery EXCEPT the following:-send insulin to holding with patient -HOLD oral hypoglycemics, NSAIDS, diabetic medications, diuretics (except when a diuretic drug is a component of an antihypertensive combination), ACE inhibitors, and vitamins, including herbal supplements (herbal supplements should be held for one week)-hold anticoagulants and Aspirin unless specifically told by surgeon or cardiologist. Patients should continue to take their Aspirin, if the patient has a stent in place. Permission from the patient's cardiologist is necessary to stop Aspirin and/or other antiplatelet drugs Comments: Instruct patient to remove contact lenses, glasses, hearing aids and body piercings prior to entering OR. May wear all dental appliances without adhesive.instruct patient to NOT wear body lotion, perfume, powder, deodorant or makeup day of surgery. Notify Anesthesia if Pacemaker or AICD battery check is GREATER than 6 months Page 1 of 6
2 DRUG AND TREATMENT Comments: 1. Copy of the device card of the CIED (pacemaker/aicd) and document device model and number. This provides the manufacturer information. If the patient doesn't have the card, a chest xray can show the same information.2. Recent (within past year) 12-lead EKG.3. Contact the patient's physician/clinic who manages the CIED to obtain a plan of action for the perioperative management of the patient's CIED; complete the Perioperative Management Form for Cardiac Rhythm Management Devices form. For most patients, the patient's CIED clinic should be able to review their records to provide a plan of action for the perioperative management of the patient's CIED. This information should include when device was placed and why (Bradycardia or Tachyarrhythmia), if an AICD has ever fired or shocked patient and when the battery was last checked. A small percentage of patients may require a consultation from CIED specialists if the information is not available.4. Many patients will need the CIED reevaluated within one month after the procedure.5. Elective procedures might have to be rescheduled if the CIED registration card, EKG, or requested information from the patient's CIED clinic is not available on the date of the procedure.6. The perioperative management of CIEDs must be individualized to the patient, the type of CIED and the procedure being performed. A single recommendation for all CIED patients is not appropriate.7. Pacemakers need to have been interrogated within the past 12 months to proceed with elective surgery. Copies of the report must be available.8. Defibrillators, including battery check, need to have been interrogated be within the past 6 months to proceed with elective surgery. Copies of the report must be available.9. Copies of any cardiac studies done within the past 2 years including echocardiogram, stress tests, catheterizations, etc.10. Some pacemakers/aicds will need to be interrogated postoperatively which will be specified by the Anesthesia Provider. Start IV/INT Insert 18 gauge. May infiltrate insertion site w/lidocaine 1% prior if patient not allergic ***(NOTE)***Order Blood Glucose (POC) if patient is on oral hypoglycemic agents, insulin, has diabetes, has gastroparesis, is pregnant, or is morbidly obese Blood Glucose Monitor POC ONCALL, for OR Blood Glucose Monitor POC Q2H, Check glucose every 2 hours if patient given insulin and call if LESS than 100 mg/dl or GREATER than 200 mg/dl Notify Anesthesiologist if glucose is LESS than 100 mg/dl or GREATER than 200 mg/dl. If glucose mg/dl, give 1/3 of usual insulin dose and start D5LR at 125 ml/hr Notify Anesthesiologist if glucose is GREATER than 200 mg/dl Notify Anesthesiologist if patient has history of difficult intubation ***(NOTE)***Select the "Transfuse Blood Previously on Hold" order below, to transfuse blood on hold Transfuse Blood Previously on Hold Medications GEN Correction Insulin (Sliding Scale)(SUB)* ***Reminder: Order GEN Correction Insulin (Sliding Scale) (SUB) on a separate form*** Page 2 of 6
3 DRUG AND TREATMENT Lidocaine 1% MDV inj 1 ml INFILTRATE inj ONCE Comments: At IV insertion site if patient is not allergic ***(NOTE)***Hold Reglan for Parkinson's disease, agitation, hallucination, depression movement disorder, seizure disorder, GI obstruction or bowel perforation metoclopramide (Reglan) 10 mg tab PO ONCALL (DEF)* GREATER than30), renal failure and/or GERD. HOLD if allergic or if LESS than 12 years of age. HOLD for Parkinson's disease, agitation, hallucination, depression movement disorder, seizure disorder, GI obstruction or bowel perforation 10 mg inj IV PUSH ONCALL Comments: Give slowly over 10 minutes to reduce incidence and severity of akathisia. Give for diabetics, obesity (BMI GREATER than30), renal failure and/or GERD. HOLD if allergic or if LESS than 12 years of age. HOLD for Parkinson's disease, agitation, hallucination, depression movement disorder, seizure disorder, GI obstruction or bowel perforation ranitidine (Zantac) 150 mg tab PO ONCALL (DEF)* 50 mg inj IV PUSH ONCALL 150 mg tab PO BEDTIME, Duration: 1 dose 300 mg tab PO BEDTIME, Duration: 1 dose famotidine (Pepcid) 20 mg tab PO ONCALL (DEF)* Comments: Give On call to OR, prior surgery with sips of water 20 mg inj IV PUSH ONCALL Comments: Give On call to OR, prior surgery if unable to take PO medication glycopyrrolate (Robinul) 1 mg tab PO ONCALL (DEF)* Comments: HOLD in patients with glaucoma, tachycardia (HR GREATER than 100), obstructive uropathy, paralytic ileus, GI obstruction, myasthenia gravis, ulcerative colitis, toxic mega colon, or unstable cardiovascular status in acute hemorrhage.give if BMI GREATER than 40 and contact Anesthesia if the patient has a history of difficult intubation. 0.1 mg inj IV PUSH ONCALL Comments: HOLD in patients with glaucoma, tachycardia (HR GREATER than 100), obstructive uropathy, paralytic ileus, GI obstruction, myasthenia gravis, ulcerative colitis, toxic mega colon, or unstable cardiovascular status in acute hemorrhage.give if BMI GREATER than 40 and contact Anesthesia if the patient has a history of difficult intubation. Page 3 of 6
4 DRUG AND TREATMENT citric acid sodium citrate (Bicitra) 30 ml PO soln ONCALL Comments: In OR Holding midazolam (Versed) 2 mg inj IV PUSH PRE-OP (DEF)* Comments: In OR holding after Anesthesiologist & Surgeon has obtained/confirmed informed consent and Circulator has completed interview 1 mg inj IV PUSH PRE-OP Comments: In OR holding after Anesthesiologist & Surgeon has obtained/confirmed informed consent and Circulator has completed interview diazepam (Valium) 5 mg tab PO PRE-OP Comments: In OR holding after Anesthesiologist & Surgeon has obtained/confirmed informed consent and Circulator has completed interview SUB ANES Scopolamine(SUB)* The above subphase is available at the end of the plan IV Solutions Lactated Ringers IV bag 125 ml/hour Comments: Use Sodium Chloride 0.9% (Normal Saline) at 25 ml/hr if patient is on dialysis or undergoing craniotomy Sodium Chloride 0.9% IV bag 25 ml/hour Comments: If patient is on dialysis or is undergoing craniotomy D5LR IV bag 125 ml/hour Laboratory ***(NOTE)***Order CBC if history of Anemia, Hemorrhage, Radiation/Chemotherapy, Systemic Lupus, Transplant Rejection, Leukemia, Sickle Cell Disease, Renal Disease or active infection process. Hemoglobin and Hematocrit Complete Blood Count ***(NOTE)***Order PT/PTT if history of Coagulation Disorder, Anticoagulation Therapy, Hemorrhage, Anemia, Ethanol Abuse, or Liver Disease Prothrombin INR Partial Thromboplast Time ***(NOTE)***Order Chem 7/BMP if patient is currently taking diuretics, steroids, Diabetes, Thyroid or Pancreatic disease medications and patients with history of gastric bypass or transplants. Post dialysis chem 7 on day of surgery for renal failure patients. Potassium Level Basic Metabolic Panel Page 4 of 6
5 DRUG AND TREATMENT ***(NOTE)***Order Liver Profile if recent history and/or current Hepatitis and Ethanol Abuse Liver Profile ***(NOTE)***Obtain Thyroid Studies, if patient has a history of thyroid disease or goiter and has not been checked in the past 6 months (get results), or if patient experiencing symptoms (increased heart rate, sweating, weight gain, hair loss, and cold intolerance) Thyroid Stimulating Hormone TBG Triiodothyronine Total ***(NOTE)***Obtain a Beta HCG (Quantitative Serum) within 7 days of surgery. Urine HCG morning of surgery (EXCLUDING those who have had a hysterectomy) HCG Quantitative ***(NOTE)***If on the day of surgery the documented first day of the last menstrual period is GREATER than 21 days AND if a HCG Screen Quantitative Serum test was performed GREATER than 72 hours prior, obtain a Urine HCG (EXCLUDING those with a missed/incomplete AB OR who have had a hysterectomy OR undergone menopause). Patient needs to have been free of menses (vaginal bleeding) for 12 months Comments: Obtain Urine HCG if on the day of surgery the documented first day of the last menstrual period is GREATER than 21 days AND if a HCG Screen Quantitative Serum test was performed GREATER than 72 hours prior (EXCLUDING those with a missed/incomplete AB OR who have had a hysterectomy OR undergone menopause). Patient needs to have been free of menses (vaginal bleeding) for 12 months Urine HCG Pre-Op, URINE, ONCE Digoxin Level Comments: For all patients taking digoxin Phenytoin Level Comments: For all patients taking phenytoin ***(NOTE)***If wanting to place specific blood products on Hold, select the GEN Blood Administration subphase and select your products with a Transfusion Priority of Hold GEN Blood Administration(SUB)* ***Reminder: Order GEN Correction Insulin (Sliding Scale) (SUB) on a separate form*** Radiology ***(NOTE)***Obtain Chest X-ray if any of the following conditions are met: history of Pulmonary Disease, including Infection (Pneumonia, Bronchitis), CHF, COPD, symptomatic Asthma, OSA, SOB, and BMI GREATER than 40, or if changes in these conditions are noted within 3 months XR Chest *2 view PA and LAT Pre-op, Pending Discharge No Page 5 of 6
6 DRUG AND TREATMENT XR Chest *1 view AP Portable Pre-op, Pending Discharge - No Cardiology ***(NOTE)***Obtain ECG Standard if any of the following conditions are met: male patients age 40 and over, female patients age 50 and over OR if a copy of a previous ECG is not available within 6 months and if abnormal ECG changes are noted within 3 months; if history of CAD, Cardiac Arrhythmias, CHF, Chest Pain, Sleep Apnea, High Blood Pressure, Diabetes and BMI GREATER than 40 ECG Standard Pre-op, ONCE Comments: Call Anesthesia for abnormal ECG Notify Anesthesia for abnormal ECG Consults ***(NOTE)***In patients with Sickle Cell disease, if Hematocrit is less than 30% consult anesthesia; patient may need hematology consult for moderated to high risk surgical procedures and pre-op transfusion to a Hematocrit of 30%. Any patient with a history of sickle cell crisis within the last 6 months should be seen by a hematologist prior to elective surgery. Physician Consult Hematology Physician Consult Baptist Heart Specialists Physician Consult Pulmonary, Post Op Sleep Study evaluation and possible Obstructive Sleep Apnea Available at: BMC-B BMC-D BMC-N BMC-S SUB ANES Scopolamine Non Categorized ***(NOTE)***Contraindications: Closed angle glaucoma, Acute Hemorrhage, Tachycardia secondary to cardiac insufficiency or hyperthyroidism, pregnancy, lactating (breast feeding) females, possible intestinal obstruction, prostatic hyperplasia, chronic renal, hepatic, pulmonary or cardiac disease. Use with caution for elderly patients. ***(NOTE)***Patients considered high risk must have at least 3 of the following risk factors: non-smoking status, female gender, previous history of PONV and history of motion sickness Nursing Orders Patient Education Instruct patient on side effects seen with Scopolamine: dry mouth, blurry vision and confusion in the elderly. Medications scopolamine 1.5 mg patch TRANSDRM ONCE, Clinical Instructions: apply disc behind the ear 2 hours prior to surgery for patients at high risk for Post Operative Nausea and Vomiting. Page 6 of 6
ALL orders are active unless: 1. Order is manually lined through to inactivate 2. Orders with check boxes ( ) are unchecked DRUG AND TREATMENT ORDERS
DRUG AND TREATMENT Diet Diet NPO After Midnight NPO except for meds with sip of water NPO NPO except for meds with sip of water Diet Message Clear liquids until 0800 if surgery after 1400 (except for CV
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
Available at ALL facilities Non Categorized SUB ED Chest Pain: STEMI Protocol(SUB)* SUB ED Chest Pain: STEMI Protocol Lab Orders(SUB)* ED Rainbow Tubes(SUB)* ***Reminder: Order ED Rainbow Tubes (SUB) as
ALL orders are active unless: 1. Order is manually lined through to inactivate 2. Orders with check boxes ( ) are unchecked DRUG AND TREATMENT ORDERS
Available at: ALL Adult Facilities Non Categorized SUB Protocol(SUB)* SUB Protocol Lab Orders(SUB)* ED Rainbow Tubes(SUB)* ***Reminder: Order ED Rainbow Tubes (SUB) as a separate form*** Nursing Orders
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
Available at: BMC-B BMC-D BMC-N BMC-S Activity Activity Bedrest with BRP, with assistance at nurse's discretion (DEF)* Ambulate with Assistance Diet Communication Order Patient to remain NPO while in PACU
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available at: ALL Adult Facilities Non Categorized SUB ED Abdominal Pain Protocol(SUB)* ***The above subphase is available at the end of the plan*** SUB ED Abdominal Pain Protocol Lab
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available at: ALL Adult Facilities Non Categorized SUB Protocol(SUB)* SUB Protocol Lab Orders(SUB)* ED Rainbow Tubes(SUB)* ***Reminder: Order ED Rainbow Tubes (SUB) as a separate form***
CBC with Differential. PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Non Categorized SUB ED Snakebite Protocol (SUB)* Non Categorized ***(NOTE)*** This plan is designed to be used as part of a larger plan, not independently. Please do NOT order individually.
CARD THORACOTOMY PRE-OP PLAN
CARD THORACOTOMY PRE-OP PLAN PHYSICIAN S Diagnosis Weight Allergies Patient Care Perform Oral Care Perform night before surgery. Brush teeth with toothpaste, then swish and spit 15 ml chlorhexidine mouth
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available ONLY at: BMC-B BMC-D BMC-N BMC-S Nursing Orders Communication Order If CVP unavailable, administer fluid boluses every 30 minutes except monitor O2 requirements Comments: Every
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Non Categorized SUB Sub Phase (SUB)* Non Categorized Quality Measures STK Diet ED NPO Until Bedside Swallow Screen passed Nursing Orders Activate Code Stroke Vital Signs Q15MINS Int
ALL orders are active unless: 1. Order is manually lined through to inactivate 2. Orders with check boxes ( ) are unchecked DRUG AND TREATMENT ORDERS
DRUG AND TREATMENT Available at: BMC-B BMC-D BMC-N BMC-S Vital Signs Vital Signs Q4H (DEF)* Q2H Q1H Vital Signs Orthostatic Activity Activity Bedrest, for 12 hours then Up ad lib (DEF)* Bedrest, for 24
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REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
CARD OPEN HEART PRE-OP PLAN
PHYSICIAN S Diagnosis Weight Allergies Patient Care Perform Oral Care Per Unit Standards, Perform night before surgery. Brush teeth with toothpaste. Peridex mouth wash (15 ml swish and spit). chlorhexidine
Pre-Admission Testing Questionnaire
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PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies:
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I will be contacting you with the day, time and location of the scheduled procedure.
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PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
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PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
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PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT *****ALSO ORDER SUB ACUTE DKA IV FLUIDS REGIMEN & SUB ACUTE ELECTROLYTE REPLACEMENT on separate forms ***** Condition/Status For purpose of this DKA Regimen, DKA is considered clear
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City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
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I will be contacting you with the day, time and location of the scheduled procedure.
Low Country ENT is happy you have chosen us to assist you and your family in obtaining your healthcare needs. The following packet is to help you further understand your future surgical procedure as well
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ALL orders are active unless: 1. Order is manually lined through to inactivate 2. Orders with check boxes ( ) are unchecked DRUG AND TREATMENT ORDERS
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