Pediatric Outpatient Surgery Plan - Diagnostic/Pre-Op Orders

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Dennis Frederick McDowell
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1 Pediatric Outpatient Surgery Plan - Diagnostic/Pre-Op Orders Diagnosis Weight PHYSICIAN S Allergies Admit/Discharge/Transfer Request for Outpatient Services Location: Outpatient Surgery Communication Misc Patient Care Order Misc Patient Care Order Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. sodium biphosphate-sodium phosphate (Fleet Enema) 1 ea, rectally, enema, ONE TIME Send home with patient for Pre-Op. If patient is less than 12 years old, order the Fleet Enema for Children. sodium biphosphate-sodium phosphate (Fleet Enema for Children) 1 ea, rectally, enema, ONE TIME Send home with patient for Pre-Op. ***If Bowel Prep meds and instructions given to patient in the clinic, use "Notify Nurse" order*** Notify Nurse (DO NOT USE FOR MEDS) Bowel Prep meds and instructions have been given to the patient in the clinic. Additional Medication ***If addtional medications are needed, complete the following "misc medication" order to allow pharmacy to enter into PowerChart*** misc medication misc medication Laboratory CBC CBC with Differential Basic Metabolic Panel Comprehensive Metabolic Panel Prothrombin Time with INR PTT Order Taken by Signature: Page: 1 Pediatric Outpatient Surgery Plan Version: 1 Effective on: 08/01/15 Page 1 of 14

2 Pediatric Outpatient Surgery Plan - Diagnostic/Pre-Op Orders PHYSICIAN S Urine Beta hcg Urine, Beta hcg Quantitative Urinalysis Urine, Diagnostic Tests EKG-12 Lead Routine DX Chest Single View Routine DX Chest PA & Lateral Routine Pulmonary Function Test, Complete Routine Order Taken by Signature: Page: 2 Pediatric Outpatient Surgery Plan Version: 1 Effective on: 08/01/15 Page 2 of 14

3 Pediatric Outpatient Surgery Plan - Diagnostic/Pre-Op Orders - Outpatient BB Type and Screen PHYSICIAN S Laboratory BB Blood Type (ABO/Rh) BB Antibody Screen BB Clot to Hold Order Taken by Signature: Page: 3 Pediatric Outpatient Surgery Plan Version: 1 Effective on: 08/01/15 Page 3 of 14

4 Pediatric Outpatient Surgery Plan - OPS/OR Holding Pre-Op Orders PHYSICIAN S Patient Care Pre-Operative Warming Orders ***See Reference Text*** Vital Signs Per Unit Standards Insert Peripheral Line Apply Elastic Stockings Apply to: Bilateral Lower Extremities, Length: Knee High Apply to: Bilateral Lower Extremities, Length: Thigh High Apply Sequential Compression Device Apply to Bilateral Lower Extremities Communication ***Code Status must be declared upon admission to Outpatient Surgery*** Code Status Code Status: Full Code Code Status: DNR - Do Not Resuscitate Code Status: DNI - Do Not Intubate Code Status: Partial Resuscitative Effort Code Status: DNR/DNI - Do Not Resuscitate or Intubate Notify Nurse (DO NOT USE FOR MEDS) Start IV in OR. Pre-Op Instructions Instruct on incentive spirometry. Misc Patient Care Order Misc Patient Care Order Dietary Outpatient Diet NPO IV Solutions LR IV, ml/hr NS IV, ml/hr Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. Antibiotics cefazolin (cefazolin pediatric) 20 mg/kg, IVsyr, syringe, OCTOR Diluent NS. Give over 30 min. 30 mg/kg, IVsyr, syringe, OCTOR Diluent NS. Give over 30 min. cefuroxime (cefuroxime pediatric) 75 mg/kg, IVsyr, syringe, OCTOR Diluent NS. Give over 30 min. Order Taken by Signature: Page: 4 Pediatric Outpatient Surgery Plan Version: 1 Effective on: 08/01/15 Page 4 of 14

5 Pediatric Outpatient Surgery Plan - OPS/OR Holding Pre-Op Orders PHYSICIAN S vancomycin (vancomycin pediatric) 10 mg/kg, IVsyr, syringe, OCTOR Give over min. Diluent NS. Dose + 3 ml overfill. 15 mg/kg, IVsyr, syringe, OCTOR Give over min. Diluent NS. Dose + 3 ml overfill. gentamicin (gentamicin pediatric) 1 mg/kg, IVsyr, syringe, OCTOR Diluent NS. Give over 60 min. 2 mg/kg, IVsyr, syringe, OCTOR Diluent NS. Give over 60 min. clindamycin (clindamycin pediatric) 10 mg/kg, IVsyr, syringe, OCTOR Diluent NS. Give over 60 min. Gastrointestinal Agents sodium biphosphate-sodium phosphate (Fleet Enema) 1 ea, rectally, enema, ONE TIME If patient is less than 12 years old, order the Fleet Enema for Children. sodium biphosphate-sodium phosphate (Fleet Enema for Children) 1 ea, rectally, enema, ONE TIME Other Pre-Op Medication mupirocin topical (mupirocin 2% nasal ointment) 1 app, intra-nasal, nasal oint, OCTOR ***Apply contents of tube evenly between both nostrils*** acetaminophen (acetaminophen pediatric) 10 mg/kg, IVsyr, syringe, OCTOR 12.5 mg/kg, IVsyr, syringe, OCTOR ***Single Dose*** tranexamic acid 10 mg/kg, IVPB, ivpb, OCTOR To be give INTRAOPERATIVELY. Recommended maximum is 50 mg/kg. ***Continuous Infusion*** Order Taken by Signature: Page: 5 Pediatric Outpatient Surgery Plan Version: 1 Effective on: 08/01/15 Page 5 of 14

6 Pediatric Outpatient Surgery Plan - OPS/OR Holding Pre-Op Orders PHYSICIAN S tranexamic acid 1,000 mg IVPB IV To be give INTRAOPERATIVELY. Final concentration = 20 mg/ml. Usual maintenance is 1-10 mg/kg. Start at rate: mg/kg/hr Additional Medication ***If addtional medications are needed, complete the following "misc medication" order to allow pharmacy to enter into PowerChart*** misc medication misc medication Laboratory Urine Beta hcg Urine, BUN STAT Outpatient/PACU Creatinine STAT Outpatient/PACU POC Blood Sugar Check ONE TIME, upon arrival q4h ABO/Rh Confirmation STAT Outpatient/PACU Respiratory Arterial Blood Gas Consults/Referrals Consult MD Service: Anesthesiology, Reason: Pre-Op Service: Anesthesiology, Reason: Pre-Op and Nerve Block Order Taken by Signature: Page: 6 Pediatric Outpatient Surgery Plan Version: 1 Effective on: 08/01/15 Page 6 of 14

7 Pediatric Outpatient Surgery Plan - PACU Orders PHYSICIAN S Patient Care Vital Signs Per Unit Standards Apply Sequential Compression Device Apply to Bilateral Lower Extremities Communication Notify Provider of VS Parameters Laboratory CBC STAT Outpatient/PACU Hemoglobin and Hematocrit STAT Outpatient/PACU POC Hemoglobin and Hematocrit Basic Metabolic Panel STAT Outpatient/PACU POC Chem 8 Comprehensive Metabolic Panel STAT Outpatient/PACU Diagnostic Tests Order Taken by Signature: Page: 7 Pediatric Outpatient Surgery Plan Version: 1 Effective on: 08/01/15 Page 7 of 14

8 Pediatric Outpatient Surgery Plan - PACU Orders - PACU Post-Op Diagnostic Tests PHYSICIAN S Diagnostic Tests EKG-12 Lead Radiography DX Chest PA & Lateral DX Abdomen AP (KUB) DX Ankle Complete 3+ (Left) DX Ankle Complete 3+ (Right) DX Elbow Complete 3+ (Left) DX Elbow Complete 3+ (Right) DX Femur AP/Lat (Left) DX Femur AP/Lat (Right) DX Foot Complete 3+ (Left) DX Foot Complete 3+ (Right) DX Forearm AP/Lat (Left) DX Forearm AP/Lat (Right) DX Hand Complete 3+ (Left) DX Hand Complete 3+ (Right) DX Heel-Os Calsis 2+ (Left) DX Heel-Os Calsis 2+ (Right) DX Hip 2+ (Left) DX Hip 2+ (Right) Order Taken by Signature: Page: 8 Pediatric Outpatient Surgery Plan Version: 1 Effective on: 08/01/15 Page 8 of 14

9 Pediatric Outpatient Surgery Plan - PACU Orders - PACU Post-Op Diagnostic Tests PHYSICIAN S DX Wrist Complete 3+ (Left) DX Wrist Complete 3+ (Right) DX Tib/Fib AP/Lat (Left) DX Tib/Fib AP/Lat (Right) DX Shoulder Complete 2+ (Left) (DX Shoulder 4 vw AP,Y,Grashey,Ax (Left)) DX Shoulder Complete 2+ (Right) (DX Shoulder 4 vw AP,Y,Grashey,Ax (Right)) DX Pelvis Complete 3+ (DX Pelvis w Juda Views) DX Pelvis Complete 3+ (DX Pelvis w Inlet and Outlet) DX Pelvis AP 1 or 2 vw DX Knee 1or 2 vws (Left) DX Knee 1or 2 vws (Right) Order Taken by Signature: Page: 9 Pediatric Outpatient Surgery Plan Version: 1 Effective on: 08/01/15 Page 9 of 14

10 Pediatric Outpatient Surgery Plan - OPS Post- Op Orders PHYSICIAN S Admit/Discharge/Transfer ***If returning patient to PACU, right click and REPLICATE the PACU Orders Phase*** Return Patient to PACU Patient Care Vital Signs Per Unit Standards Convert IV to INT Discontinue Peripheral Line When vital signs stable, tolerating fluids, and pain contolled. Discontinue Urinary Catheter Do NOT DC Foley Communication ***Code Status must be declared post operatively as the patient has had a change in the level of care*** Code Status Code Status: Full Code Code Status: DNR - Do Not Resuscitate Code Status: DNI - Do Not Intubate Code Status: Partial Resuscitative Effort Code Status: DNR/DNI - Do Not Resuscitate or Intubate Notify Provider of VS Parameters Notify Provider (Misc) Notify Nurse (DO NOT USE FOR MEDS) Patient NOT required to void prior to discharge. Notify Nurse (DO NOT USE FOR MEDS) Do Not Discharge patient until seen by physician. Dietary Outpatient Diet Clear Liq. Advance to Pre-Hospital Diet Pre-Hospital Diet Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. Pain Management acetaminophen (acetaminophen pediatric) 15 mg/kg, PO, liq, q6h, PRN pain-mild (scale 1-3) *****If acetaminophen ineffective/contraindicated, use ibuprofen(first) OR ketorolac IF ordered.***** Order Taken by Signature: Page: 10 Pediatric Outpatient Surgery Plan Version: 1 Effective on: 08/01/15 Page 10 of 14

11 Pediatric Outpatient Surgery Plan - OPS Post- Op Orders PHYSICIAN S 325 mg, PO, tab, q4h, PRN pain-mild (scale 1-3) *****If acetaminophen ineffective/contraindicated, use ibuprofen(first) OR ketorolac IF ordered.***** ibuprofen (ibuprofen pediatric) 10 mg/kg, PO, liq, q6h, PRN pain-mild (scale 1-3) *****If ibuprofen ineffective, use ketorolac IF ordered.***** 200 mg, PO, tab, q6h, PRN pain-mild (scale 1-3) *****If ibuprofen ineffective, use ketorolac IF ordered.***** 400 mg, PO, tab, q6h, PRN pain-mild (scale 1-3) *****If ibuprofen ineffective, use ketorolac IF ordered.***** 600 mg, PO, tab, q6h, PRN pain-mild (scale 1-3) *****If ibuprofen ineffective, use ketorolac IF ordered.***** ketorolac 0.5 mg/kg, IVPush, inj, q6h, PRN pain-mild (scale 1-3) tramadol 50 mg, PO, tab, q6h, PRN pain-moderate (scale 4-7) *****If tramadol ineffective/contraindicated, use acetaminophen-codeine (first) OR acetaminophen-hydrocodone IF ordered.***** acetaminophen-codeine (Tylenol with Codeine Liquid) 0.2 ml/kg, PO, liq, q4h, PRN pain-moderate (scale 4-7), [0.2 ml = 0.5 mg codeine] ***If acetaminophen/codeine ineffective/contraindicated, use or acetaminophen/hydrocodone IF ordered.*** 0.4 ml/kg, PO, liq, q4h, PRN pain-moderate (scale 4-7), [0.4 ml = 1 mg codeine] ***If acetaminophen/codeine ineffective/contraindicated, use or acetaminophen/hydrocodone IF ordered.*** Order Taken by Signature: Page: 11 Pediatric Outpatient Surgery Plan Version: 1 Effective on: 08/01/15 Page 11 of 14

12 Pediatric Outpatient Surgery Plan - OPS Post- Op Orders PHYSICIAN S 2.5 ml, PO, liq, q4h, PRN pain-moderate (scale 4-7) ***If acetaminophen/codeine ineffective/contraindicated, use or acetaminophen/hydrocodone IF ordered.*** 5 ml, PO, liq, q4h, PRN pain-moderate (scale 4-7) ***If acetaminophen/codeine ineffective/contraindicated, use or acetaminophen/hydrocodone IF ordered.*** acetaminophen-codeine (Tylenol with Codeine #3 oral tablet) 1 tab, PO, q4h, PRN pain-moderate (scale 4-7) ***If acetaminophen/codeine ineffective/contraindicated, use or acetaminophen/hydrocodone IF ordered.*** HYDROcodone-acetaminophen (HYDROcodone-acetaminophen 5 mg-325 mg oral tablet) 1 tab, PO, tab, q4h, PRN pain-moderate (scale 4-7) HYDROcodone-acetaminophen (HYDROcodone-acetaminophen 7.5 mg-325 mg/15 ml oral solution) 0.2 ml/kg, PO, soln, q4h, PRN pain-moderate (scale 4-7) 0.4 ml/kg, PO, soln, q4h, PRN pain-moderate (scale 4-7) 15 ml, PO, soln, q4h, PRN pain-moderate (scale 4-7) HYDROcodone-acetaminophen (HYDROcodone-acetaminophen 7.5 mg-325 mg oral tablet) Order Taken by Signature: Page: 12 Pediatric Outpatient Surgery Plan Version: 1 Effective on: 08/01/15 Page 12 of 14

13 Pediatric Outpatient Surgery Plan - OPS Post- Op Orders PHYSICIAN S 1 tab, PO, tab, q4h, PRN pain-moderate (scale 4-7) Anti-pyretics acetaminophen (acetaminophen pediatric) 15 mg/kg, PO, liq, q6h, PRN fever *****If acetaminophen ineffective/contraindicated, use ibuprofen IF ordered:***** 325 mg, PO, tab, q6h, PRN fever *****If acetaminophen ineffective/contraindicated, use ibuprofen IF ordered:***** ibuprofen (ibuprofen pediatric) 10 mg/kg, PO, liq, q6h, PRN fever 200 mg, PO, tab, q6h, PRN fever 400 mg, PO, tab, q6h, PRN fever 600 mg, PO, tab, q6h, PRN fever Laboratory POC Blood Sugar Check Physical Medicine and Rehab Consult PT Mobility for Eval & Treat Crutch Training Consults/Referrals Social Services for DME for Home Social Services for Home Health Care Order Taken by Signature: Page: 13 Pediatric Outpatient Surgery Plan Version: 1 Effective on: 08/01/15 Page 13 of 14

14 Pediatric Outpatient Surgery Plan - Discharge Orders PHYSICIAN S Admit/Discharge/Transfer General Discharge Patient (Outpatient) Discharge Condition Discharge Condition: Improved Discharge Condition: Stable Discharge Condition: Fair Discharge Disposition Discharge To: Home Discharge To: Home with Home Health Discharge To: Another Hospital Discharge To: Home with Hospice Discharge To: Children s Hospital Discharge Instructions Pediatric/Infant Discharge Misc Education for Patient Diet Discharge Pediatric Diet Diet: Resume pre-hospital diet Diet: Regular Discharge Infant Feeding Activity Discharge Pediatric Activity Activity: As tolerated Activity: Car seat for all car rides Place infant on back to sleep Activity: No restriction Discharge Bathing Instructions Discharge Extremity Care (ROM, CPM, etc) Line, Drain, and Wound Care Discharge Wound Care Discharge Surgical Drain/Tube Care Follow Up Discharge Follow-up Appointment Discharge Follow-up Appointment Services that have been arranged This section is to be filled out by Social Services. Discharge DME Instructions Discharge Home Health Instructions Communication Patient May Return to Work/School Order Taken by Signature: Page: 14 Pediatric Outpatient Surgery Plan Version: 1 Effective on: 08/01/15 Page 14 of 14

PEDIATRIC SPINE SURGERY POST-OP PLAN - Phase:.

PEDIATRIC SPINE SURGERY POST-OP PLAN - Phase:. - Phase:. PHYSICIAN S Diagnosis Weight Allergies DETAILS Patient Care Patient Activity Bedrest Maintain Surgical Drain Maintain JP Drain, Measure Output q12h, and PRN Convert IV to INT when tolerating