GENERAL SURGICAL ADULT POST-OPERATIVE ORDERS 1 of 4

Transcription

1 down ADULT POST-OPERATIVE 1 of 4 9 Actual 9 Estimated Patient ID Area Weight kg 9 Actual 9 Estimated Height cm ALLERGIES: REFER TO ALLERGY PROFILE/ POWERCHART Admit to: Post Anesthesia Care Unit (PACU), then Surgical Unit Procedure: Large Bowel Resection Team (BGH only): Blue Team White Team Red Team Level of Care: Ambulatory Surgery Inpatient Location: Med Surg Telemetry (complete Orders KH00280) Critical Care Unit ( ) Check, circle and/or fill in all orders to be implemented as appropriate. NURSING ASSESSMENT/INTERVENTIONS Vital Signs: Vital signs including pulse oximetry every 4 hours x 48 hours, then every 8 hours Notify Physician if: temperature is greater than F (38.5 C) pulse less than 60 beats per minute or greater than 110 beats per minute respiratory rate less than 10 breaths per minute or greater than 18 breaths per minute pulse oximetry less than 92% Cardiac Monitor Intake & Output: Strict intake & output. Notify physician if urine output less than 120 ml in 4 hours Indwelling urinary (foley) catheter. Discontinue post-operative day 2 Nasogastric Tube (NG): NG to continuous wall suction: low suction high suction NG to low intermittent suction: measured every hour(s) discontinue post-operative day Drain Care: Glucose Control: Blood glucose fingerstick every 6 hours or (refer to glycemic control sheet) RESPIRATORY Oxygen at liters/minute by. Monitor oxygen saturation and titrate per protocol. Initials Place STAT barcode sticker within this box only on form copy being scanned

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3 down ADULT POST-OPERATIVE 2 of 4 Patient ID Area ( ) Check, circle and/or fill in all orders to be implemented as appropriate. ACTIVITY Elevate head of bed 30 while in bed Ambulate Out of bed to chair/bathroom privileges Bedrest DIET Advance diet as tolerated Ice chips Nothing by mouth except medication Clear Liquids Regular Special: INTRAVENOUS (IV) INFUSION Lactated Ringers at ml/hour Sodium Chloride 0.9% at ml/hour Dextrose 5% / Sodium Chloride 0.9% at ml/hour LABS Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) every morning x 3 days PATIENT EDUCATION Pain management Cough and deep breathing / Incentive spirometry Smoking cessation Wound/Drain care CONSULTATION/REFERRAL (include indication) Medical Consult: Care Management / Social Work: Wound Team: Physical Therapy to evaluate and treat: MEDICATIONS 1. Deep Vein Thrombosis (DVT) Prophylaxis (Risk Assessment on Back) REQUIRED to ( ) check all that apply: Heparin 5000 units subcutaneous every 8 hours Pneumatic Compression Device (PCD): Knee High Pump Pneumatic Compression Device (PCD): Foot Pump Antiembolism Stockings Other Orders: DVT Prophylaxis not indicated (Reason): DVT Prophylaxis contraindicated (Reason): 2. Existing Medications: NEW ADMISSION: Refer to Powerchart Medication History INPATIENT: Refer to Kaleida Transfer Profile (KTP) form for medication orders (available in Powerchart) Initials Place STAT barcode sticker within this box only on form copy being scanned

4 down ADULT POST-OPERATIVE 3 of 4 Patient ID Area RISK FACTORS DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS RISK ASSESSMENT AGE points IMMOBILITY points SURGERY points greater than 60 years 2 Coma 2 Hip/Pelvic/Long Bone Fracture years 1 Patient confined to bed greater than 72 Multiple Trauma 5 2 hours Laparoscopic/Pelvic Surgery 2 Recent uninterrupted travel greater than 4 hours 1 Major Surgery greater than 45 minute duration PRE-EXISTING/CURRENT MEDICAL CONDITIONS points Ischemic Stroke/Paralysis 5 Current Heart Failure/ Myocardial Infarction 1 Previous DVT or Pulmonary Embolism (PE) 3 Obesity (greater than 20% Ideal Body Weight [IBW]) 1 Hypercoagulation State* 3 Pregnancy/Postpartum less than 1 month 1 Cancer 2 Severe Dehydration 1 Central Venous Catheter greater than 1 week (excludes Renal Nephrotic syndrome 1 2 Access) Varicose Veins/Vein Surgery/Phlebitis 1 Infection (severe/sepsis) 1 Inflammatory Bowel Disease 1 Chronic Obstructive Pulmonary Disease (COPD)/Respiratory Distress/Steroid or Oxygen Dependent 1 Chemotherapy 1 Estrogen Use (oral contraceptives, hormone replacement therapy [HRT]) 1 Family Medical History unexplained DVT 1 * Examples of Hypercoagulation State: Protein C or S deficiency Antithrombin III deficiency Lupus Anticoagulant Homocysteinemia LOW RISK (Score of 1 or less) No prophylaxis Ambulate MODERATE TO HIGH RISK* (Score of 2-4) Heparin 5000 units subcutaneous every 8 hours -OR- Pneumatic Compression Device (PCD) HIGHEST RISK/MULTI MODAL* (Score of 4 or higher) Heparin 5000 units subcutaneous every 8 hours -AND- Pneumatic Compression Device (PCD) * Recommendations apply to general medical and surgical patients. Please see below for additional recommendations for specific patient populations. ALTERNATIVE RECOMMENDATIONS FOR SPECIFIC PATIENT POPULATIONS 2 points Neurosurgery Heparin 5000 units subcutaneous every 8 hours - AND - Pneumatic Compression Device (PCD) Orthopaedic Surgery See form KH00202 Total Knee/Hip Arthroplasty Post-Operative Orders Trauma/ Spinal Cord Injury Enoxaparin 30 mg subcutaneous every 12 hours - AND - Pneumatic Compression Device (PCD) Consider platelet monitoring for prolonged anticoagulation Coronary Artery Bypass Surgery Enoxaparin 40 mg subcutaneous daily (Enoxaparin 30 mg subcutaneous daily if Creatinine Clearance [CrCl] less than 30 ml/minute) Bariatric Surgery Enoxaparin 40 mg subcutaneous every 12 hours High Risk Bleeding (any population with moderate to high venous thromboembolism [VTE] risk) Pneumatic Compression Device (PCD) History of Heparin-induced Thrombocytopenia Fondaparinux 2.5 mg subcutaneous daily (Contraindicated if Creatinine Clearance [CrCl] less than 30 ml/minute) References: Modified From: Motyke, GD, Zebal, LP and Caprini, et al. A Guide to Venous Thromboembolism Risk Factor Assessment. Journal of Thrombosis and Thrombolysis, Geerts W, Bergqvist D, Pineo G et al. Prevention of Venous Thromboembolism. Chest 2008; 133: 381S-453S

5 down ADULT POST-OPERATIVE 4 of 4 Patient ID Area ( ) Check, circle and/or fill in all orders to be implemented as appropriate. 3. New Medications Pain Medication Patient controlled analgesia (see order sheet KH00507) Parenteral Pain Medication dose route interval Oral Pain Medication dose interval Surgical Infection Prophylaxis Anesthesia End Time: Cefazolin intravenous every 8 hours x 24 hours (discontinue 24 hours from anesthesia end ): 1 gram (weight less than 80 kg) -OR- 2 grams (weight 80 kg or more) Vancomycin 1 gram intravenous every 12 hours x 24 hours (if penicillin allergy) PACU Antibiotic Medication dose route interval indication dose given at a. b. c. (If antibiotics are for treatment of infection, please document source of infection) Post-Operative Ileus Prophylaxis indicated: partial large or small bowel surgery with primary anesthesia contraindicated: patients who have taken therapeutic doses of opioids for more than 7 consecutive days immediately prior to taking almivopan Alvimopan (Entereg) 12 mg by mouth twice a day for 7 days beginning the day after surgery (14 total postoperative doses) Other Medication Throat lozenges by mouth every hour(s) as needed for sore throat Acetaminophen 650 mg by mouth every 4 hours as needed for headache dose route interval indication 4. Immunizations Per New York State Department of Health Mandatory Immunization Program and Kaleida Policy CL.6: All patients 6 to 64 years old with chronic health conditions and all patients age 65 or older admitted to Kaleida will be screened to determine eligibility for the pneumococcal immunization and all eligible patients will be offered the vaccine. All patients admitted to Kaleida age 6 months and older will be screened to determine eligibility for influenza immunization and all eligible patients will be offered the vaccine. The immunization(s) will be held if the patient has a contraindication. Please select the appropriate contraindication(s) and sign the Adult Pneumococcal/Influenza Vaccination Orders (KH01183) to have the immunization(s) held. NURSING 9 TORB From: Date: Time: Signature: NOTED BY RN Date: Time: Signature: PROVIDER Date: Time: Print Name/Stamp: Signature: TORB = Telephone Orders Read Back Place STAT barcode sticker within this box only on form copy being scanned

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