SPINE ORTHOPAEDIC SURGERY POST-OPERATIVE ORDERS 1 of 5

Transcription

1 9 Actual 9 Estimated DOWNTIME POST-OPERATIVE 1 of 5 Weight kg 9 Actual 9 Estimated Height cm ALLERGIES: REFER TO ALLERGY PROFILE/ POWERCHART Admit to Service: Admit to: Post Anesthesia Care Unit (PACU) Patient Condition: (3) Check, circle and/or fill in all orders to be implemented as appropriate. 1. VITAL SIGNS: 9 PACU routine, then every 4 hours x 24 hours, then every 8 hours 9 Neurovascular checks to upper and lower extremities (to include color, temperature, pulses, motor function and capillary refill) every 4 hours x 48 hours, then every 8 hours 2. DIET: 9 Nothing by mouth until bowel sounds, flatus, then advance diet slowly 9 Clear liquids to as tolerated 3. ACTIVITY: a. Exercises to be performed every 2 hours while awake. Quadriceps setting, ankle flexion/extension gluteal sets b. Flat for hour(s). Log roll every 2 hours as needed. c. Head of bed may be elevated d. Out of bed post-operative day 1: 9 with brace 9 without brace e. Special bed required: Type: Activity: f. Physical Therapy for evaluation and treatment on with/without brace: 9 daily 9 twice daily g. Brace Type: Vendor: 9 Buffalo 9 Nelson 9 Cleve-Hill 9 Companella 9 Other: h. Occupational Therapy to evaluate and treat: 9 daily 9 twice daily 4. OXYGEN SUPPORT: 9 Incentive Spirometry 9 Cough and deep breathe every hour while awake 5. INTRAVENOUS (IV) FLUIDS: 9 at ml/hour 9 Convert to intermittent infusion device post-operative day 2 if tolerating by mouth greater than 250 ml every 8 hours 6. INTAKE AND OUTPUT: 9 Intake and output x 48 hours 9 Indwelling urinary catheter to gravity. Discontinue on post-operative day 2. 9 Straight catheter every 6-8 hours if unable to void. 7. LABS: 9 Complete Blood Count (CBC) daily x 3 9 Basic Metabolic Panel (BMP) in morning (AM) 9 CBC and BMP in AM 9 Other: Initials Place STAT barcode sticker within this box only on form copy being scanned

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3 POST-OPERATIVE 2 of 5 (3) Check, circle and/or fill in all orders to be implemented as appropriate. 8. DIAGNOSTICS: 9 X-ray of: Indication: 9. DRAINS: 9 Record contents every 8 hours 9 Hemovac to suction 9 House Officer/NP/PA to discontinue post-operative day DRESSING CHANGES: a. May change original dressing as needed b. Nurse to change original dressing post-operative day 2: 9 dry sterile dressing applied 9 open to air post-operative day 3 c. After Provider has completed original dressing change then: 9 change dressing as needed 9 leave to open air on post-operative day MEDICATIONS: A. DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS (Risk Assessment on Back) REQUIRED to (3) check all that apply: 9 Pneumatic Compression Device (PCD): Knee High Pump 9 Pneumatic Compression Device (PCD): Foot Pump 9 Other Orders: 9 DVT Prophylaxis not indicated (Reason): 9 DVT Prophylaxis contraindicated (Reason): B. EXISTING MEDICATIONS: If new admission, refer to Powerchart Medication History -OR- If inpatient, refer to Kaleida Transfer Profile (KTP) form for medication orders (available through Pharmacy) C. NEW MEDICATIONS: Analgesic Medication 9 Patient controlled analgesia (see PCA order sheet - KH00507) 9 Discontinue PCA on post-operative day 2 then start: 9 Parenteral Analgesic Medication dose route interval 9 By Mouth Analgesic Medication dose interval 9 Sleep Medication dose route interval. Initials Place STAT barcode sticker within this box only on form copy being scanned

4 POST-OPERATIVE 3 of 5 RISK FACTORS 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 hours Recent uninterrupted travel greater than 4 hours 2 1 Multiple Trauma 5 Laparoscopic/Pelvic Surgery 2 Major Surgery greater than 45 minute duration 2 PRE-EXISTING/CURRENT MEDICAL CONDITIONS points 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 5 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 Neurosurgery Heparin 5000 units subcutaneous every 8 hours -AND- Pneumatic Compression Device (PCD) DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS RISK ASSESSMENT 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 History of (any population with moderate Heparin-induced to high venous Thrombocytopenia thromboembolism [VTE] risk) Pneumatic Compression Device (PCD) 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 POST-OPERATIVE 4 of 5 (3) Check, circle and/or fill in all orders to be implemented as appropriate. Inflammation Medication 9 Ketorolac (Toradol) 30 mg intravenous: 9 in PACU x 1 dose 9 every 6 hours as needed x 3 doses 9 Ketorolac (Toradol) 15 mg intravenous every 6 hours as needed x 3 doses (recommended for patients greater than 65 years of age, weighing less than 65 kg, or estimated creatinine clearance less than 50 ml/minute) 9 Dexamethasone (Decadron) 10 mg intravenous in PACU x 1 dose 9 Dexamethasone (Decadron) 10 mg every 8 hours x 3 doses via: 9 intravenous 9 by mouth Constipation Medication 9 Docusate/Senna 1 tab by mouth twice a day 9 Milk of Magnesia 30 ml by mouth daily as needed 9 Bisacodyl (Dulcolax) suppository 1 per rectum daily as needed 9 Fleets enema per rectum daily as needed Nausea Medication 9 Metoclopramide 10 mg intravenous every 6 hours as needed 9 Ondansetron (Zofran) 4 mg intravenous every 6 hours as needed Prophylaxis Medication 9 Cefazolin 1 gram intravenous every 8 hours x 24 hours (surgical infection) 9 Pantoprazole (Protonix) 40 mg by mouth daily (gastrointestinal ulcer) Other Medication 9 Acetaminophen 650 mg by mouth every 4 hours as needed for temperature greater than C and/or headache 9 Methocarbamol (Robaxin) 1000 mg by mouth three s a day for muscle relaxant 9 Aluminum with Magnesium Hydroxide (Maalox) 30 ml by mouth every 8 hours as needed for gastrointestinal upset 9 Ferrous Sulfate 325 mg by mouth for iron supplementation: 9 twice a day 9 three s a day with meals D. IMMUNIZATIONS Per New York State Department of Health (NYS DOH) Mandatory Immunization Program and Kaleida Policy CL.6, administer vaccine(s) if patient meets criteria. 1 Pneumococcal Vaccine 0.5 ml intramuscular x 1 for prophylaxis If contraindicated please ( ) check one of the NYS DOH acceptable contraindications below: 9 Allergy to pneumococcal vaccine 9 Previously immunized Date: 1 Influenza Vaccine 0.5 ml intramuscular x 1 for prophylaxis (September 1 - April 1) If contraindicated please ( ) check one of the NYS DOH acceptable contraindications below: 9 Allergy to influenza vaccine 9 Vaccinated this flu season Date: 12. ADDITIONAL : 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

6 POST-OPERATIVE 5 of 5 NEW YORK STATE DEPARTMENT OF HEALTH LAW SECTION , CHAPTER 443: 1 Every in-patient must be assessed for pneumococcal and influenza vaccine need 1 Appropriate vaccines must be administered 1 Standing Physician Order for all in-patients, signed by Dr. Margaret Paroski, EVP CMO 1 Additional physician order is not required CRITERIA INDICATIONS for BOTH PNEUMOVAX and INFLUENZA: 1 Age 65 or greater 1 Age greater than 18 with chronic illnesses such as diabetes, asthma, emphysema, pneumonia, congestive heart failure, coronary artery disease, chronic renal failure, immunosuppression 1 If previous vaccination unknown, and criteria met, revaccinate 1 NO VACCINATION INDICATED if patient is between 18 and 65 years old, without chronic illness CONTRAINDICATIONS: PNEUMOVAX (must be administered year round) 1 Received pneumococcal vaccine at age 65 or greater. If unknown, revaccinate 1 Received pneumococcal vaccine at age 65 or less, wait 5 years to revaccinate. If unknown, revaccinate. 1 Previous severe reaction to pneumococcal vaccine (urticaria, laryngeal edema, anaphylaxis) CONSENTS: PNEUMOVAX (must be administered year round) Patient read Vaccine Information Sheet (KH01159) 1 Patient consented - patient/ health care proxy signed Vaccine Information Sheet. Form scanned to pharmacy for vaccine dispensing. 1 Patient refused and reason stated INFLUENZA (Flu season is September 1 - April 1, as vaccine available from pharmacy) 1 Received vaccine earlier THIS flu season. If unknown, revaccinate 1 History of allergic reaction to eggs or contact lens solution (Thimerosal - preservative in solution) 1 Previous severe reaction to influenza vaccine (urticaria, laryngeal edema, anaphylaxis) INFLUENZA (Flu season is September 1 - April 1, as vaccine available from pharmacy) Patient read Vaccine Information Sheet (KH01160) 1 Patient consented - patient/ health care proxy signed Vaccine Information Sheet. Form scanned to pharmacy for vaccine dispensing. 1 Patient refused and reason stated