PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
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- August Arnold
- 5 years ago
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1 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 or until directed by Anesthesiologist Nursing Orders ***(NOTE)***Order Blood Glucose POC if patient is on oral hypoglycemic agents or insulin Blood Glucose Monitor POC On arrival to PACU Notify Provider Routine, Notify Anesthesiologist if blood sugar LESS than 90 mg/dl or GREATER than 200 mg/dl Notify Provider Notify pacemaker-icd service to interrogate/restore device pacemaker and/or ICD function unless interrogation of Pacemaker-ICD deferred per manufacturer's recommendation Discontinue PACU Orders PACU staff to discontinue all Anesthesia Post Op Power Plan when patient leaves PACU PACU Discontinue IV Access When tolerating PO fluids. PACU Discontinue Arterial Line When blood pressure and pulmonary status are stable Release from PACU When PACU discharge criteria is met Medications GEN Correction Insulin (Sliding Scale)(SUB)* ***Reminder: Order GEN Correction Insulin (Sliding Scale) (SUB) on a separate form*** Analgesics ***(NOTE)***Reduce Toradol dose to 15 mg for patients over 65 years old or for estimated CrCl of 60 ml/minute. HOLD Toradol for patients with significant intra-op hemorrhage or who are at risk of post-op hemorrhage. ketorolac (PACU Toradol) 30 mg inj IV PUSH ONCE, PRN Pain Moderate/Severe, Duration: 6 hour, Clinical Instructions: Give ONCE only (DEF)* Comments: If patient is over 65 years old or has an estimated CrCl of 60 ml/minute or less, reduce the dose to 15 mg 15 mg inj IV PUSH ONCE, PRN Pain Moderate/Severe, Duration: 6 hour Page 1 of 7
2 acetaminophen (PACU Ofirmev) Available only at BMCB 1 g bottle IVPB ONCE, PRN Pain Moderate/Severe, Duration: 6 hour (DEF)* Comments: Weight based recommendation: For adults GREATER than or EQUAL to 50 kg administer 1 g IVPB 15 mg/kg bottle IVPB ONCE, PRN Pain Moderate/Severe, Duration: 6 hour Comments: Weight based recommendation: For adults LESS than 50 kg, give 15 mg/kg IVPB PACU fentanyl 12.5 mcg inj IV PUSH Q5MINS Int, PRN Pain Moderate/Severe, Duration: 6 hour (DEF)* Comments: Only if respirations are GREATER than or equal to 12 per minute. MAXIMUM of 125 mcg. If Fentanyl not effective after maximum dose, administer morphine if ordered or call Anesthesiologist 25 mcg inj IV PUSH Q5MINS Int, PRN Pain Moderate/Severe, Duration: 6 hour Comments: Only if respirations are GREATER than or equal to 12 per minute. MAXIMIUM of 250 mcg. If Fentanyl not effective after maximum dose, administer morphine if ordered or call Anesthesiologist 50 mcg inj IV PUSH Q5MINS Int, PRN Pain Moderate/Severe, Duration: 6 hour Comments: Only if respirations are GREATER than or equal to 12 per minute. MAXIMUM of 250 mcg. If Fentanyl not effective after maximum dose, administer morphine if ordered or call Anesthesiologist. PACU morphine 2 mg inj IV PUSH Q5MINS Int, PRN Pain Moderate/Severe, Duration: 6 hour (DEF)* Comments: Only if respirations are GREATER than or equal to 12 per minute. MAXIMUM of 20 mg. 1 mg inj IV PUSH Q5MINS Int, PRN Pain Moderate/Severe, Duration: 6 hour Comments: Only if respirations are GREATER than or equal to 12 per minute. MAXIMUM of 10 mg. 4 mg inj IV PUSH Q5MINS Int, PRN Pain Moderate/Severe, Duration: 6 hour Comments: Only if respirations are GREATER than or equal to 12 per minute. MAXIMUM of 20 mg. hydromorphone (PACU Dilaudid) 0.25 mg inj IV PUSH Q5MINS Int, PRN Pain Moderate/Severe, Duration: 6 hour (DEF)* Comments: Only if respirations are GREATER than or equal to 12 per minute. MAXIMUM 2 mg. 0.5 mg inj IV PUSH Q5MINS Int, PRN Pain Moderate/Severe, Duration: 6 hour Comments: Only if respirations are GREATER than or equal to 12 per minute. MAXIMUM 2 mg. 0.2 mg inj IV PUSH Q5MINS Int, PRN Pain Moderate/Severe, Duration: 6 hour Comments: Only if respirations are GREATER than or equal to 12 per minute. MAXIMUM 2 mg. meperidine (PACU Demerol) 6.25 mg inj IV PUSH Q5MINS Int, PRN Rigors, Duration: 6 hour (DEF)* Comments: May repeat 1 time to a MAXIMUM dose of 12.5 mg 12.5 mg inj IV PUSH Q5MINS Int, PRN Rigors, Duration: 6 hour Comments: May repeat 1 time to a MAXIMUM dose of 25 mg Antiemetics/Antacids metoclopramide (PACU Reglan) 10 mg inj IV Q15MINS Int, PRN Nausea/Vomiting, Duration: 6 hour (DEF)* 10 mg inj IV ONCE, PRN Nausea/Vomiting Page 2 of 7
3 ondansetron (PACU Zofran) 4 mg inj IV PUSH ONCE, PRN Nausea/Vomiting, Duration: 6 hour promethazine (PACU Phenergan) 6.25 mg inj IV PUSH Q15MINS Int, PRN Nausea/Vomiting, Duration: 6 hour (DEF)* Comments: If ineffective within 15 minutes, may give additional 6.25 mg IV. MAX dose is 12.5 mg. If the patient has an IV running, the promethazine (PHENERGAN) should be mixed in 10 ml of saline and administered slowly over at least 3 minutes at the port furthest away from the IV insertion site. If the patient does not have an IV running, the promethazine (PHENERGAN) 6.25 mg inj IV PUSH ONCE, PRN Nausea/Vomiting, Duration: 6 hour Comments: If the patient has an IV running, the promethazine (PHENERGAN) should be mixed in 10 ml of saline and administered slowly over at least 3 minutes at the port furthest away from the IV insertion site. If the patient does not have an IV running, the promethazine (PHENERGAN) 2.5 mg inj IV PUSH Q15MINS Int, PRN Nausea/Vomiting, Duration: 6 hour Comments: If ineffective within 15 minutes, may give additional 2.5 mg IV. MAX dose is 5 mg. If the patient has an IV running, the promethazine (PHENERGAN) should be mixed in 10 ml of saline and administered slowly over at least 3 minutes at the port furthest away from the IV insertion site. If the patient does not have an IV running, the promethazine (PHENERGAN). 2.5 mg inj IV PUSH ONCE, PRN Nausea/Vomiting, Duration: 6 hour Comments: If the patient has an IV running, the promethazine (PHENERGAN) should be mixed in 10 ml of saline and administered slowly over at least 3 minutes at the port furthest away from the IV insertion site. If the patient does not have an IV running, the promethazine (PHENERGAN) 12.5 mg inj IV PUSH Q15MINS Int, PRN Nausea/Vomiting, Duration: 6 hour Comments: If ineffective within 15 minutes, may give additional 12.5 mg IV. MAX dose is 25 mg. If the patient has an IV running, the promethazine (PHENERGAN) should be mixed in 10 ml of saline and administered slowly over at least 3 minutes at the port furthest away from the IV insertion site. If the patient does not have an IV running, the promethazine (PHENERGAN) 12.5 mg inj IV PUSH ONCE, PRN Nausea/Vomiting, Duration: 6 hour Comments: If the patient has an IV running, the promethazine (PHENERGAN) should be mixed in 10 ml of saline and administered slowly over at least 3 minutes at the port furthest away from the IV insertion site. If the patient does not have an IV running, the promethazine (PHENERGAN) droperidol (PACU Inapsine) mg inj IV PUSH Q15MINS Int, PRN Nausea/Vomiting, Duration: 6 hour (DEF)* Comments: If ineffective after 2 doses, notify physician mg inj IV PUSH ONCE, Nausea/Vomiting, Duration: 6 hour Page 3 of 7
4 Antihypertensives labetalol (PACU Trandate) 5 mg inj IV PUSH Q15MINS Int, PRN Blood Pressure, Duration: 6 hour (DEF)* pressure GREATER than 100 mmhg and heart rate GREATER than 60 beats per minute. HOLD for heart rate LESS than 60 beats per minute 5 mg inj IV PUSH Q15MINS Int, PRN Blood Pressure, Duration: 6 hour pressure GREATER than 90 mmhg and heart rate GREATER than 60 beats per minute. HOLD for heart rate LESS than 60 per minute pressure GREATER than 100 mmhg and heart rate GREATER than 60 beats per minute. HOLD for heart rate LESS than 60 beats per minute pressure GREATER than 90 mmhg and heart rate GREATER than 60 beats per minute. HOLD for heart rate LESS than 60 beats per minute enalapril (PACU Vasotec) 1.25 mg inj IV PUSH ONCE, PRN Blood Pressure, Duration: 6 hour (DEF)* pressure GREATER than 100 mmhg. If 1.25 mg inj IV PUSH ONCE, PRN Blood Pressure, Duration: 6 hour pressure GREATER than 90 mmhg. If hydralazine (PACU Apresoline) 5 mg inj IV PUSH Q15MINS Int, PRN Blood Pressure, Duration: 6 hour (DEF)* Comments: Up to a MAX dose of 20 mg total. For systolic blood pressure GREATER than 160 mmhg and/or diastolic blood pressure GREATER than 100 mmhg. HOLD for heart rate GREATER than 100 beats per minute. If 5 mg inj IV PUSH Q15MINS Int, PRN Blood Pressure, Duration: 6 hour pressure GREATER than 90 mmhg. HOLD for heart rate GREATER than 100 beats per minute.. If Comments: Up to a MAX dose of 20 mg total. For systolic blood pressure GREATER than 160 mmhg and/or diastolic blood pressure GREATER than 100 mmhg. HOLD for heart rate GREATER than 100 beats per minute. If pressure GREATER than 90 mmhg HOLD for heart rate GREATER than 100 beats per minute. If Page 4 of 7
5 metoprolol (PACU Lopressor) 2.5 mg inj IV PUSH ONCE, PRN Other (see comment), Duration: 6 hour (DEF)* pressure GREATER than 100 mmhg and heart rate GREATER than 60 beats per minute. If 2.5 mg inj IV PUSH ONCE, PRN Other (see comment), Duration: 6 hour pressure GREATER than 90 mmhg and heart rate GREATER than 60 beats per minute. If 5 mg inj IV PUSH ONCE, PRN Other (see comment), Duration: 6 hour pressure GREATER than 100 mmhg and heart rate GREATER than 60 beats per minute. If 5 mg inj IV PUSH ONCE, PRN Other (see comment), Duration: 6 hour pressure GREATER than 90 mmhg and heart rate GREATER than 60 beats per minute. If Anti-pruritics nalbuphine (PACU Nubain) 2.5 mg inj IV PUSH Q2H Int, PRN Itching, Duration: 6 hour (DEF)* Comments: If not effective after 2 doses, Administer Benadryl if ordered OR call physician 2.5 mg inj SUBCUT Q2H Int, PRN Itching, Duration: 6 hour Comments: If not effective after 2 doses, Administer Benadryl if ordered OR call physician 5 mg inj IV PUSH Q2H Int, PRN Itching, Duration: 6 hour Comments: If not effective after 2 doses, Administer Benadryl if ordered OR call physician diphenhydramine (PACU Benadryl) 12.5 mg inj IV PUSH ONCE, PRN Itching, Duration: 6 hour (DEF)* 6.25 mg inj IV PUSH ONCE, PRN Itching, Duration: 6 hour Antiarrhythmics esmolol (PACU Brevibloc) 10 mg inj IV PUSH Q15MINS Int, PRN Heartrate, Duration: 6 hour Comments: For heart rate GREATER than 100 beats per minute. HOLD for a heart rate LESS than 100 beats per minute. Do NOT administer more than 2 doses Respiratory Medications albuterol (PACU Proventil Neb 0.083%) 2.5 mg neb inh INHALE ONCE, PRN Shortness of Breath, Duration: 6 hour albuterol (PACU Proventil MDI) 2 puff INHALE aerosol ONCE, PRN Shortness of Breath, Duration: 6 hour albuterol-ipratropium (PACU DuoNeb) 3 ml INHALE neb inh ONCE, PRN Shortness of Breath, Duration: 6 hour Page 5 of 7
6 Reversal Agents naloxone (PACU Narcan) 0.1 mg inj IV PUSH ASDIR, PRN Other (see comment), Duration: 24 hour Comments: For Respiratory Rate LESS than 6, patient cyanotic or Sedation Scale of 5. Administer 0.4 mg IV, stimulate patient, start oxygen at 2 liters/min via nasal cannula and STOP epidural infusion. If patient unresponsive CALL CODE BLUE STAT and call Anesthesiologist.For Respiratory Rate between 7 and 10, or Sedation Scale GREATER than or EQUAL to 4, Administer 0.2 mg IV, stimulate patient, start oxygen at 2 liters/min via nasal cannula and STOP epidural infusion. If patient unresponsive CALL CODE BLUE STAT and call Anesthesiologist.For Respiratory rate between 11 and 12, Administer 0.1 mg IV, stimulate patient, start oxygen at 2 liters/min via nasal cannula and STOP epidural infusion (dilute 1 ampule in 4 ml Normal Saline for a final concentration of 1mg/mL). Laboratory Complete Blood Count Hematocrit and Hemoglobin Basic Metabolic Panel Potassium Level Glucose Level PTT PT INR Radiology PACU Chest Xray (Portable) Central line placement, Stat, Pending Discharge - No, ONCE, Patient in PACU (DEF)* Pulmonary artery catheter placement, Stat, Pending Discharge - No, ONCE, Patient in PACU Respiratory PACU ABG/VBG Notification Stat, On arrival to PACU (DEF)* Stat, With Profile, On arrival to PACU Arterial Blood Gas Stat, On arrival to PACU Venous Blood Gas Stat, On arrival to PACU Page 6 of 7
7 PACU O2 Therapy. Nasal Cannula, 2, liters per minute. Titrate to maintain oxygen saturation GREATER than 92% Pulse Oximetry (Continuous) Special Instructions: PACU, Stat Comments: Q8H sensor site must be inspected; IF circulatory condition or skin integrity has changed, the sensor should be applied to a different site. Endtidal CO2 Monitoring Stat, Continuous CPAP For OSA Precautions please Initiate ANES Obstructive Sleep Apnea (OSA) PowerPlan(NOTE)* Consult MD Pulmonology, Ventilator Management Page 7 of 7
WHS POSTOPERATIVE POWERPLAN CHANGES
Medications simplified and standardized to improve safety and effectiveness in the management of pain, itching, nausea/vomiting. Management: o The Anesthesiologist will continue to manage pain in the PACU.
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***
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
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
PEDIATRIC SPINE SURGERY POST-OP PLAN - Phase: Pediatric Spine Surgery General Orders
- Phase: Pediatric Spine Surgery General Orders PHYSICIAN S Diagnosis Weight Allergies Patient Care Patient Activity Bedrest Maintain Surgical Drain Maintain JP Drain, Measure Output q12h, and PRN Convert
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
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
(30689) PROT Pain PCA Adult Patient Controlled Analgesia
Diagnosis Allergies Nursing Assess and Document PCA: 1. Assess and document pain rating, sedation level and respiratory rate every 2 hours; assess and document pain rating, sedation level and respiratory
***SPECIAL CONSIDERATION:
ADULT ANESTHESIA POST-OP OUTPATIENT SURGERY PLAN Dx PHYSICIAN S Weight Allergies DETAILS Admit/Discharge/Transfer Return Patient to PACU Patient Care ***Patients who are at high risk for obstructive sleep
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
Available ONLY at: BMC-B BMC-D BMC-N BMC-S Intubation Phase Notify Therapy for STAT intubation SUB Rapid Sequence Induction(SUB)* ***The above subphase is available at the end of the powerplan under the
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 Intubation Phase Notify Therapy for STAT intubation Medications SUB Rapid Sequence Induction (SUB)* ***Reminder: Order SUB Rapid Sequence Induction (SUB) on a separate form*** lidocaine
Gabapentin Research Pain Study for Ortho Total Knee Replacement Post-Op Plan - PACU Ortho Phase
Total Knee Replacement Post-Op Plan - PACU Ortho Phase Diagnosis Weight Allergies Admit/Discharge/Transfer Patient Status Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights) Patient Condition
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
ORTHO TOTAL KNEE REPLACEMENT POST-OP PLAN - Phase: PACU Ortho Phase
- Phase: PACU Ortho Phase PHYSICIAN S Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Patient Condition Acuity Level Floor Status Acuity Level Critical Acuity Level Intermediate
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 Orders ADULT: ANES Enhanced Recovery After Surgery (ERAS) Plan
Initiate Orders Phase Non Categorized R Powerplan Open Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: Anes (ERAS) Pre-insertion Phase, When to Initiate: Other-See Special Instructions,
DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available ONLY at: BMC-B BMC-D BMC-N BMC-S Pre-Op Nursing Orders Communication Order Confirm patient has brought corresponding films for surgery (e.g. back films for back surgery, brain
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available at: BMC-B BMC-D BMC-N BMC-S Condition/Status Patient Status Inpatient Patient Status: Inpatient, Level of Care: Med/Surg without Telemetry (1) (DEF)* Patient Status: Inpatient,
INPATIENT INTERVENTIONAL RADIOLOGY PLAN - Phase: Pre-Procedure Orders
- Phase: Pre-Procedure Orders DETAILS Patient Care Obtain Consent If one is not present on chart today. Vital Signs Per Policy Insert Peripheral Line T;N, Start IV on right side If left radial access is
DRUG ALLERGIES WT: KG
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
PICU ADMIT DKA PLAN - Phase: Begin Immediately
- Phase: Begin Immediately Diagnosis Weight Allergies Admit/Discharge/Transfer Patient Status Requested Location: PICU, Pt Status: Inpatient (LOS > 2 midnights) Requested Location: PICU, Pt Status: Observation
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
Available at: BMC-A BMC-B BMC-C BMC-D BMC-N BMC-S BMC-T BMC-W PACE Nursing Orders Patient Education Instruct patient to bring corresponding films to surgery (e.g. back films for back surgery, brain films
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.
THROMBOLYTIC THERAPY FOR PERIPHERAL OCCLUSION
THROMBOLYTIC THERAPY FOR PERIPHERAL OCCLUSION PHYSICIAN S Diagnosis Weight Allergies Admit/Discharge/Transfer ***PROVIDER MUST CHECK MEDICATION LIST PRIOR TO PLACING THESE S*** Patient Care Vital Signs
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
Bariatric Surgery Post Op Day Version 2 Approved 11/13/2017
Patient Name: Diagnosis: Allergies with reaction type: Bariatric Surgery Post Op Day Version 2 Approved 11/13/2017 Diagnosis Preferred Location/Unit Surgical ICU Code Status: Full Code Activity Ambulate
Emergency Department Chest Pain, Suspected Cardiac Adult Order Set
Form Title Form Number Chest Pain, Suspected Cardiac Adult Order Set 20746 2018, Alberta Health Services, CKCM This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT PACE Vital Signs Vital Signs PRE-OP, On arrival Nursing Orders Initiate ANES Anesthesia PACE PowerPlan Weigh Patient PRE-OP Pre op. Provide patient with incentive spirometry teaching
PHYSICIAN SIGNATURE DATE TIME
DRUG AND TREATMENT Condition/Status Patient Status (WCH) Patient Status: Inpatient Update Resident Team C (DEF)* A B X Vital Signs Vital Signs Q4H, Do not wake for vitals 2300-0700 (DEF)* DAILY Q4H Blood
morphine 30 mg/ 30 ml (1 mg/ml) Opioid of choice
PATIENT CONTROLLED ANALGESIA (PCA) PLAN Allergies: Medication Selection: morphine 30 mg/ 30 ml (1 mg/ml) Opioid of choice HYDROmorphone (Dilaudid ) 6 mg/ 30 ml (0.2 mg/ml) fentanyl 300 mcg/ 30 ml (10 mcg/ml)
IV Acetaminophen Pain Study for Neurosurgery Post Op Non ICU Admit Plan Begin Immediately/PACU
Post Op Non ICU Admit Plan Begin Immediately/PACU PHYSICIAN S Weight Allergies Admit/Discharge/Transfer Request Patient Bed Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights) Patient Condition
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available at: BMC-B BMC-D BMC-N BMC-S PACE Vital Signs Vital Signs PRE-OP, On arrival Nursing Orders Initiate ANES Anesthesia PACE PowerPlan Weigh Patient PRE-OP Pre op. Provide patient
Physician Orders PEDIATRIC: LEB Critical Care Respiratory Plan
LEB Critical Care Respiratory Plan Patient Care Cardiopulmonary Monitor T;N Routine, Monitor Type: End Tidal Co2 (DEF)* T;N Routine, Monitor Type: Transcutaneous Co2 Respiratory Care Initiate Pediatric
DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available at ALL facilities Condition/Status Place in Outpatient to a Bed Status Requested Location: PCU H3S (DEF)* Requested Location: CCU - Heart Hospital Requested Location: Heart
DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available ONLY at: BMC-B BMC-D BMC-N BMC-S Non Categorized Quality Measure Sepsis Bundle Admit to Inpatient Patient Status: Inpatient, Level of Care: Intensive Care (8), Diagnosis: Please
LIFEGIFT BRAIN DEATH PLAN
Diagnosis Weight Allergies Admit/Discharge/Transfer ***THIS PLAN IS TO BE ED ONLY ON THE LIFEGIFT ENCOUNTER, WITH DR LIFEGIFT AS THE ATTENDING*** Patient Status Pt Status: Inpatient (Inpatient only procedure)
Gabapentin Research Pain Study for Ortho Total Knee Replacement Post Op Plan PACU Ortho Phase
Total Knee Replacement Post Op Plan PACU Ortho Phase PHYSICIAN S Weight Allergies DETAILS Admit/Discharge/Transfer Request Patient Bed Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights),
Sample. Affix patient label within this box.
Instructions for completing orders: Determine PRAM Clinical Score as per the Alberta Acute Childhood Asthma Pathway for Emergent/Urgent Care and select orders based on PRAM Score. Custom orders can be
Physician Orders ADULT: Kidney-Panc/PancTransplant Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase T;N, Phase: Kidney-Panc/Panc Transp Post Op Phase, When to Initiate: Kidney-Panc/Panc Transp Post Op Phase Vital Signs Vital
BARIATRIC SURGERY POST-OP PLAN - Phase: PACU Phase
- Phase: PACU Phase Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Pt Status: Inpatient (Inpatient
ADMIT STROKE NEUROINTERVENTION PLAN - Phase: Begin Immediately
- Phase: Begin Immediately PHYSICIAN S Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Pt
Physician Orders PEDIATRIC: LEB Oral Maxillofacial Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: LEB Oral Maxillofacial Postop Phase, When to Initiate: LEB Oral Maxillofacial Post Op Phase Admission/Transfer/Discharge
GENERAL SURGERY POST-OP PLAN
GENERAL SURGERY POST-OP PLAN PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest Bedrest Bathroom
PEDIATRIC LIFEGIFT BRAIN DEATH PLAN
PHYSICIAN S Diagnosis Weight Allergies Admit/Discharge/Transfer THIS PLAN IS TO BE ED ONLY ON THE LIFEGIFT ENCOUNTER, WITH DR LIFEGIFT AS THE ATTENDING. Patient Status Pt Status: Inpatient (Inpatient only
1. Attending Physician: Dr Syn Pager: Cell: Co-Morbidities:
BARIATRIC SURGERY IMMEDIATE POST-OP PLAN (Includes Post Op Day 1) Denotes order requirement Antibiotic administered in the OR at: 1. Attending Physician: Dr Syn Pager: 740-6545 Cell: 438-9415 2. To remain
* * FORM REV. 02/2019 Page 1 of 4. TNKASE (tenecteplase) / ACUTE STEMI ORDERS SCHEDULED MEDICATIONS:
1. Is this a CMS inpatient only procedure? Yes, admit as inpatient, proceed to # 3 No, proceed to # 2 2. Do you expect that the patient s condition will require a hospital stay that will cross two midnights
(Page 1 of 5) Diagnosis: Procedure: Right Total Knee Replacement Unicompartmental Knee Left Total Hip Revision Total Shoulder
(Page 1 of 5) Allergies/Sensitivities/Reactions: Height: Inches cm Weight: Kg Pounds = Automatic = Physician s option, Check off to Order Diagnosis: Procedure: Right Total Knee Replacement Unicompartmental
DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Acute Diabetic Ketoacidosis Condition/Status ***(NOTE)*** For purpose of this DKA Regimen, DKA is considered clear only when the CO2 is GREATER than 18 meq/l and the anion gap is LESS
POST-OP CARDIAC SURGERY PHYSICIAN S ORDER SHEET USE BALLPOINT PEN ONLY. CARDIAC INTENSIVE CARE UNIT
PHYSICIAN S SHEET Automatically Activate, if not in agreement, cross out and initial Activated by Checking Box ALLERGIES: None known YES Patient s Height: Patient s Weight: ALL MEDICATION and INTRAVENOUS
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available ONLY at: BMC-B BMC-D BMC-N BMC-S PACE Nursing Orders ***NOTE*** Select the "Transfuse Blood Previously on Hold" order below, to transfuse blood on hold. Transfuse Blood Previously
DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available ONLY at: BMC-B BMC-D BMC-N BMC-S NEURO Intracranial Hemorrhage (Factor VII) Condition/Status Patient Status Inpatient Patient Status: Inpatient, Level of Care: Intensive Care
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
EPIDURAL / INTRATHECAL POST-OP PLAN
EPIDURAL / INTRATHECAL POST-OP PLAN Diagnosis Weight PHYSICIAN S Allergies Patient Care Vital Signs Per Unit Standards, PLUS check and record RR q1h x 12, then q2h x 6, until 24h following narcotic administration.
Physician Orders ADULT: LEB Asthma Admit Plan. Anticipated LOS: 2 midnights or more Patient Status Initial Outpatient T;N Attending Physician:
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase, Phase: LEB Asthma Admit Phase, When to Initiate: LEB Asthma Admit Phase Non Categorized Add To Problem List Problem: Asthma
NEUROSURGERY ICU PLAN
NEUROSURGERY ICU PLAN PHYSICIAN S Diagnosis Weight Allergies DETAILS Patient Care Vital Signs Per Unit Standards Per Unit Standards, including cerebral perfusion pressure (CPP) and end tidal CO2. Perform
Pediatric Outpatient Surgery Plan - Diagnostic/Pre-Op Orders
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
Orthopedic Admission Hip Fracture Version 2 1/25/2017
Patient Name: Initial each page and Sign/Date/Time last page Diagnosis: Allergies with reaction type: Orthopedic Admission Hip Fracture Version 2 1/25/2017 Patient Placement Patient Status If the physician
OPEN AAA/MAJOR ABDOMINAL POST-OP PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Maintain Gastric Tube Maintain Nasogastric - NG, Low Intermittent Suction Maintain Nasogastric - NG, Low Constant
IDPH ESF-8 Plan: Pediatric and Neonatal Surge Annex Sample Pediatric Admission Orders 2015
Purpose: To provide guidance to practitioners caring for pediatric patients who need inpatient hospital care during a disaster. Disclaimer: This guideline is not meant to be all inclusive, replace an existing
Reducing the risk of patient harm: A focus on opioids
Reducing the risk of patient harm: A focus on opioids New York State Partnership for Patients (NYSPFP) Initiative Regional Educational Session November 2013 1 Disclosure Matthew Fricker, Matthew Grissinger,
PICU BRONCHIOLITIS PLAN
PICU BRONCHIOLITIS PLAN Diagnosis Weight PHYSICIAN S Allergies Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Patient Care Code
PEDIATRIC CYSTIC FIBROSIS PLAN - Phase:.
PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Per Unit Standards, with Sleeping SpO2 nightly until sat greater than 92% Daily Weight Every AM In AM on Monday, Wednesday,
Bariatric Surgery Post Op Plan PACU Phase
Bariatric Surgery Post Op Plan PACU Phase PHYSICIAN S Weight Allergies Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Code Status
UMC Health System Patient Label Here. PHYSICIAN ORDERS Diagnosis
COPD PLAN UMC Health System PHYSICIAN S Diagnosis Weight Allergies DETAILS Patient Care Vital Signs Per Unit Standards Daily Weight Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest
Physician Orders Pediatric: LEB ED Asthma Plan
LEB ED Triage Standing SOB/Wheeze Asthma Non Categorized Criteria: Patients greater than 2 years of age with a history of asthma or airway active disease or two or more previous illnesses treated with
PHYSICIAN ORDERS Diagnosis
PICU PROCEDURE PLAN PHYSICIAN S Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Patient Care
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 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
OB/GYN CESAREAN SECTION POST-OP PLAN - Phase: General Orders
- Phase: General Orders DETAILS Patient Care Vital Signs Per Unit Standards Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest Bedrest Bathroom Privileges Bedrest Up to Bedside Commode
Therapeutic Hypothermia for Post Cardiac Arrest Plan Initial Orders
Arrest Plan Initial Orders Weight Allergies Therapeutic Hypothermia Guidelines ***Required to continue with ordering Plan.*** Strict Intake and Output q1h, throughout cooling and re warming. Set Up for
UMC Health System Patient Label Here. PHYSICIAN ORDERS Diagnosis
PICU GENERAL PLAN UMC Health System PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Daily Weight Patient Activity Bedrest Up Ad Lib/Activity as Tolerated Strict Intake
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Pre-Procedure Diet NPO NPO except for meds with sip of water, Give all medications as scheduled except diabetic medications. Nursing Orders Start IV/INT Start IV/INT To use as a dedicated
Physician Orders ADULT: Vascular Surgery AAA Endovascular Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: AAA Endovascular PACU Phase, When to Initiate: Initiate Powerplan Phase Phase: Mechanically Ventilated Patients Phase,
Neurosurgery Pre-Op [1710] Patient Name MRN. General. Nursing. Case Request [ ] Case request operating room Scheduling/ADT, Scheduling/ADT [ ] Other
![Neurosurgery Pre-Op [1710] Patient Name MRN. General. Nursing. Case Request [ ] Case request operating room Scheduling/ADT, Scheduling/ADT [ ] Other](/thumbs/96/128298591.jpg "Neurosurgery Pre-Op [1710] Patient Name MRN. General. Nursing. Case Request [ ] Case request operating room Scheduling/ADT, Scheduling/ADT [ ] Other")
Neurosurgery Pre-Op [1710] Patient Name MRN General Case Request [ ] Case request operating room Scheduling/ADT, Scheduling/ADT Inpatient Only Procedure (Single Response) ( ) Admit to Inpatient Diagnosis:
DOWNTIME Physician Order CARD CHF Heart Failure
DOWNTIME Physician Clinical Category ADT/Comm unication Patient Status ASC Extended Recovery Observation Services Inpatient Admission CCU Admit as Inpatient History and Physical by House Physician Vital
ADMIT DIABETIC KETOACIDOSIS (DKA) PLAN - Phase: Begin Immediately/Emergency Center
- Phase: Begin Immediately/Emergency Center Weight PHYSICIAN S Allergies Admit/Discharge/Transfer Patient Status Requested Location: MICU, Pt Status: Inpatient (LOS > 2 midnights) Requested Location: 5E
PHYSICIAN ORDER SET : Patient: DOB: Gender: Patient Phone #: Height: Weight:
. (Patient Sticker) CDH 208-203 Approved 2/18 - Page 1 of 5 Patient: DOB: Gender: Patient Phone #: Height: Weight: Diagnosis: ICD-10 Code: Treatment Start Date: Provider Facility Name: Ordering Provider:
Physician Orders ADULT: Vascular Surgery AAA Repair Open Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: AAA Repair Open Postop Phase, When to Initiate: Initiate Powerplan Phase Phase: Mechanically Ventilated Patients Phase,
Physician s Order Form. Physician s Order Form. Telemetry/Progressive Care Orders. Continued on next page. >>>>>>> Continued on next page.
DATE: TIME: DATE TIME INTRAVENOS FLID and MEDICATION Status: Admit to Telemetry Admit to Progressive Care nit Transfer to Progressive Care nit Note: Discontinue Previous Orders Transfer to Telemetry nit
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Condition/Status Patient Status Inpatient Patient Status: Inpatient, Level of Care: Intensive Care (8) Place in Observation Patient Status: Outpatient- Refer for Observation Status,
UMC Health System Patient Label Here. PHYSICIAN ORDERS Diagnosis
Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards q12h q12h, Temperature Only - Every Shift and PRN Patient Activity Assist as Needed, Bed Position: As Tolerated, elevate to patient
TRANSCATHETER AORTIC VALVE REPLACEMENT POST- OP PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies DETAILS Patient Care Vital Signs Per Unit Standards, q15min x 4, q30min x 2, then q1h x 4 until sheath discontinued. Per Unit Standards Perform Neurovascular
Hip Hemiarthroplasty Post Op Version 2 4/20/17
Patient Name: Diagnosis: Allergies with reaction type: Hip Hemiarthroplasty Post Op Version 2 4/20/17 Patient Placement General Diagnosis/Procedure: Preferred Location/Unit Ortho/Neuro PCU ICU General
Physician Orders ADULT Order Set: Respiratory Failure Orders
[R] = will be ordered Height: cm Weight: kg Allergies: [ ] No known allergies [ ]Medication allergy(s): [ ] Latex allergy [ ]Other: Admission/Transfer/Discharge [ ] Patient Status Initial Inpatient Attending
Diagnosis: Allergies:
Patient Name: Diagnosis: Allergies: ICU Sepsis Version 5 1/11/17 This order set must be used with an admission order set if patient not already admitted. Nursing Orders Verify that cultures have been obtained
Physician Orders ADULT: Asthma and Bronchitis Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase, Phase: Asthma and Bronchitis Phase, When to Initiate: Asthma and Bronchitis Phase Non Categorized Problem: Asthma Problem:
Physician Orders PEDIATRIC: : LEB ED Trauma (Major) Plan
LEB ED Standing Orders Trauma (Major) Ph Non Categorized Criteria: Patients between 0-18 years of age that present with a Major Trauma that meet LeBonheur Trauma stat or Trauma Alert Guidelines.(NOTE)*
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
STROKE NEUROINTERVENTION PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Notify Nurse (DO NOT USE FOR MEDS) Right Lower Extremity-Check peripheral pulse distal to the cath site. If
Initials * Page 1 of 6. (place patient label here) Patient Name: Diagnosis: Allergies with reaction type:
Patient Name: Diagnosis: Allergies with reaction type: Orthopedic Upper Ext Post Op Version 3 4/20/17 Patient Placement General Diagnosis/Procedure: Preferred Location/Unit Ortho/Neuro General Medical
ADMIT GENERAL MEDICINE PLAN - Phase: Begin Immediately
- Phase: Begin Immediately Weight PHYSICIAN S Allergies Admit/Discharge/Transfer Patient Status Patient Condition Acuity Level Floor Status Acuity Level Critical Acuity Level Intermediate Continuous Telemetry
I.D. Number: To provide effective safe pain management using epidural/intrathecal route.
Policies and Procedures Title: EPIDUAL/INTATHECAL ANALGESIA CAE OF PATIENTS ECEIVING I.D. Number: 1047 Authorization: [X] SH Nursing Practice Committee Source: Nursing Date evised: Sept 2012 Date Effective:
Sample. Affix patient label within this box.
Instructions for completing orders Complete pages 1-3 for General Inpatient Orders. All pathway compatible orders (indicated by ) within the General Inpatient Orders will be followed automatically. Optional
Emergency Department Protocol Initiative
Emergency Department Protocol Initiative ACUTE ASTHMA MANAGEMENT TOOLKIT March 2006 Provincial Emergency Services Project PHYSICIAN ORDER TEMPLATE FOR CTAS LEVEL 1 ASTHMA ADULT PEDIATRIC Date: Site: Arrival
UMC Health System Patient Label Here PHYSICIAN ORDERS
Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards q12h q12h, Temperature Only - Every Shift and PRN Patient Activity Assist as Needed, Bed Position: As Tolerated, elevate to patient
Physician Orders ADULT: Head and Neck Postoperative Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase, Phase: Head and Neck Postoperative Phase, When to Initiate: Head and Neck Post Operative Phase, Monitor and Record T,P,R,BP,
Standard Precautions Droplet Precautions Standard Precautions Contact Precautions Droplet Precautions Standard Precautions Neutropenic Precautions
Unique Plan Description: Neurosurgery Subarachnoid Hemorrhage Admission Adult Plan Selection Display: Neurosurgery Subarachnoid Hemorrhage Admission Adult PlanType: Medical Version: 10 Begin Effective
TRANSCATHETER AORTIC VALVE REPLACEMENT POST- OP ADMIT PLAN - Phase: Begin Immediately/PACU Phase
- Phase: Begin Immediately/PACU Phase PHYSICIAN S Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Requested Location: CICU Patient Condition Acuity Level Critical Acuity Level
PHYSICIAN PROCEDURAL SEDATION AND ANALGESIA QUIZ
PHYSICIAN PROCEDURAL SEDATION AND ANALGESIA QUIZ 1. Which of the following statements are TRUE? (Select ALL that apply) o Sedative/analgesic drugs should be given in small, incremental doses that are titrated
RITUXIMAB RHEUMATOLOGY VASCULITIS
. PHYSICIAN (Patient Sticker) ORDER SET : CDH 208-237 Approved - Page 1 of 5 Patient: DOB: Gender: Patient Phone #: Height: Weight: Diagnosis: ICD-10 Code: Treatment Start Date: Provider Facility Name: