(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 Knee Left Total Hip Revision Total Shoulder Admit to Physician: Date/Time Notified: Level of Care: Center for Joint Replacement Unit General Practice Unit Critical Care Unit Telemetry, Reason: Code Status: Full Code DNAR - See DNAR Form Consult and Participate: For Medical Management, Use Consultation Order Form Physical Therapy to evaluate and treat. Begin on post operative day one (1). Occupational Therapy to evaluate and treat. Begin on post operative day one (1). Other: 1. Medications Antibiotics (Check One Antibiotic Only) Cefazolin (Kefzol) IVPB every eight (8) hours times two (2) doses. Give the first dose in PACU. One (1) gm if patient weighs less than 80kg Two (2) gms if patient weighs more than 80kg Clindamycin 600 mg IVPB every six (6) hours times two (2) doses if history of β-lactam allergy. Start six (6) hours after pre-operative dose. Vancomycin IVPB, one (1) dose twelve (12) hours after pre-operative dose if history of β-lactam allergy or known colonization with MRSA. One (1) gm if patient weighs less than 100kg One and half (1.5) gms if patient weighs more than 100kg Anti-Emetics Ondanestron (Zofran) four (4) mg IV every six (6) hours as needed for Nausea/Vomiting Prochlorperazine (Compazine) ten (10) mg IV every six (6) hours as needed for Nausea/Vomiting Other: YES FM was faxed or copy was tubed to Pharmacy Date: / / Time: Initials: CHART TAB: PHYSICIAN DERS
(Page 2 of 5) 1. Medications Continued... Comfort/Pain Management Medications PCA pump (See PCA order sheet). Discontinue: Morning of post-op day. Other: Anesthesia to manage epidural pain control Choose One (1) of the following: IV Dextrose five (5) percent/0.45 normal saline: ml, infuse at ml/hr. IV Normal saline 0.90 percent: ml, infuse at ml/hr. Saline lock IV when PCA discontinued and last dose of IVPB antibiotics given and tolerating oral diet. Other: When PCA pump discontinued begin: F SEVERE PAIN Morphine two (2) mg IVP every two (2) hours as needed for severe breakthrough pain mg every hours as needed for severe breakthrough pain or if patient cannot tolerate oral pain medications. Hydromorphone (Dilaudid) mg IVP every hours as needed for severe breakthrough pain or if patient cannot tolerate oral pain medications. Oxycodone (Oxycontin) 20 mg orally every 12 hours around the clock for severe pain. Oxycodone (Oxycontin) 10 mg orally every 12 hours around the clock for severe pain. Ketorolac (Toradol) IVP every six (6) hours as needed for severe pain. Choose one dose 15 mg if 65 years of age or older, less than 50 kg, or renal insufficiency. 30 mg F MODERATE PAIN (Choose one) Hydrocodone 7.5 mg/acetaminophen 500 mg (Lortab 7.5/500) orally tablet every hours as needed for moderate pain.* Oxycodone 5 mg/acetaminophen 325mg (Percocet 5/325) orally tablet every hours as needed for moderate pain.* F MILD PAIN Acetaminophen 325 mg/codeine 30 mg (Tylenol #3) orally tablet every hours as needed for mild pain.* Acetaminophen (Tylenol) 650 mg orally as needed every four (4) hours for temperature over 101.5 or headache pain.* *WARNING: No more than four (4) grams of Acetaminophen per 24 hours from all sources or two (2) grams of Acetaminophen per 24 hours from all sources in chronic liver disease. Elimination Bowel Protocol YES FM was faxed or copy was tubed to Pharmacy Date: / / Time: Initials: CHART TAB: PHYSICIAN DERS
(Page 3 of 5) 1. Medications Continued... Sleep Zolpidem (Ambien) five (5) mg orally at bed time if needed for sleep Other: Deep Vein Thrombosis Prophylaxis as per risk assessment (Complete risk assessment sheet) Warfarin (Coumadin) five (5) mg orally the evening of surgery. Physician to dose Warfarin (Coumadin) Pharmacy to dose Warfarin (Coumadin) Enoxaparin (Lovenox) 30 mg Subcutaneously twice a day or 40 mg Subcutaneously daily. Begin post operative day one (1). Knee: Lovenox 30 mg Subcutaneously twice daily for 14 days from date of surgery. Hip: Lovenox 40 mg Subcutaneously every day for 21 days from date of surgery. On day of epidural catheter removal, hold dose of Enoxaparin (Lovenox) for a minimum of two (2) hours after catheter discontinued by anesthesiology. Instruct patient regarding self-administration of Enoxaparin (Lovenox). 2. Activity Chair sitting to tolerance. Post operative day number one (1). Bathroom with walker and assistance post operative day one (1). Activity as tolerated TOE-TOUCH, 25%, 50%, 75%, 100% weight bearing Continuous Passive Motion exerciser during the day. Start in Recovery Room Hip Precautions: Circle: Right or Left extremity pertaining to following orders. Do not internally rotate Do not externally rotate. Do not flex greater than 90 degree. Do not adduct. Abduction pillow (may use regular pillow) day of surgery, then during sleep only. Abduction pillow at all times when in bed. Discontinue after ambulating. Set up overhead bar with trapeze. Elevated toilet seat in bathroom. Compression boots bilateral while in bed. YES FM was faxed or copy was tubed to Pharmacy Date: / / Time: Initials: CHART TAB: PHYSICIAN DERS
(Page 4 of 5) 2. Activity contiued... Knee High TEDS / Thigh High TEDS: Bilateral ACE Wraps: Right / Left / Bilateral Elevate surgical leg. Keep heel off bed. Keep knee straight. Pillow not to be above mid calf or directly under knee. Non weight bearing to Right upper extremity Left upper extremity Maintain sling to Right upper extremity Left upper extremity 3. SURGICAL SITE CARE Check dressing status every four (4) hours, reinforce as needed After initial dressing change, nurse to change as needed Ice to incision twenty minutes out of every hour Ice to incision continuously Other: 4. Nutritional Needs Culinary Options from Room Service: Clear liquid initially, advance as tolerated Regular Heart Healthy Consistent Carbohydrate Mechanical Soft 5. Monitoring Post-operative vital signs with pulse oximetry reading every 15 minutes times four (4), then every 30 minutes times (2), then every four (4) hours. Notify Physician if: Systolic Blood Pressure greater than 180 or less than 90, Diastolic greater than 100 or less than 60, Pulse Oximetry less than 92% Neuro-vascular checks every one (1) hour times (4), then every four (4) hours times 24 hours, then every shift. Jackson Pratt drain Hemovac Drain, monitor and record drainage every shift. Notify surgeon if drainage is greater than ml. Intake and Output every four (4) hours times 24 hours, then every shift. Notify Physician if urine output less than 30 ml per hour if foley present or 120 ml in four (4) hours, notify Physician if less than 240 ml in eight (8) hours when no foley present. Assess for other: 6. Labs CBC Post Operative day one (1), Post Operative day two (2), Electrolytes Post Operative day one (1), Post Operative day two (2), YES FM was faxed or copy was tubed to Pharmacy Date: / / Time: Initials: CHART TAB: PHYSICIAN DERS
(Page 5 of 5) 6. Labs continued... BUN Post Operative day one (1), Post Operative day two (2), Creatinine Post Operative day one (1), Post Operative day two (2), Glucose Post Operative day one (1), Post Operative day two (2), Daily PT/INR while on Warfarin (Coumadin) 7. Medical Imaging XRAY two (2) VIEWS (AP/LATERAL) OF HIP KNEE Circle one: (Right or Left) reason: Prosthesis Placement Do in Recovery Room Done in Recovery Room 8. Ancillary Orders If Foley present, remove in the morning. If unable to void, perform bladder scan and straight cath for volume greater than 300ml every six (6) hours. Spirometer 10 times every one (1) hour while awake. Oxygen at liters per nasal cannula until fully reactive, wean off oxygen when room air oxygen saturation is greater than 92 percent. Peripheral blood glucose before meals and at bed time. See sliding Insulin scale orders. 9. CASE MANAGEMENT TO FOLLOW YES FM was faxed or copy was tubed to Pharmacy Date: / / Time: Initials: CHART TAB: PHYSICIAN DERS