Microsoft word - incavo - tha_tka orders 11-2009.doc

When printing this form make sure the following selections are indicated: - Under "Page Scaling" select "None" - Under "Print What" select "Document" Initial Bed Type: Place in Observation Admit to Inpatient Non-monitored bed Principal Diagnosis: Medications may be stopped based on the current Medical Staff Bylaws automatic stop order policy. A therapeutic equivalent drug approved by Pharmacy and Therapeutics Committee may be dispensed in accordance with the Medical Staff Bylaws.
PHYSICIANS ORDERS Page 1 of 3 PHYSICIAN'S PRE-PRINTED ORDERS: TOTAL KNEE / HIP REPLACEMENT
Admit to Floor. Orthopedics: Place results of LABS, CXR, and EKG, done as outpatient, and H&P # on chart. ‰ Total Hip Arthroplasty ‰ Hip Resurfacing vs. Total Hip Arthroplasty ‰ Primary ‰ Revision ‰ Total Knee Arthroplasty ‰ Partial vs. Total Knee Arthroplasty PREP
; With clippers or depilatory, remove hair on operative extremity.
; Apply thigh-high TED hose to non-operative extremity. Place unused TED hose to chart.
; T&C _ Units PRBC
IV THERAPY: Start IV (above the wrist/hand and below the anticubital). Start IV of 1000 mL NS at 100 mL/hr.
‰ Cefazolin (Kefzol®) 1 Gm IVPB within 60 minutes of incision (Recommended if patient 80kg or less)
‰ Cefazolin (Kefzol®) 2 Gm IVPB within 60 minutes of incision (Recommended if patient greater than 80kg)
‰ If allergic to PCN or Cephalosporin: Clindamycin (Cleocin®) 900mg IVPB within 60 minutes prior to incision.
‰ Vancomycin (Vancocin®) 1 Gm IVPB x1 dose within 2 hours prior to incision. Reason for Vancomycin administration (must select).
‰ ȕ-lactam (Penicillin or Cephalosporin) allergy. ‰ Known colonization with MRSA. ‰ Increased MRSA rate facility-wide or operation-specific. ‰ Chronic wound care or dialysis. ‰ Continuous inpatient stay > 24 hours prior to procedure. ‰ Patient high-risk due to nursing home or extended care facility setting within the last year prior to admission. ‰ Patient transferred from another inpatient hospitalization after a 3-day stay. ‰ Other Physician/APN/PA/Pharmacist documented reason: _. ‰ Cefepime (Maxipime®) 1 Gm IVPB within 2 hours prior to incision Indiciation: ‰ Known ‰ Suspected colonization / infection
PRE-OPERATIVE MEDICATIONS (at patient check-in)
; Acetaminophen (Tylenol®) 500mg orally x1 dose
; Famotidine (Pepcid®) 20mg orally x1 dose.
; Hydroxyzine (Atarax®)
; Scopolamine Patch 1.5mg applied to mastoid area if age less than 65 years
; Celecoxib (Celebrex®) 400mg orally x1 dose. Do not give if Sulfa allergy / Renal Disease.
; Oxycodone SR 10mg orally x1 dose if age less than 70 years
Physician's Signature Physician's ID (Dictation) Number Page 2 of 3 PHYSICIAN'S PRE-PRINTED ORDERS: TOTAL KNEE / HIP REPLACEMENT
IN OR BY ANESTHESIA
; Onadestron (Zofran®) 4mg IV x1 dose
; Dexamethasone (Decadron®) 4mg IV x1 dose post-APMS. Do not give if Diabetic.
; Ephedrine ‰ 25mg ‰ 50mg IM x1 dose post procedure
; Preservative-Free Morphine Spinal ; Fentanyl ‰ 10 ‰ 20mcg IV every 2 minutes up to 300mcg PRN pain.
; Nalbuphine (Nubain®) 205mg IV every 6 hours PRN pruritus
; Prochlorperazine (Compazine®) 2.5mg IV every 4 hours PRN nausea
; Promethazine (Phenergan®) ‰ 6.25mg ‰ 12.5mg IV every 4 hours PRN nausea only if patient is allergic/sensitive to Compazine®.
For peripheral administration, dilute dose in 10mL 0.9% NaCl and give slowly, over at least 2 minutes. ; May start PCA in PACU if PCA is ordered. See PCA Physician Order Form OR APMS Order Form.
; X-Ray Operative Limb(s) in PACU: Hips Æ AP Film only; Knees Æ AP/Lateral
; IV: Uni joints: 1000 mL LR over 30 minutes before transfer to floor; Bilat. joints: 2000 mL LR over 1 hour before transfer to floor
ADMIT to ‰ Ortho Floor
‰ ICU Orthopedics: Dr. S/P ‰ Right ‰ Left _ ‰ Fair ‰ Critical NOTIFTY Dr. of patient's location for consult ‰ in recovery ‰ on arrival to floor.
Every 15 min x4, then every 30 min x4, then every 1 hour x4, then every 4 hours x24 hours, then every 8 hours if stable. Include Pulse Oximeter x24 hours and while on PCA. Titrate Nasal Cannula oxygen to maintain SaO2 at 90% IV THERAPY: Unilateral joints: Complete IV from OR, then start IV of 1000 mL LR at 250 mL/hr on arrival to floor then 75 mL/hr
Bilateral joints: Complete IV from OR, then start IV of 2000 mL LR at 250 mL/hr on arrival to floor then 75 mL/hr KVO when tolerating fluids. Discontinue IV 24 hours after antibiotics/PCA discontinued ; CBC Hemogram POD #1 AM ; CBC Hemogram POD #2 AM ; OOB with assistance ; Up to chair for all meals as tolerated ; Foley catheter to BSD (if in place). D/C POD #1 by mid-morning. IF unable to void, insert Foley and leave in place x24. ; Hemovac to suction. Discontinue POD #2.
; Incentive Spirometry x10 every 1 hour while awake. Respiratory Therapy to instruct. Encourage CDB. ; PNV ASSESSMENT: every 2 hours x24 hours, then every 4 hours x24 hours, then every shift until discharge. ; I&O every shift. Discontinue when IV/Foley/Drain discontinued. ; Initiate Bowel Protocol. ; Overhead Frame and Trapeze. ; For THA, order adjustable BSC. ; Ice Pack PRN to affected extremity. ; Dressing change POD #1, then daily/PRN. ‰ If diabetic, start Insulin Sliding Scale Protocol – Low Dose. Accuchecks per protocol. DIET: Clear Liquid diet, progress to regular as tolerated. ‰ 1800 Cal ADA ‰ Other: _
; Call APMS for: Inadequate pain control; RR less than 9; pruritis or nausea; Excessive sedation/confusion; Any pain/sedation concerns
; Naloxone (Narcan®) 0.2mg IVP PRN unarrousable and/or patients with a RR less than 9. May repeat x1. Call APMS STAT.
; No oral or parenteral pain medications are to be given except as ordered by APMS for 24 hours.
; Celecoxib (Celebrex®) 200mg orally two times a day. Start evening of surgery. Do not give if Sulfa allergy / Renal Disease.
; Oxycodone SR ‰ 10mg ‰ 20mg orally every 12 hours x5 doses. Do not give if patient age greater than 70.
Physician's Signature Physician's ID (Dictation) Number Page 3 of 3 PHYSICIAN'S PRE-PRINTED ORDERS: TOTAL KNEE / HIP REPLACEMENT
(*NOTE: Do not exceed 4 grams of Acetaminophen per 24 hours)
; Acetaminophen 325mg / Hydrocodone ‰ 5mg ‰ 7.5mg ‰ 10mg (Norco®) 2 tabs orally every 4 hours PRN moderate pain*
; Acetaminophen 650mg / Propoxyphene 100mg (Darvocet®) 2 tabs orally every 4 hours PRN moderate pain* (if codeine allergy)
ANTICOAGULATION / DVT PROPHYLAXIS
Managed by ‰ Orthopedics ‰ ASA (Aspirin) 325mg orally starting night of surgery. Continue twice daily x4 weeks.
‰ Enoxaparin (Lovenox®) 30mg subcutaneous every 12 hours x10 days. Start POD #1 at 09:00 and 21:00. Teach Patient self-injection.
‰ Enoxaparin (Lovenox®) 40mg subcutaneous daily x21 days. Start POD #1 at 09:00. Teach Patient self-injection.
‰ Hold anticoagulant for now. Contraindicated. Reason: _
; Bilateral thigh-high TED hose. Remove once daily for 1 hour. May use ace wrap from foot/ankle to thigh when hose inadequate.
; Sequential Compression Devices (calf sleeves) bilateral LE while in bed x48 hours.
Surgery End Time:
Last Abx Dose Given:

‰ Cefazolin (Kefzol®) 1 Gm IVPB every 6 hours x3 doses (Recommended if patient 80kg or less)
‰ Cefazolin (Kefzol®) 2 Gm IVPB every 6 hours x3 doses (Recommended if patient greater than 80kg)
‰ If allergic to PCN or Cephalosporin: Clindamycin (Cleocin®) 900mg IVPB every 6 hours x2 doses
‰ Vancomycin (Vancocin®) 1 Gm IVPB every 12 hours x2 doses. See reason for Vancomycin administration on pre-op orders.
‰ Cefepime (Maxipime®) 1 Gm IVPB within 2 hours prior to incision Indiciation: ‰ Known ‰ Suspected colonization / infection
SYMPTOM MANAGEMENT
; Onadestron (Zofran®) 4mg IV daily at 09:00 on POD #1 and #2
; Esomeprazole (Nexium®) 40mg orally daily
; Docusate-Senna (Senna-S®) 1 tab orally two times daily
; MOM® 30mL orally every 6 hours PRN constipation ; Aluminum-Magnesium Hydroxide (Maalox®) 30mL orally every 6 hours PRN indigestion
CONSULTS
; Physical Therapy – Assess and treat. Total Knee / Hip Protocol. Weight Bearing: ‰ WBAT ‰ PWB ‰ TDWB ‰ NWB
THA: ‰ Anterior Precautions
‰ Posterior Precautions ‰ Trochanteric Precautions ‰ Abduction Pillow TKA: ‰ Knee Immobilizer ‰ Knee brace set to _ o to _ o . ; Occupational Therapy – Assess and provide equipment/treatment as needed. ; Case Manager / Social Work for Discharge Placement and post-discharge equipment needs. Plan discharge on POD# 2-3. ‰ Community SNF ‰ Community Rehab ‰ Continue Routine Home Medications. May take own meds dispensed by nursing. Pharmacy to verify home medications and schedule. PRN Reason or Clarification Physician's Signature Physician's ID (Dictation) Number

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