PLACE LABEL HERE
ANTERIOR CRUCIATE LIGAMENT SURGERY
POST-OP ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
1.
Diagnosis Same as preprocedure plan _______ (initials)
and
Admit as Inpatient ________________________________________________(reason for admission)
Status:
Place in Observation ______________________________________________(reason for observation)
2.
VS per PACU routine with neurovascular checks q 15 min x 1 hr
3.
 X-ray AP/LAT in PACU  Right knee  Left knee
4.
Routine VS per post-op patient care routine
5.
 Neurovascular checks q 1 hr x 4 hrs, then q 2 hrs x 4 hrs, then q 4 hrs
6.
 Instruct for crutches  ROM  Quad rehab  WBAT  PWB
7.
Instruct (q 15 min while awake)
 Straight leg lifts
 QUAD sets  Ankle pumps
8.
 Ice
 Cold therapy pad
 Right knee  Left knee
9.
 Leg brace:
 At all times
 Except when CPM in use
 CPM
Brace:  Locked ___________________________
 Unlocked __________________________________
10. Straight cath if unable to void
11. Drain recharge prn
 Discontinue in AM
12. Dressing:  Reinforce as needed  Change dressing in AM
 Other: _______________________________
13. Regular diet as tolerated
14. Ambulate: ❑ Bedrest with BRP (affected leg elevated) With crutches:  WBAT  PWB  NWB
15. IVF:
D5 LR at _____ ml/hr. When tolerating po fluids, change to INT; Discontinue in AM
MEDICATIONS
16. Antibiotic:
 Ancef 1 gm IV q 8 hrs x ______ dose(s)
 Other: _______________________________
17. Pain:  PCA: See PCA orders (form 2119)  Epidural: per anesthesia
PRN MEDICATIONS (if not ordered by Anesthesia during peri-operative phase)
18. Moderate Pain:  Toradol 30 mg IV q 6 hrs (may give IM if no IV access) (15 mg if greater than age 65 or
weight less than 50 kg)
 Lortab 5 mg, 1-2 tablets po q 4 hrs prn
OR
 Percocet 5 mg, 1-2 tablets po q 4 hrs prn
19. Mild pain/temp greater than 100.5 F/HA:
Tylenol 650 mg po q 4 hrs prn
20. Nausea/vomiting:  Phenergan 12.5-25 mg po q 4 hrs prn
 Phenergan 12.5-25 mg per rectum q 4 hrs prn
 Zofran 4mg IV q 6 hrs prn
 Other: ____________________________________________________________________
21. Sleep:
 Restoril 30 mg po at bedtime prn (7.5 mg if greater than age 65, may repeat x 1 dose)
OR
 Ambien 10 mg po at bedtime prn (5 mg if greater than age 65, may repeat x 1 dose)
22. Constipation:
Milk of Magnesia (MOM) 30 ml po daily prn
23. Additional orders: _____________________________________________________________________________
24. Discharge home:  When discharge criteria met
 In AM
25. Pt education
 Start aspirin 81 mg po daily tomorrow
Follow-up in office in _____________ days/week(s)
_________________
______________
________________________________
_____________
Send copy to pharmacy
*1-18110*
1
FORM 1-18110 REV. 07/2012
Page 1 of
PLACE LABEL HERE
ANTERIOR CRUCIATE LIGAMENT SURGERY
POST-OP ORDERS
Date
Time
Physician Signature
PID Number
Send copy to pharmacy
*1-18110*
1
FORM 1-18110 REV. 07/2012
Page 1 of