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Pre-Op Total Joint Orders v8
Admission
Patient Name: _____________________________________________________
Patient DOB: ______________________________________________________
Procedure: ________________________________________________________
Diagnosis:
DM 2 250.00
CAD 414.01
HTN 401.9
Renal Insufficiency 593.9
Chronic Kidney Disease 585.4
Anticoagulation Therapy V58.61
Iron Deficiency Anemia, unspecified 280.9
Venous Insufficiency 459.81
Afib 427.31
Other _______________________________
Surgery Date: ______________________________________________________
Height: ___________________________________________________________
Weight: __________________________________________________________
Hospital Status
Inpatient
Allergies
Update Allergies w Reactions: _______________________________________________________
Blood Conservation
Obtain H&H Preop if patient is in Blood Conservation program (see surgery schedule or medical
record)
Microsample all labs if in Blood Conservation Program
Laboratory
CBC-O CBC W Auto Differentiation – if Hgb less than 13 g/dL run Reflex Studies:
Include Iron Panel (serum iron, transferrin saturation), Ferritin Level, B-12 Level, Retic Count
Prothrombin Time – (PT/INR)
Partial Thromboplast Time – (Partial Thromboplastin Time-PTT)
Urinalysis
Culture, Urine
Metabolic Panel (Basic)
Metabolic Panel (Complete)
Rapid Plasma Reagin
Glucose (Random)
Type & Screen
Crossmatch ___________ Units
MRSA Culture Screen (Nasal Swab)
______________________________________________________________________
Radiology
Chest PA & Lateral Xray – Reason for exam - _________________________________
______________________________________________________________________
______________________________________________________________________
Cardiology
Electrocardiogram- (12 Lead EKG) – Reason for exam - _________________________________
_____________________________________________________________________________
Physician Signature:
Date / Time:
PATIENT STICKER
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Pre-Op Total Joint Orders v8
Nursing Orders
Insert Catheter Indwelling OR
Insert Catheter Indwelling Pre-op Holding
Sequential Compression Device (SCD) Left Calf
Sequential Compression Device (SCD) Right Calf
Sequential Compression Device (SCD) Left Foot
Sequential Compression Device (SCD) Right Foot
Reason(s) for no mechanical prophylaxis
[
Contraindicated
Refusal of treatment by patient
Refusal of treatment by parents
No response to treatment
Complication of medical care
Patient noncompliance-general
Patient requests alternative treatment
Treatment not tolerated
Treatment not indicated ]
Other
_____________________________________________________________________________
Pre-OP
Pre-OP done @: _______________________________________________________________
Medications
For a Revision, hold antibiotic until cultures have been obtained.
If NOT a Revision, proceed as follows:
Cefazolin (Ancef) 1 gram as below if patient weight is <= 80 kg unless allergic:
Cefazolin (Ancef) 2 grams as below if patient weight is greater than 80 kg unless allergic:
If patient states he/she is allergic to penicillins or cephalosporins, or if patient is actively infected with
a methicillin resistant Staphylococcal organism, give Vancomycin 1 gram IVPB over 60 minutes x 1 dose
(Consult MD if patient is allergic to Vancomycin).
Other Antibiotics __________________________________________________________
Tranexamic Acid Dosing – 20 mg/kg Intraop – Pharmacy to Dose
Knee Intraarticular Injection Intraop (Total Volume 100 mL)
Ropivicaine 5 mg/mL (50 mL)
Epinephrine 1 mg/mL (0.5 mL)
Ketorolac 30 mg/mL (1 mL)
Normal Saline (48.5 mL)
VTE Prophylaxis Heparin ____________________________________________________
Multi Modal Pre-Load Medictions – PO with sip of water in holding area
Oxycodone 5 mg
Celebrex 200 mg
Neurontin 600 mg
Other ___________________________________________________________________
Miscellaneous
Prep for Procedure
Per Protocol
Additional or Other Prep ______________
Obtain Consent
Procedure
Blood Transfusion
Other ___________________________________________________________________
Special
___________________________________________________________________________
CPT Codes ___________ ___________ __________ __________ __________ __________ __________
ICD-9
___________ ___________ __________ __________ __________ __________ __________
Physician Signature:
Date / Time:
PATIENT STICKER