PLACE LABEL HERE
GENERAL SURGERY
Outpatient / Observation
POST-OP
ORDERS
These orders include: Mastectomy (18035), Thyroidectomy (18038), Appendectomy (18041), Lap Nissen Fund
(14292), Hemorrhoidectomy (18042), Lap Chole (18043)
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).
Allergies: ______________________________________________________________________________________
1.  Status order was addressed pre-procedure and has NOT CHANGED
or
 Status order was addressed pre-procedure and HAS CHANGED to:  Place in Observation
2. Diagnosis: ________________________________________________________________________________
Level of Care: Acute Care
Location/Specialty Unit Preference: ___________________
3.  Telemetry: If patient Medical/Surgical, must complete form # 36084
4.  Isolation:  Contact  Droplet  Airborne For: _________________
5. Diagnostics:
BMP
 Stat in PACU
 in am
CMP
 Stat in PACU
 in am
CBC
 Stat in PACU
 in am
H&H
 Stat in PACU
 in am
PT/PTT
 Stat in PACU
 in am
 Serum Calcium
 Stat in PACU
 in am
 Serum Magnesium
 Stat in PACU
 in am
 iPTH
 PCXR, Reason: Post op Lap Nissen Procedure Immediately post op in recovery
 Other: ________________________________________
6.
Vital signs per unit routine
7.
I & O per unit routine or  Other: ____________________________________________________________
8.
Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)
9.
Activity:
 Bedrest  BRP with assistance, then ambulate as tolerated
 Dangle at bedside within 4 hrs post-op, then ambulate with assistance, as tolerated
10. Elevate HOB 30-45° or  Other: ____________________________________________
11. Cold therapy:  Ice to operative site
12. Dressing:  Reinforce prn (notify physician after 2 times)
 Change prn
 Remove on post op day: _____________________
 Do not remove until post op follow up visit  Other: ____________________________
13. Diet:
 Clear liquids, advance diet as tolerated to: ______________________________________


 Clear liquids, advance to low fat diet
 Clear liquid diet, advance to Nissen diet POD# 1 (Avoid caffeine and carbonated drinks)
 Other: ________________________________________________________
14. Thyroidectomy patients: tracheostomy tray and betadine solution at bedside
15. Mastectomy patients: Post sign: “No blood pressure, needle sticks, or IV’s in  Right  Left  Bilateral arm(s)”
16. Drains:  NGT to LIS  JP to bulb suction ( instruct patient in drain care)
 Hemovac
 J-Vac
 Other: _________________________________
17. VTE Prophylaxis:
 None needed, low risk/ambulatory
 See VTE form # 33058
 Sequential compression device while in bed  Discontinue when ambulatory
Order writer’s initials _______
Copy to pharmacy
*3-18052*
FORM 3-18052 REV. 12/2014
Page 1 of 3
PLACE LABEL HERE
GENERAL SURGERY
Outpatient / Observation
POST-OP
ORDERS
These orders include: Mastectomy (18035), Thyroidectomy (18038), Appendectomy (18041), Lap Nissen Fund
(14292), Hemorrhoidectomy (18042), Lap Chole (18043)
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).
MEDICATIONS:
18.  D5 ½ NS with KCl 20 mEq /liter IV at ______ ml/hr
 Other: _________________________ at _____ ml/hr
Discontinue IV fluids when po fluids tolerated
19. Antibiotic: Post-op antibiotic will be automatically stopped within 24 hrs unless indication is documented
 
  None needed
 Ancef (cefazolin) 2 gm IV q 8 hrs x 2 doses or  continue > 24 hrs for _______________ (Reason REQUIRED)
 Mefoxin (cefoxitin) 2 gm IV q 8 hrs x 2 doses or  continue > 24 hrs for _____________ (Reason REQUIRED)
 Other: _________________________________________________________________________________
20. Thyroidectomy and non-renal hyperparathyroidism patients:
 Initiate Hypocalcemia Post-thyroidectomy/Parathyroidectomy Protocol (form # 21121)
21. Thyroidectomy and Hyperparathyroidism Renal patients:
 Calcium Gluconate 20 gm in 1,000 ml NS IV at 50 ml/hr
Calcium level q 6 hrs while on calcium infusion.
If Calcium level < 7.5, increase rate by 10 ml/hr
If Calcium level > 9.5, decrease rate by 10 ml/hr
22.  Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs x 3 doses (15 mg if CrCl 31-50, > 65 y/o old or < 50 kg)
DC if CrCl ≤ 30. DC if ordered as prn.
23.  Lap Nissen Fundoplication or Lap Hiatal Hernia Surgery patients:
No capsules or tablets; all meds must be crushed, elixir, IM or IV
Colace (docusate) 100 mg liquid po two times daily
24.  Hemorrhoidectomy patients:
PRN MEDICATIONS
Colace (docusate) 100 mg po two times daily
Mineral oil 30 ml po twice daily
See policy 520-06 for range orders and pain intensity guidelines.
25.  Electrolyte Replacement Protocol (form # 21340)
26. Mild Pain, Temp >100.5F, HA:  Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
27. Moderate Pain:
 Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered.
or  If patient can not take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po q 4 hrs
prn intead of Norco. DC if Percocet ordered.
or  Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Norco ordered.
and/or  Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (15 mg if CrCl 31-50, > 65 y/o old or < 50 kg)
or 10 mg po q 6 hrs prn (max combined duration of IV and po ketorolac is 5 days). DC if CrCl < 30.
Copy to pharmacy
FORM 3-18052 REV. 12/2014
Order writer’s initials _______
Page 2 of 3
PLACE LABEL HERE
GENERAL SURGERY
Outpatient / Observation
POST-OP
ORDERS
These orders include: Mastectomy (18035), Thyroidectomy (18038), Appendectomy (18041), Lap Nissen Fund
(14292), Hemorrhoidectomy (18042), Lap Chole (18043)
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).
28. Severe Pain (Begin when Epidural or PCA has been discontinued)
 Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered.
or  Dilaudid (HYDROmorphone) 0.25-0.5 mg IV q 3 hrs prn. If CrCl < 30, dose at 0.25 mg. Hold for
excessive sedation. DC if Morphine ordered.
29. Nausea/Vomiting:  Zofran (ondansetron) 4 mg IV or po q 6 hrs prn
 If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)
30. Sleep:
 Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn
31. Indigestion:
 Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
32. Stool Softener:
 Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
33. Constipation:
 Milk of Magnesia (MOM) 30 ml po daily prn
If no BM after 48 hrs  Dulcolax (biscodyl) 10 mg per rectum daily prn
and/or
 Senokot-S (docusate/senna) 2 tablets po at bedtime nightly
34. Cough:  Robitussin (guaifenesin) 15 ml po q 4 hrs prn
34. Sore Throat:  Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn
DISCHARGE:
36. Discharge Patient:
 May go when discharge criteria met
 May go in _______ hrs when discharge
criteria met
37.  May go when patient has voided and discharge criteria met
38. Return to office in:  ________ days/week(s)
 As scheduled
39. Instruct Patient on Activity:


 Do not lift > _______ lbs  Pelvic rest x _______ weeks
 Other: _______________________________________
40. Instruct Patient on Hygeine:
May bathe/shower on post op day: _______
 Begin sitz baths: _________
41. Drain(s):
 D/C prior to discharge
 Instruct patient on care of drain(s)
42.
Education:  Pain pump instructions (type ________)
 Instruct patient on anticoagulant therapy injections
43. Discharge instructions to patient/family
44. Post-op Prescriptions:

 Prescription(s) already given to patient, list drug names: __________________________________________

 Prescription(s) on chart, nurse to give to patient on discharge
45.
 Discharge to home with Foley catheter to drainage bag. Give catheter care instructions.
46.  Instruct patient to remove catheter at home on ________ post-op day
47. Patient may take the following over the counter medications
 Tylenol (acetaminophen) 500 mg po q 4 hrs prn pain (D/C if taking any drug with acetaminophen)
 Advil or Motrin (ibuprofen) 200-400 mg po q 6 hrs prn pain
 Colace (docusate sodium) 200 mg po daily prn constipation
 Other: _________________________________________________________________________________
______________
Date
____________
Time
_________________________________
Physician Signature
__________
PID Number
Copy to pharmacy
FORM 3-18052 REV. 12/2014
Page 3 of 3