PLACE LABEL HERE
LOWER EXTREMITY BYPASS / VASCULAR 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.
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15.
Diagnosis Same as preprocedure plan ___________ (initials)
and
Admit as Inpatient ________________________________________(reason for admission)
Status:
Place in Observation _____________________________________(reason for observation)
Unit:
 Surgical Floor  ICU  IMCU/PCU  Telemetry
Consults: Hospitalist for medical management  Notified
 Consult: _________________________, Reason ___________________________  Notified
Diagnostics in AM:  CBC  Chem 7  Other: ____________________________________
Vital signs per routine
Incentive spirometry q 1 hr while awake
Vascular check q 4 hrs in affected extremity. Notify Physician for change in vascular check.
 Telemetry monitoring
 Foley catheter to bedside bag. Discontinue on post op day (POD ) #1 at 6 am
Urinary Retention Orders (form # 31620), initiate if patient has urinary retention or difficulty voiding
Diet:  Clear liquids  Advance as tolerated  Other: ______________
Nutrition Supplement Orders (form # 31417), initiate if patient meets criteria
Activity:  Bedrest  PT Consult in AM  Other: _________________________________________
Dressing:  Reinforce prn  Change ______________________  Other: _____________________
 Prosthetic Consult for residual limb protective device
 Notified
SCHEDULED MEDICATIONS:
 D5 ½ NS IV at 100 ml/hr  D5½ NS IV at _______ ml/hr
 Other: ____________________________________________________________________
 Discontinue IVF when tolerating oral fluids
17. Antibiotic:  Ancef (cefazolin) 1 gm IV q 8 hrs x 2 doses  Other: ______________________________
Post-op antibiotic will be automatically stopped within 24 hrs unless indication is documented,
Document indication for > 24 hrs: _________________________________________________
18.  Aspirin 81mg po daily
19.  Plavix (clopidogrel) 75 mg po daily 
20. DVT/ P.E. Prophylaxis:
 Lovenox (enoxaparin) 40 mg SQ q 24 hrs (if CrCl < 30, give 30 mg SQ q 24 hrs), begin in am
on POD # 1 (if pt has an epidural, do not begin enoxaparin until epidural has been out for 12
hrs)
 Apply / maintain antiembolic stockings

 Sequential compression device while in bed/chair
16.
IVF:
Send copy to pharmacy
*3-31816*
Order writer’s Initials___________
FORM 3-31816 REV. 07/2012
Page 1 of 2
PLACE LABEL HERE
LOWER EXTREMITY BYPASS / VASCULAR 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).
PRN MEDICATIONS (If > one drug is ordered for the same indication, clinical assessment will be used per policy 520-06)
 Adult Electrolyte Replacement Orders, implement form # 21340
Severe Pain:  Morphine 1-4 mg IV q 3 hrs prn (if no epidural or PCA)
 Dilaudid (HYDROmorphone) 0.5-1 mg IV q 3 hrs prn (if no epidural or PCA)
23.
Moderate Pain:
 Percocet (oxyCODONE/acetaminophen) 5/325 mg 1-2 tabs or 10/325 mg 1 tab po q 4 hrs prn
 Lortab (HYDROcodone/acetaminophen) 5/500 mg 1-2 tabs or 10/500 mg 1 tab po q 4 hrs prn
 Hycet elixir (HYDROcodone 7.5 mg / acetaminophen 325 mg/15 ml) 15 ml po q 4 hrs prn
 Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (15 mg if > 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)
24.
Mild Pain, Temp >100.5
25.
Nausea/Vomiting:  Zofran (ondansetron) 4 mg IV or po q 6 hrs prn
 Reglan (metoclopramide) 10 mg IV or po q 6 hrs prn (5 mg if > 65 y/o)
 Phenergan (promethazine) 12.5-25 mg po or per rectum q 4 hrs prn
26.
Sleep:  Ambien (zolpidem) 5-10 mg po at HS prn. If 5 mg given, may repeat x 1 dose after 2 hrs
If > 65 year old, begin with 5 mg po at HS, may repeat x 1 dose after 2 hrs
 Other: ____________________________________________________________________
27.
Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po 4 times daily prn
28.
Stool Softener: Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
29.
Constipation:  Milk of Magnesia (MOM) 30 ml po daily prn
 Dulcolax (biscodyl) 10 mg per rectum x 1 dose
 Senokot-S (docusate/senna) 2 tablets po at bedtime
nightly
30.
Anxiety:
 Ativan (lorazepam) 0.5 - 1 mg po q 8 hrs prn
 Xanax (alprazolam) 0.25 - 0.5 mg po q 6 hrs prn
31.
Cough:
Robitussin (guaifenesin) 15 ml po q 4 hrs prn
32.
Sore Throat: Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn
33.
Itching:
Benadryl (diphenhydrAMINE) 12.5-25 mg IV or po q 6 hrs prn
21.
22.
ADDITIONAL ORDERS:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________
Date
___________________
Time
_________________________________
Physician Signature
__________
PID Number
Send copy to pharmacy
FORM 3-31816 REV. 07/2012
Page 2 of 2