PLACE LABEL HERE
ORTHOPEDIC
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.  Status was addressed pre-procedure and has NOT CHANGED.
or
 Status order was addressed pre-procedure and HAS CHANGED to  Admit as Inpatient, expected stay will cross two midnights
 Place in Observation
 Outpatient, DC home
2. Diagnosis: ________________________________________________________________________________
Level of Care:  Critical  Intermediate  Acute Care Location/Specialty Unit Preference___________
3.  Telemetry: If patient Medical/Surgical, must complete form # 36084
4.  Isolation:  Contact  Droplet  Airborne For: _________________
5. Consults:
 Hospitalist consult for medical management
 Notified
 Occupational Therapy consult on POD # ___: Shoulder exercises, OT may consult PT for mobility  Other: ____

 Physical Therapy consult on POD # ____Transfer to training bed to chair Gait training Therapeutic exercises
Weight bearing status:  WBAT_______LE
 TDWB_______LE
PWB
 TTWB
 NWB________LE
 ______% WB______LE
 Case Manager to arrange:  Anticoagulant therapy for home
 Referral to rehab facility: __________
 Equipment for home use: ____________  Home health services: __________  Other: ____________
6. X-Rays:
Exam
Chest
Laterality Option
N/A
Ordered Views
AP
Clavicle
 Left  Right
 Bilateral
 Left  Right
 Bilateral
 Left  Right
 Bilateral
 Left  Right
 Bilateral
 Left  Right
 Bilateral
 Left  Right
 Bilateral
 Left  Right
 Bilateral
 Left  Right
 Bilateral
N/A
AP
Scapula
Shoulder
Humerus
Elbow
Forearm
Wrist
Hand
Pelvis
Hip
Femur
Knee
Tibia
Ankle
Calcaneus
Foot 
Patella
 Left  Right
 Bilateral
 Left  Right
 Bilateral
 Left  Right
 Bilateral
 Left  Right
 Bilateral
 Left  Right
 Bilateral
 Left  Right
 Bilateral
 Left  Right
 Bilateral
 Left  Right
AP AP/Lateral
AP/Y/Axillary
AP/Y/Valpeau
AP Lateral
AP
Lateral
AP
Lateral
AP Lateral
Oblique
AP Lateral
Oblique
AP Inlet/Outlet
Judet
AP/Lateral
AP/Cross Table
AP/Lateral
AP/Lateral  Sunrise
 45° PA Standing
AP/Lateral
AP/Lateral/Mortise
Lateral Harris
AP Lateral
Oblique
AP Lateral
4
Reason for Exam


















Location of Exam
Portable
Done in OR
Portable
Done in OR
Portable
Done in OR
Portable
Done in OR
Portable
Done in OR
Portable
Done in OR
Portable
Done in OR
Portable
Done in OR
Portable
Done in OR
Portable
Done in OR
Portable
Done in OR
Portable
Done in OR
Portable
Done in OR
Portable
Done in OR
Portable
Done in OR
Portable
Done in OR
Portable
Done in OR
Portable
Order writier’s initials _______
Copy to pharmacy
*3-18111*
Priority
Stat or
Routine
Stat or
Routine
Stat or
Routine
Stat or
Routine
Stat or
Routine
Stat or
Routine
Stat or
Routine
Stat or
Routine
Stat or
Routine
Stat or
Routine
Stat or
Routine
Stat or
Routine
Stat or
Routine
Stat or
Routine
Stat or
Routine
Stat or
Routine
Stat or
Routine
Stat or
FORM 3-18111 REV. 08/2015
Page 1 of
PLACE LABEL HERE
ORTHOPEDIC
POST-OP ORDERS
 Bilateral
Routine
Order writier’s initials _______
Copy to pharmacy
*3-18111*
4
Done in OR
FORM 3-18111 REV. 08/2015
Page 2 of
PLACE LABEL HERE
ORTHOPEDIC
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).
 Chem 7  CMP  CBC  H&H  PT/PTT
 Other_____________________________
Acetabular/Pelvic Fracture patients: H&H in am and POD # 2 (notify physician if HGB ≤ 7.0)
Vital signs per routine
Neurovascular checks q 1 hr x 4 hrs, then q 2 hrs x 4 hrs, then q 4 hrs, or other_________________________

 Left lower extremity or   Right lower extremity
Elevate affected extremity and apply ice or  Cold therapy pad  Other: ______________
Brace/Immobilizer:
Patient already has brace
 Shoulder Sling
 With abductor pillow
 Shoulder immobilizer
 With abductor pillow
 Leg brace:
 At all times  Except when CPM in use
 CPM (settings) ________________
7. Labs:
8.
9.

10.
11.

12.
13.
14.
 Knee immobilizer
 Cam Boot
 Post Op Shoe
 Knee Hinge: Locked at ___° or  Unlocked and adjusted for freedom between_____°
 Elbow Hinge: Locked at __° or  Unlocked and adjusted for freedom between_____°
Dressing:  Keep intact unless saturated  Reinforce prn (notify physician after 2 times)  Change ________
Drains:  Hemovac  JP  NPWT (Wound Vac), consult Wound Care
 Acetabular/Pelvic Fracture patients: Surgical drain to self suction. Record output q 8 hrs.
DC no sooner than POD # 1 when drainage < 25 ml for 8 hrs
 DC Drain__________________________
Instruct patient in use of:  Sling  Knee immobilizer  Hinge Knee  Hinge elbow  shoulder brace
 Instruct for crutches ROM  Quad rehab
 WBAT
 PWB

Instruct (q 15 min while awake)  Straight leg lifts
 QUAD sets  Ankle pumps
 Other: _________________________________________________________

18.
15.
16.
17.
19.
20.
21.
22.
24.
 Shoulder Surgery:
 Start pendulum swings tomorrow x 3 day. Otherwise, stay in sling at all times/no other shoulder motion
 Start elbow flexion and extension exercises tomorrow
 Acetabular/Pelvic Fracture Patients:
Monitor urine output q 2 hrs x 48 hrs.
Call physician if urine output is < 0.5 ml/kg over 4 hrs
 Hip precautions
 Abduction pillow while in bed
 Incentive spirometry q one hr while awake
 Foley catheter to bedside bag. D/C Foley catheter on POD # 1 by 11am.
Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)
O2 per Protocol (form # 34431)
Diet: Clear liquids; advance as tolerated to:  Regular  Cardiac  Diabetic ______ calorie  Renal
or  npo
Oral Nutritional Standing Orders (form # 31417), initiate if patient meets criteria
Activity:  Bedrest x ___ hrs
 Bedrest with BRP (affected leg elevated) With crutches:  WBAT  PWB  NWB
 Ambulate with assistance
Notify physician if:
Temp > 102F
DBP < 50 or > 100
RR less than 10 or > 30
Changes in neurovascular status
HR less than 50 or > 140
Excessive drainage from incision

Copy to pharmacy
FORM 3-18111 REV. 08/2015
Order writer’s initials _______
Page 3 of 4
PLACE LABEL HERE
ORTHOPEDIC
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).
SCHEDULED MEDICATIONS
25.
26.





27.
28.
29.
30.
31.
32.
33.
 D5 ½ NS
 D5 NS  ½ NS  D5 LR
 LR
at ________________ ml/hr IV 
 Discontinue IVF when tolerating oral fluids
Antibiotic:
(1st dose due at: ___________)
Post-op antibiotic will be automatically stopped within 24 hrs unless indication is documented above
   Ancef (cefazolin) 2 gm IV q 8 hrs x 2 doses
or  x 48 hrs for_____________(Reason) or  > 48 hrs for_____________(Reason)
   Rocephin (ceftriaxone) 1 gm IV q 24 hrs x 1 dose
or  x 48 hrs for_____________(Reason) or  > 48 hrs for_____________(Reason)
   Zosyn (piperacillin/tazobactrim) 3.375 gm IV q 8 hrs x 2 doses
or  x 48 hrs for_____________(Reason) or  > 48 hrs for_____________(Reason)
   Cleocin (clindamycin) 600 mg IV q 8 hrs x 2 doses
or  x 48 hrs for_____________(Reason) or  > 48 hrs for_____________(Reason)
   Vancomycin, pharmacy to dose x 24 hrs
or  x 48 hrs for_____________(Reason) or  > 48 hrs for_____________(Reason)
VTE prophylaxis (Do not begin anticoagulant therapy until epidural catheter out for 4 hrs)
 Apply/maintain antiembolic stockings
 Sequential compression device  Foot compression device (document reason): _______________
Surgery end time_____________
 Coumadin (warfarin) ____mg po q day at 1700; start today.
 Aspirin 325 mg po q day bid Begin POD # 1
 Lovenox (enoxaparin)
 12 hrs post-op: 30 mg SQ q 12 hrs x 2 doses, then 40 mg SQ q 24 hrs x ___ days
 40 mg SQ q 24 hrs x _____ days. First dose in am POD 1, If CrCl < 30, 30 mg SQ daily
 Arixtra (fondaparinux)
 2.5 mg SQ, give 8 hrs postop, then 2.5 mg SQ q 24 hrs x ___ days
 2.5 mg SQ q 24 hrs x ____ days. First dose in am POD 1
If CrCl < 30 or weight < 50 kg, Arixtra will be therapeutically interchanged to Lovenox
 Xarelto (rivaroxaban)
 10 mg po, give 8 hrs post-op, then 10 mg po q 24 hrs x ____ days
 10 mg po q 24 hrs x ____ days. First dose in am POD 1
If CrCl < 30, Xarelto will be therapeutically interchanged to Lovenox
 No Pharmacological Prophylaxis, Document reason:
 Active Bleeding (GI bleeding, cerebral hemorrhage, hemorrhage, retroperitoneal bleeding)
 Bleeding Risk  Thrombocytopenia  Patient Refusal  Other: ________________
 Other: ________________________________________________________________________
Bowel Management:
Senokot-S (docusate/senna) 2 tablets po at bedtime nightly
POD # 2, if no BM: Dulcolox (bisacodyl) 10 mg po x 1 dose on POD # 2
POD # 3, if no BM: Dulcolax (bisacodyl) 10 mg suppository per rectum x 1 dose, on POD # 3
If no BM 4 hrs post suppository, give Fleets Enema (sodium phosphate) per rectum x 1 bottle
PCA:  See PCA orders (form # 2119)  See Sleep Apnea PCA orders (form # 21261)
If not on PCA:  OxyCONTIN (oxyCODONE)  10 mg  20 mg po q 12 hrs x 4 doses .
 Indocin (indomethacin) 25 mg po three times daily. Start in AM of _________
 CeleBREX (celecoxib) 100 mg or 200 mg 400 mg
po
q day or bid
 Ultram (tramadol) 50 mg or 100 mg
po
q 6hr or q 8 hrs or q 12 hrs (CrCl < 30)
IVF:
Copy to pharmacy
FORM 3-18111 REV. 08/2015
Order writer’s initials _______
Page 4 of 4
PLACE LABEL HERE
ORTHOPEDIC
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 See policy 520-06 for range orders and pain intensity guidelines.
34.  Electrolyte Replacement Protocol (form # 21340)
35. Mild Pain, Temp >100.5F, HA:  Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
36. 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 cannot take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po q 4 hrs prn
instead 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.
37. 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.
38. 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)
39. Sleep:
 Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn
40. Indigestion:
 Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
41. Stool Softener:
 Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
 Milk of Magnesia (MOM) 30 ml po daily prn
42. Constipation:
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
43. Cough:
 Robitussin (guaifenesin) 15 ml po q 4 hrs prn
44. Sore Throat:
 Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn
ADDITIONAL ORDERS:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________
Date
____________
Time
_________________________________
Physician Signature
___________
PID Number
Copy to pharmacy
FORM 3-18111 REV. 08/2015
Page 5 of 4