PLACE LABEL HERE
GYN 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.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
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
Consult: _________________________, Reason ___________________________  Notified
Consult: _________________________, Reason ___________________________  Notified
Diagnostics: In PACU:
 H&H  CBC  Chem 7  CMP
 Other: ______________
POD # 1:
 H&H  CBC  Chem 7  CMP
 Other: ______________
Vital signs per routine
Notify physician for temp > 101°F, urine output < 0.5 ml/kg/hr over 4 hrs, BP > 160/100 or < 90/60, RR
> 30, P > 130 or excessive bleeding
O2 per Respiratory Care Protocol (7504-10-01-03)
 Adjust O2 to maintain SpO2 > 90% or 88% in COPD. Call physician for O2 usage > 4 L/min or >
40%.
 Reassess daily, wean O2 to maintain SpO2 > 90% or 88% in COPD. Wean to room air if SpO 2 is
acceptable and patient has no known exclusions per 7504-10-01-03. May restart O2 as needed.
 Post op patients will be weaned to room air the morning following surgery unless SpO2 is < 90%
(88% for COPD) or patient has other exclusions.
Foley catheter to drainage bag
Discontinue Foley catheter in AM POD #1 at 0600
 Straight cath if unable to void q 4-6 hrs OR if bladder scan reads > _________ mls
 Do NOT discontinue (document reason): _________________  Other: ______________
 Vaginal packing: RN to remove in AM  physician to remove
 Ice packs to incisions x 48 hrs  Other: ______________________________________
Incentive spirometer 10 repetitions q 1 hr while awake
Remove dressing POD #1  Other: ________________________
Diet: Clear liquid, advance as tolerated  Other: _______________________________________
 No carbonated beverages, straws, or gum
Initiate Nutrition Supplement Orders (form # 31417), if patient meets criteria
Activity: Progressive ambulation: Dangle @ 4 hrs post-op with assist; Ambulate @ 6 hrs post-op with
assist. Advance ambulation to 4-6 times a day starting POD # 1, then progressing to up ad lib.
 Bed rest until AM
 May shower  Other: ________________________
SCHEDULED MEDICATIONS:
17.
18.
19.
IVF: D5 ½ NS at ___ ml/hr  Other: _________________  Add KCI 20 mEq to each liter of IVF
Convert to INT if tolerating diet and temp < 100.5°F
Pain:  See PCA orders (form # 2119)  See Sleep Apnea PCA orders (form # 21261)
 Toradol (ketorolac) 30 mg IV q 6 hrs x ____ doses (15 mg if > 65 y/o or < 50 kg, max duration is 5 days)
D/C PCA:in AM POD # 1  in AM POD # 2  When tolerating oral fluids
Order writer’s Initials _______
Send copy to pharmacy
*3-16013*
FORM 3-16013 REV. 06/2012
Page 1 of 2
PLACE LABEL HERE
GYN 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).
20.
21.
22.
23.
Colace (docusate) 100 mg po bid
 Dulcolax (bisacodyl) 10 mg per rectum in AM of POD#1
Antibiotic: _________________________________________________________________ x 2 doses
If > 2 doses needed, must document indication: ____________________________________________
DVT/ PE Prophylaxis:
 Apply/maintain antiembolic stockings
 Sequential compression device  Foot compression device (document reason): ______________
 Lovenox (enoxaparin) 40 mg SQ q 24 hrs, begin in am on POD # 1
(if patient has an epidural, do not begin enoxaparin until epidural has been out for 12 hrs)
PRN MEDICATIONS (If > one drug is ordered for the same indication, clinical assessment will be used per policy 520-06)
24.
If patient receiving insulin, initiate Hypoglycemia Treatment Protocol (form # 2513)
25.
If patient is in ICU, IMCU or PCU: initiate Critical Care Insulin Orders (form # 21386)
26.
 Adult Electrolyte Replacement Orders (form # 21340), initiate
27.
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)
28.
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
 Motrin (ibuprofen) 600 mg po q 6 hrs prn after Toradol (ketorolac) has been d/c’d
29.
Mild pain/temp >100.5
30.
Nausea/Vomiting:
 Zofran (ondansetron) 4-8 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
31.
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:___________________________________________________________________
32.
Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
33.
Constipation:  Milk of Magnesia (MOM) 30 ml po daily prn
 Dulcolax (bisacodyl) suppository per rectum daily prn
34.
Anxiety:
 Ativan (lorazepam) 0.5 - 1 mg po q 8 hrs prn
 Xanax (alprazolam) 0.25 - 0.5 mg po q 6 hrs prn
35.
Cough: Robitussin (guaifenesin) 15 ml po q 4 hrs prn
If cough unrelieved by guaifenesin, Hycodan (HYDROcodone/homatropine) 5 ml po q 4 hrs prn
36.
Sore Throat: Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn
37.
Itching: Benadryl (diphenhydrAMINE) 12.5-25 mg IV or po q 6 hrs prn
38.
Gastric Bloating: Mylicon (simethicone) 80 mg po at meals and at bedtime prn
_____________
Date
___________________
Time
_________________________________
Physician Signature
__________
PID Number
Send copy to pharmacy
FORM 3-16013 REV. 06/2012
Page 2 of 2