PLACE LABEL HERE
POST-PROCEDURE HEPATIC INTRAARTERIAL
BRACHY THERAPY PHYSICIAN 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).
Diagnosis Admit as Inpatient: S/P hepatic intraarterial brachy therapy_____________________(reason for admission)
& Status: Place in Observation S/P hepatic intraarterial brachy therapy___________________(reason for observation)
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Unit: _________________________________________
Condition:  Fair  Other: ___________________________________________________________________
Allergies:___________________________________________________________________________________
Vital signs: see post angiogram orders
Activity: see post angiogram orders
Diet: Advance as tolerated
IVF: ____________________ at __________ ml/hr __________ liters then KVO
Medications:
8.
Hold medications containing metformin (Glucophage or related medications) for 48 hrs post procedure
9.
Antiemetics (choose one):  Ondansetron (Zofran) 8 mg IV every 8 hrs prn
 Promethazine (Phenergan) 12.5 – 25 mg po q 4 hrs prn
 Other: _____________________________________________________________
10.
Antibiotics:
 Ceftriaxone (Rocephin) 500 mg IVPB daily
or
 Penicillin AND cephalosporin allergic patients: Cipro 400 mg IVPB q 24 hrs
 Other: ______________________________________________________________________
11.
Anxiety/restlessness:  Ativan 0.5 – 1 mg IV q 4 hrs prn
 Other: _______________________________________________________________
12.
Severe pain:
 Hydromorphone (Dilaudid) 0.5 – 2 mg IV q 4 hrs prn
 Other: ______________________________________________________________________
13.
Moderate pain:  Hydrocodone/Acetaminophen (Lortab) 5/500 1-2 tabs po q 4 hrs prn
 Other: ______________________________________________________________________
14.
Mild pain/temp >100.5°F/HA:
 Acetaminophen (Tylenol) 650mg po q 4 hrs prn
 Other: _________________________________________________________
15.
Gastrointestinal prophylaxis:
 Nexium 40 mg po daily
 Other: _________________________________________________________
16.
Post-embolization syndrome prophylaxis:
 Methylprednisolone (Medrol) 40 mg po daily
 Other: ____________________________________________
17.
Tumor localization scan in nuclear medicine within the first 24 hrs of procedure
Additional Orders: ________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_______________
Date
________________
Time
_________________________________________
Physician Signature
_____________
PID Number
Send copy to pharmacy
*1-16619*
FORM 1-16619 REV. 07/2012
Page 1 of 1
PLACE LABEL HERE
POST-PROCEDURE HEPATIC INTRAARTERIAL
BRACHY THERAPY PHYSICIAN ORDERS
Send copy to pharmacy
*1-16619*
FORM 1-16619 REV. 07/2012
Page 1 of 1