PLACE LABEL HERE
PRE-ANESTHESIA TESTING (PAT)
STANDING ORDERS
Nurse initiated standing order based on medical staff approved policy (6602-02 and 6602-01).
Orders with a “” are indicator choices and are NOT implemented unless checked. Initial bottom of each page.
1.
Diagnostics:
Pre-Operative Conditions / Indications
Order:
If condition not listed below, consult anesthesia
Surgery scheduled patient
Female > 12 y/o menstruating
High risk procedures(peripheral vascular, aortic/other major vascular) or
potential blood loss > 500 ml:
Hysterectomy, hysteroscopy, myomectomy, cystectomy, open
cholecystectomy, laminectomy, major orthopedic spinal, hip/knee replacement,
nephrectomy, major laparoscopic, resection/reconstruction of GI tract, radical
prostatectomy, panniculectomy, lower body lift
Central Nervous System (CNS) Disease (affects either the brain or the spinal
cord: encephalitis/meningitis, Alzheimer, Parkinson, multiple sclerosis, nonpsych )
EKG per algorithm (6602-02)
Serum HCG or UPT, or UPT DOS
Cardiovascular (patient presents with current/recent CP, SOB, DOE
worsened, not evaluated)
Consult Anesthesia if patient presents
with recent chest pain. EKG if patient
has not had within 6 months
Pacemaker/ICD (EKG within 6 months)
Pulmonary (planned thoracic sx, acute or chronic process changed past 6
months or unexplained dyspnea)
EKG within 6 months
Hepatic—Cirrhosis or Hepatic cancer (regardless of date of diagnosis)
CBC, PT/PTT, Liver profile
EKG per algorithm (6602-02)
CBC, PT/PTT, Liver profile
EKG per algorithm (6602-02)
CBC, Chem 7
Whole Blood Potassium (DOS)
Chem 7, EKG per algorithm (6602-02)
Chem 7
TSH, Total T3, Free T4
Hepatic--Hardening of liver, fatty liver, hepatitis (within the past 12 months)
Renal Disease/Insufficiency(ESRD, dialysis); Calculi scheduled for lithotripsy
ESRD/Dialysis
Diabetes
Hyperparathyroidism
Hyperthyroidism
Bleeding Disorder (diagnosed coagulopathy, abnormal bleeding, clotting
disorders)
Stated anemia with signs/symptoms (syncope, HR > 100) or iron therapy
Leukemia
Chemotherapy use within 3 months
Radiation Therapy within 3 months
Epidural/spinal planned (HDR, T&O, Cervical Cerclage, Cysto)
Diuretic use or prescription potassium supplement
Digoxin, current use
Cocaine, current use
Lithium, current use
Steroid, current use (excludes inhaled)
Coumadin (warfarin) or Heparin use within 10 days
Angiotensin-converting-enzyme (ACE) or Angiotensin II receptor blocker (ARB),
current use
CBC
CBC, Chem 7
Chest x-ray
CBC, PT/PTT
CBC
CBC
CBC
CBC
CBC
Chem 7
Chem 7, EKG per algorithm (6602-02)
EKG
Chem 7
Chem 7
CBC (day of interview); PT/PTT (DOS)
Chem 7
2.
Instruct patients regarding pre-op meds to hold or take per policy # 6602-01, attachment A and B
3.
Notify anesthesiologist for abnormal lab values per policy # 6602-02, attachment B
________ ________ _________________________
Date
Time
Nurse Signature
_________________________ ___________
Physician Signature
PID Number
Copy to pharmacy
*1-33644*
FORM 1-33644 REV. 11/2015
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