PLACE LABEL HERE GENERAL SURGERY Outpatient / Observation POST-OP ORDERS These orders include: Mastectomy (18035), Thyroidectomy (18038), Appendectomy (18041), Lap Nissen Fund (14292), Hemorrhoidectomy (18042), Lap Chole (18043) 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). Allergies: ______________________________________________________________________________________ 1. Status order was addressed pre-procedure and has NOT CHANGED or Status order was addressed pre-procedure and HAS CHANGED to: Place in Observation 2. Diagnosis: ________________________________________________________________________________ Level of Care: Acute Care Location/Specialty Unit Preference: ___________________ 3. Telemetry: If patient Medical/Surgical, must complete form # 36084 4. Isolation: Contact Droplet Airborne For: _________________ 5. Diagnostics: BMP Stat in PACU in am CMP Stat in PACU in am CBC Stat in PACU in am H&H Stat in PACU in am PT/PTT Stat in PACU in am Serum Calcium Stat in PACU in am Serum Magnesium Stat in PACU in am iPTH PCXR, Reason: Post op Lap Nissen Procedure Immediately post op in recovery Other: ________________________________________ 6. Vital signs per unit routine 7. I & O per unit routine or Other: ____________________________________________________________ 8. Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620) 9. Activity: Bedrest BRP with assistance, then ambulate as tolerated Dangle at bedside within 4 hrs post-op, then ambulate with assistance, as tolerated 10. Elevate HOB 30-45° or Other: ____________________________________________ 11. Cold therapy: Ice to operative site 12. Dressing: Reinforce prn (notify physician after 2 times) Change prn Remove on post op day: _____________________ Do not remove until post op follow up visit Other: ____________________________ 13. Diet: Clear liquids, advance diet as tolerated to: ______________________________________ Clear liquids, advance to low fat diet Clear liquid diet, advance to Nissen diet POD# 1 (Avoid caffeine and carbonated drinks) Other: ________________________________________________________ 14. Thyroidectomy patients: tracheostomy tray and betadine solution at bedside 15. Mastectomy patients: Post sign: “No blood pressure, needle sticks, or IV’s in Right Left Bilateral arm(s)” 16. Drains: NGT to LIS JP to bulb suction ( instruct patient in drain care) Hemovac J-Vac Other: _________________________________ 17. VTE Prophylaxis: None needed, low risk/ambulatory See VTE form # 33058 Sequential compression device while in bed Discontinue when ambulatory Order writer’s initials _______ Copy to pharmacy *3-18052* FORM 3-18052 REV. 12/2014 Page 1 of 3 PLACE LABEL HERE GENERAL SURGERY Outpatient / Observation POST-OP ORDERS These orders include: Mastectomy (18035), Thyroidectomy (18038), Appendectomy (18041), Lap Nissen Fund (14292), Hemorrhoidectomy (18042), Lap Chole (18043) 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). MEDICATIONS: 18. D5 ½ NS with KCl 20 mEq /liter IV at ______ ml/hr Other: _________________________ at _____ ml/hr Discontinue IV fluids when po fluids tolerated 19. Antibiotic: Post-op antibiotic will be automatically stopped within 24 hrs unless indication is documented None needed Ancef (cefazolin) 2 gm IV q 8 hrs x 2 doses or continue > 24 hrs for _______________ (Reason REQUIRED) Mefoxin (cefoxitin) 2 gm IV q 8 hrs x 2 doses or continue > 24 hrs for _____________ (Reason REQUIRED) Other: _________________________________________________________________________________ 20. Thyroidectomy and non-renal hyperparathyroidism patients: Initiate Hypocalcemia Post-thyroidectomy/Parathyroidectomy Protocol (form # 21121) 21. Thyroidectomy and Hyperparathyroidism Renal patients: Calcium Gluconate 20 gm in 1,000 ml NS IV at 50 ml/hr Calcium level q 6 hrs while on calcium infusion. If Calcium level < 7.5, increase rate by 10 ml/hr If Calcium level > 9.5, decrease rate by 10 ml/hr 22. Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs x 3 doses (15 mg if CrCl 31-50, > 65 y/o old or < 50 kg) DC if CrCl ≤ 30. DC if ordered as prn. 23. Lap Nissen Fundoplication or Lap Hiatal Hernia Surgery patients: No capsules or tablets; all meds must be crushed, elixir, IM or IV Colace (docusate) 100 mg liquid po two times daily 24. Hemorrhoidectomy patients: PRN MEDICATIONS Colace (docusate) 100 mg po two times daily Mineral oil 30 ml po twice daily See policy 520-06 for range orders and pain intensity guidelines. 25. Electrolyte Replacement Protocol (form # 21340) 26. Mild Pain, Temp >100.5F, HA: Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn 27. 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 can not take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po q 4 hrs prn intead 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. Copy to pharmacy FORM 3-18052 REV. 12/2014 Order writer’s initials _______ Page 2 of 3 PLACE LABEL HERE GENERAL SURGERY Outpatient / Observation POST-OP ORDERS These orders include: Mastectomy (18035), Thyroidectomy (18038), Appendectomy (18041), Lap Nissen Fund (14292), Hemorrhoidectomy (18042), Lap Chole (18043) 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). 28. 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. 29. 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) 30. Sleep: Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn 31. Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn 32. Stool Softener: Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement 33. Constipation: Milk of Magnesia (MOM) 30 ml po daily prn 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 34. Cough: Robitussin (guaifenesin) 15 ml po q 4 hrs prn 34. Sore Throat: Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn DISCHARGE: 36. Discharge Patient: May go when discharge criteria met May go in _______ hrs when discharge criteria met 37. May go when patient has voided and discharge criteria met 38. Return to office in: ________ days/week(s) As scheduled 39. Instruct Patient on Activity: Do not lift > _______ lbs Pelvic rest x _______ weeks Other: _______________________________________ 40. Instruct Patient on Hygeine: May bathe/shower on post op day: _______ Begin sitz baths: _________ 41. Drain(s): D/C prior to discharge Instruct patient on care of drain(s) 42. Education: Pain pump instructions (type ________) Instruct patient on anticoagulant therapy injections 43. Discharge instructions to patient/family 44. Post-op Prescriptions: Prescription(s) already given to patient, list drug names: __________________________________________ Prescription(s) on chart, nurse to give to patient on discharge 45. Discharge to home with Foley catheter to drainage bag. Give catheter care instructions. 46. Instruct patient to remove catheter at home on ________ post-op day 47. Patient may take the following over the counter medications Tylenol (acetaminophen) 500 mg po q 4 hrs prn pain (D/C if taking any drug with acetaminophen) Advil or Motrin (ibuprofen) 200-400 mg po q 6 hrs prn pain Colace (docusate sodium) 200 mg po daily prn constipation Other: _________________________________________________________________________________ ______________ Date ____________ Time _________________________________ Physician Signature __________ PID Number Copy to pharmacy FORM 3-18052 REV. 12/2014 Page 3 of 3