PLACE LABEL HERE
HEPATIC INTRA-ARTERIAL
BRACHYTHERAPY
PRE-PROCEDURE 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.
Diagnosis Admit as Inpatient _____________________________________(reason for admission)
and Status: Place in Outpatient ______________________________________________(diagnosis)
2.
Unit:  ICU  IMCU/PCU  Telemetry Floor  Any Floor Telemetry  Any Floor (No Telemetry)
3.
Allergies: __________________________________________________________________________
If patient is allergic to contrast, notify the radiologist for possible pre-treatment orders. Radiologist will
need to know the type of reaction, previous treatment, test that induced reaction and approximate date of
last reaction.
4.
Diet:
5.
Insert Foley catheter; bedside gravity drainage
6.
CBC, CMP, PT, PTT on chart (within 2 weeks)
7.
Clip hair from both groins to midline of abdomen
8.
Baseline vital signs: Temperature, pulse, respirations, BP and pulse oximeter
9.
IV Fluids:

 NPO after 12 MN, except for AM medications
 NPO 4 hrs prior to procedure

 D5 ½ NS at __________ ml/hr
 ½ NS at __________ ml/hr (diabetic patients)
 Pepcid (famotidine) 20 mg po x 1 dose pre-procedure
 Other: _________________________________________
10.
Gastrointestinal prophylaxis:
11.
Antiemetics:
12.
Antibiotics (30 min prior to procedure):
 Rocephin (ceftriaxone) 1gm IVPB x 1 dose
or
 Penicillin AND Cephalosporin allergic patients: Cipro 400 mg IV x 1 dose
or
 Other: __________________________________________________________________
 Zofran (ondansetron) 16 mg IV x 1 dose 30 min prior to procedure
 Other: ____________________________________________________________
ADDITIONAL ORDERS:
______________________________________________________________________________________
______________________________________________________________________________________
______________
Date
___________________
Time
_________________________________
Physician Signature
__________
PID Number
Send copy to pharmacy
*1-16243*
FORM 1-16243 REV. 07/2012
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