Post Duramorph 24 Hour Orders Post-Operative and Post C-Section [30400557]
Height ________________
Weight ________________
Allergies ______________________________________________________________________
Please consider the following:
Avoid using Ketorolac in patients with known or suspected renal insufficiency, thrombocytopenia, or other bleeding disorders.
CNS Depressants / Narcotics must be approved by on-call anesthesiologist/CRNA. (If ordered by physician other than an
anesthesiologist/CRNA, the order will be placed on hold by Pharmacy department for first 12 hours post spinal block.)
Un-fractionated Heparin / Anticoagulants in post C-Section patients - have obstetrician contact on-call anesthesiologist/CRNA.
General
Vital Signs
[X] Check respiratory rate/ Sedation level
[X] Measure blood pressure and Pulse rate
[X] Oxygen therapy
[X] Lower Extremity Motor / Sensory Checks
[ ] Other
Highline and Harrison Pulse Oximetry
[X] Pulse Oximetry
[ ] Other
SAH, SCH, SFH, SJMC Continuous Pulse Oximetry
[X] Continuous Pulse Oximetry
Routine, Per unit routine, Starting today, Check every hour for 12 hours
(from time of spinal placement), then every 2 hours for the next 12
hours., Post-op
Routine, Every 4 hours, Starting today
Q1 hour x (# of occurrences): 4
Q4 hours x (# of occurrences): 8
Then: Per unit routine
Post-op
Routine, Continuous, Starting today
O2 Delivery Method: Nasal cannula
Titrate to saturation of: 92%
Indications for O2: Hypoxemia
Indicate LPM/FiO2: 2 LPM
Post-op
Routine, Per unit routine, Starting today, Q4 for 12 hours., Post-op
Routine, Per unit routine, Starting today
Keep O2 saturation greater than or equal to:
Check every hour for 12 hours (from time of spinal placement), then
every 2 hours for the next 12 hours, Post-op
Routine, Until discontinued, Starting today
Keep O2 saturation greater than or equal to:
Monitor heart rate for duration of treatment
[ ] Other
PATIENT INFORMATION
Provider Initials ______
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PHYSICIAN ORDERS
POST CESAREAN SECTION,
POST DURAMORPH 24 HOUR ORDERS
(01/18/13)
Revision Q
Notify Provider
[X] Notify provider
[X] Notify provider
[ ] Other
Nursing Interventions
[X] Maintain IV access
[X] Out of bed with assistance
[ ] Oxygen supplemental
Routine, Until discontinued, Starting today
Pulse greater than:
Respiratory rate less than:
Respiratory rate greater than:
Temperature greater than (Celsius):
Urine output less than (mL/hr):
Systolic BP greater than:
Systolic BP less than:
Diastolic BP greater than:
Diastolic BP less than:
Other:
For unexpected initiation of LMWH, antiplatelet or thrombolytic agents
within 24 hours post spinal block., Post-op
Routine, Until discontinued, Starting today
Pulse greater than:
Respiratory rate less than: 10
Respiratory rate greater than:
Temperature greater than (Celsius):
Urine output less than (mL/hr):
Systolic BP greater than:
Systolic BP less than: 90
Diastolic BP greater than:
Diastolic BP less than:
Other:
For increasing sedation (moderate to severe sedation scale), persistent
blood pressure less than 90 mmHg, oxygen saturation less than 92%
with the patient on oxygen, inadequate pain relief within first 18 hours,
onset of "new" extremity weakness or persistent extremity weakness for
more than 8 hours after spinal placement. After persistent blood
pressure less than 90 mmHg, give LR 250 ml bolus as ordered.,
Post-op
Routine, Until discontinued, Starting today, Required for at least 24
hours and then D/C if not needed, Post-op
Routine, As needed, Starting today, Post-op
Routine, Continuous, Starting today
Use protocol:
O2 Delivery Method:
Titrate to saturation of: 92%
Indications for O2: Hypoxemia
Indicate LPM/FiO2:
Give Oxygen if pulse oximetry readings less than 92%., Post-op
PATIENT INFORMATION
Provider Initials ______
Page 2 of 6
PHYSICIAN ORDERS
POST CESAREAN SECTION,
POST DURAMORPH 24 HOUR ORDERS
(01/18/13)
Revision Q
[ ] Oxygen continuous
Routine, Continuous, Starting today
O2 Delivery Method: Nasal cannula
Titrate to saturation of: 92%
Indications for O2: Hypoxemia
Indicate LPM/FiO2: 2 LPM
Number of hours:
Post-op
Routine, As needed, Starting today, Post-op
[X] May Straight cath
[ ] Other
Increased Sedation Interventions
[X] Increase Sedation Intervention
[X] Naloxone (Narcan) 0.1 mg IV STAT with 10 ml normal
saline flush PRN
[X] Blood gas, arterial
[ ] Other
Ancillary Consults
[X] Pharmacy general consult for Anticoagulants
[ ] Other
IV Fluids
IV Fluids
[ ] sodium chloride 0.9 % syringe
[ ] lactated ringers infusion
Routine, Until discontinued, Starting today, Increasing sedation plus
respiratory rate less than 8 breaths per minute:
Give oxygen (ambu bag if necessary), check pulse oximetry, give
naloxone (Narcan) 0.1 mg IV STAT with 10 ml normal saline flush (may
repeat times 3, every 3 minutes). Obtain arterial blood gas STAT, and
notify on-call anesthesiologist/CRNA., Post-op
0.1 mg, IntraVENous, As needed, opioid reversal, respiratory
depression, Post-op
Dilute with 10 mL normal saline. May repeat times 3, every 3 minutes
as needed for respiratory rate depression less than 8.
STAT
As needed, Starting today
Routine, Once, Starting today, Anticoagulants ordered by the surgeon
or any provider will be modified to the following:
1. Unfractionated Heparin: May start two hours post spinal block
2. Warfarin (Coumadin) and dabigatran (Pradaxa): May start 8 hours
post spinal block
3. Aspirin (NAIDS): May start any time
4. Hold dosing of all of the following drugs for 24 hours post spinal
block: Anticoagulants[e.g. dalteparin (Fragmin), enoxaparin (Lovenox),
rivaroxaban (Xarelto)]Thrombolytics, [e.g. retreplase (Retavase),
alteplase (TPA) or antiplatelet agents [e.g. Abciximab (ReoPro),
epifibatede (Integrelin) clopidogrel (Plavix), prasugrel (Effient),
ticlopidine( ticagrelor (Brillinta)
5. Continue epidural analgesia discontinue pharm consult
2-10 mL, IntraVENous, Every 8 hours, Post-op
Maintain IV access for at least 24 hours
Routine
250 mL/hr, IntraVENous, Continuous, Post-op
For SBP less than 90 mmHg
Routine
[ ] Other
PATIENT INFORMATION
Provider Initials ______
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PHYSICIAN ORDERS
POST CESAREAN SECTION,
POST DURAMORPH 24 HOUR ORDERS
(01/18/13)
Revision Q
Medications
Anticoagulant Instructions
[X] Nursing communication
[X] Nursing communication
Routine, Until discontinued, Starting today, Anticoagulant instructions:
If ordered by the surgeon or any provider, orders will be modified to the
following: Subcutaneous unfractionated heparin: may start 1 hour post
spinal block. Intravenous unfractionated heparin infusion, warfarin
(Coumadin), antiplatelet agents [e.g. clopidogrel (Plavix), ticagrelor
(Brilinta), abciximab (ReoPro), eptifibatide (Integrilin)], argatroban,
bivalirudin: may start 2 hours post spinal block. Rivaroxaban (Xarelto),
dabigatran (Pradaxa), apixaban (Eliquis): may start 6 hours post spinal
block. Prophylactic dose low molecular weight heparin (LMWH) [e.g.
enoxaparin (Lovenox)], Fondaprinux (Arixtra): may start 12 hours post
spinal block. Aspirin/non-steroidal anti-inflammatory agents: may start
anytime., Post-op
Routine, Until discontinued, Starting today, Hold dosing of following
drugs for 24 hours post spinal block: Therapeutic dose low molecular
weight heparin (LMWH) [e.g. enoxaparin (Lovenox). Full dose
alteplase (TPA), full dose reteplase (Retavase): may start 10 days post
spinal block., Post-op
[ ] Other
Anti-Inflammatory Medications
Avoid using Ketorolac in patients with known or suspected renal insufficiency, thrombocytopenia, or other bleeding
disorders. Do not use 30 mg in patients weighing less than 50 kg or age 65 and over. May use 15 mg in patients 65
and over and weighting less than 50 kg.
[ ] ketorolac (TORADOL) injection
15 mg, IntraVENous, Every 6 hours, For 4 Doses, Post-op
Give IV/IM every 6 hours. May use in patients weighing less than 50 kg
Routine
[ ] ketorolac (TORADOL) injection
30 mg, IntraVENous, Every 6 hours, For 4 Doses, Post-op
Give IV/IM every 6 hours. DO NOT use in patients weighing less than
50 kg.
Routine
[ ] ibuprofen (MOTRIN) tablet
800 mg, Oral, Every 8 hours, Post-op
Starting 6 hours after the last Ketorolac dose. May transition to
ibuprofen when tolerating oral diet.
Routine
[ ] Other
Oral Analgesia (Single Response)
( ) oxyCODONE-acetaminophen (PERCOCET) tablet
1-2 tablet, Oral, Every 4 hours PRN, moderate pain, severe pain,
5-325 mg
Post-op
Not to exceed 9 tablets per 24 hours
Routine
( ) HYDROcodone-acetaminophen (NORCO) tablet
1-2 tablet, Oral, Every 4 hours PRN, moderate pain, severe pain,
5-325 mg
Post-op
Not to exceed 9 tablets per 24 hours
Routine
[ ] Other
PATIENT INFORMATION
Provider Initials ______
Page 4 of 6
PHYSICIAN ORDERS
POST CESAREAN SECTION,
POST DURAMORPH 24 HOUR ORDERS
(01/18/13)
Revision Q
PCA Medications (Single Response)
Continuous Background Infusions to a PCA Not Permitted
( ) HYDROmorphone (DILAUDID) PCA 1 mg/ml
IntraVENous, Continuous
Loading Dose: None
PCA Patient Bolus Dose: 0.2 mg
Lockout interval: 8 min
Continuous Infusion Rate: None
Hours of continuous infusion:
Four Hour Dose Limit: 3 mg
REQUIRED: For inadequate analgesia after 1 hour, increase PCA dose
to: (suggested dose: increase dose by 50%): ___________________
Routine
( ) morphine PCA 1 mg/mL
IntraVENous, Continuous, Post-op
Loading Dose: None
PCA Patient Bolus Dose: None
Lockout interval: 8 min
Continuous Infusion Rate: None
Four Hour Dose Limit: 20 mg
Routine
[ ] Other
Pruritus Medications
[ ] nalbuphine (NUBAIN) injection 10 mg/mL
[ ] diphenhydrAMINE (BENADRYL) injection
[ ] naloxone (NARCAN) low dose infusion
[ ] Other
Nausea/Vomiting Medications
[ ] ondansetron (ZOFRAN) injection 4 mg/2 mL
[ ] promethazine (PHENERGAN) injection 25 mg/mL
5-10 mg, IntraVENous, Every 4 hours PRN, moderate pain, pruritus,
Post-op
Med choice: 1 - First option
Give IV or subcutaneously every 4 hours PRN
Routine
25-50 mg, IntraVENous, Every 4 hours PRN, Pruritus, Post-op
Med choice: 2 - Second option
Routine
Routine, IntraVENous, 40-80 mcg/hr, Continuous PRN, Persistent
Pruritus, Nausea or Vomiting
Concentration = 0.8 mcg/mL [0.8 mg/1000 mL] -- Titrate at 40-80
mcg/hr = 50 - 100 ml/hr for 4 hours.
4 mg, IntraVENous, Every 4 hours PRN, nausea, vomiting, Post-op
If ondansetron ineffective, discontinue ondansetron and give
promethazine(Phenergan)
Routine
12.5-25 mg, IntraVENous, Every 4 hours PRN, nausea, vomiting,
Post-op
Use 6.25-12.5 mg IV for patients age 65 and over.
Routine
[ ] Other
PATIENT INFORMATION
Provider Initials ______
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PHYSICIAN ORDERS
POST CESAREAN SECTION,
POST DURAMORPH 24 HOUR ORDERS
(01/18/13)
Revision Q
Other Medications
[ ] naloxone (NARCAN) syringe 0.4 mg/mL
10 mcg, IntraVENous, Post-op
Give naloxone (Narcan) 10mcg IV stat with 10 ml normal saline flush.
(may repeat times 10, every 2 minutes) and notify on-call
anesthesiologist /CRNA
Routine
[ ] Other
Date:_______ Time:________ Printed Name of Ordering Provider:__________________________________________________
Provider Signature:__________________________________________________________
Date:_______ Time:________ RN Acknowledged: ________________________________________________
PATIENT INFORMATION
Provider Initials ______
Page 6 of 6
PHYSICIAN ORDERS
POST CESAREAN SECTION,
POST DURAMORPH 24 HOUR ORDERS
(01/18/13)
Revision Q