Download PHYSICIAN`S ORDERS - Walnut Hill Medical Center

Patient Label
Interventional Radiology Post Procedure Orders
ALLERGIES & SENSITIVITIES:
☐ NKA
Unapproved Abbreviations: QD, Q.D., qd, q.d., QOD, Q.O.D., qod, q.o.d., MgSO₄, MSO₄, MS, IU, U or –u, ug, Trailing Zero (X.0mg), Leading Zero (Xmg)
Weight
Date
Height
Diagnosis
Time
Description
LEVEL OF CARE check appropriate box
☐ Place in Day Surgery ☐ Extended Recovery (OP only) ☐ Place in Observation ☐ Admit to Inpatient
BED TYPE: ☐ SDS ☐ Med/Surg ☐ Telemetry ☐ ICU
☐ Notify Dr. __________________ of room number.
 Condition
 Patient Condition Satisfactory
☐ Patient Condition Fair
☐ Patient Condition Serious
☐ Patient Condition Critical
Code Status
Full Code
☐Do Not Recuscitate (DNR)
☐Limited Code
☐Medications only
☐Chest compressions only
☐Do not intubate
 Vital Signs
 Vital signs per unit routine
☐ Vital signs every 8 hours
☐ Vital signs every 12 hours
☐ Vital signs (Specify) _________________________
☐ Vital signs q15 min x 4, q30 min x2, q 1 hr x1, then per unit routine
☐ Vital signs q15 min x 4, q30 min x2, q 1hr x2, then per unit routine
☐ Vital signs q15 min x 4, q 30 min x2, q1 h x3, then per unit routine
☐ Neuro checks with vital signs
☐Precautions
☐ Aspiration precautions
☐ Seizure precautions
☐ Isolation precautions:
☐ Contact
☐ Airborne
Interventional Radiology Post Order Sets
Page 1 of 9
PO0140.0021 (9/23/15)
Patient Label
☐ Droplet
Laboratory
☐ Post Thrombolysis Laboratory Orders
 Fibrinogen level stat
 Fibrinogen level every 4hrs
 CBC q 6h.
 PTT q 6h
☐ Post Denver Shunt Laboratory Orders
 Stat fibrinogen level
 Stat PT/INR
 Stat CBC
 Timed fibrinogen level at _________________________
 Timed PT/INR at _________________________________
 Timed CBC at ____________________________________
☐ Post Renal Biopsy Laboratory Orders
☐ Hg/HCt every 2hrs post renal biopsy
☐ Hg/HCt every 4hrs post renal biopsy
 CBC in am
 Renal panel in am
Radiology
☐ Xray chest, PA/LAT view at _______________ diagnosis ____________________________
Respiratory
☐ Respiratory Therapy Protocol
☐ Titrate oxygen, Maintain SPO2 greater than or equal to 92% BIDRT
Pulse Oximetry
☐ Continuous
 Spot check
Diet
Oral Diets
☐ Regular/House
☐ Renal
☐ Cardiac
☐ Consistent Carbohydrate (Diabetic)
☐ Full Liquid
 Clear Liquid
☐ NPO
☐Supplement _________________________________________________________
Activity
☐ Bedrest x 2 hours, flat for first hour then ad lib
☐ Bedrest x 3 hours, flat for first 2 hours, then ad lib
☐ Bedrest x 3 hours, right side down, then ad lib
☐ Bedrest x 3 hours, right side down for the first hour, then supine HOB </= to 35-40 degrees for
2 hours, then ad lib
☐ Strict bedrest with ☐ right leg straight until _______ then ad lib
☐ left leg straight until _________ then ad lib
☐ May logroll for comfort
Interventional Radiology Post Order Sets
Page 2 of 9
PO0140.0021 (9/23/15)
Patient Label
☐ Bedrest with bathroom privileges with assistance
NURSING
 Convert any IV fluids to saline lock after procedure completed for all CHF or ESRD patient
☐ Advance diet to patient’s usual diet as tolerated
☐ NPO until __________________ then advance diet to patient’s usual diet as tolerated
☐ Remove saline lock at _____________________________________
☐ Discontinue PCA at _____________________________________
☐ Cardiac monitoring including off unit tests
☐ Cardiac monitoring except off unit tests
Notify MD for:
 Temp greater than or equal to 101 degrees F
 Systolic BP greater than 140 mm Hg
 Diastolic BP greater than 90 mm Hg
 Pulse greater than 100 or less than 60
 Respiratory rate greater than 24 or less than 10 per minute
 Abnormal CK/CKMB/Troponin results
 Notify physician for INR greater than 1.5
 Notify physician for HGB less than 8
 Notify physician for Platelett count less than 50
☐ Orthostatic vital signs every 2 hours x2:
 Lower head of bed to flat for 10 minutes, check blood pressure and heart rate
 Raise head of bed to 45 degrees and recheck blood pressure and heart rate
 Have patient stand then recheck blood pressure and heart rate
 Call IR MD if SBP drops by 20 points or pulse increases by 20 points with sitting or
Standing
☐ Post Thrombolysis Nursing Orders
 Monitor for and report blood in urine
 No new IM or IV sticks while patient is receiveing tPA. Place sign on door.
 May use sheath sideport for lab draws after wasting 10ml of blood from sheath
 Notify IR MD if bleeding, hematoma, change in neuro exam, loss of pulses, decrease in
HCT by more than 3 grams
☐ Post Denver Shunt Nursing Orders
 Elevate head of bed at least 45 degrees until 8 am tomorrow
 Pump Denver Shunt chamber 20 times in the morning and 20 times in the evening
 Check baseline blood pressure and heart rate
 Orthostatic vital signs every 2 hours x2:
 Lower head of bed to flat for 10 minutes, check blood pressure and heart rate
 Raise head of bed to 45 degrees and recheck blood pressure and heart rate
 Have patient stand then recheck blood pressure and heart rate
 Call IR MD if SBP drops by 20 points or pulse increases by 20 points with sitting or
standing
 Call IR MD if INR>2. Drop in fibrinogen of 30% or greater from baseline or fibrinogen less
than 100
☐ Remove foley catheter at _____________________________________
☐ Nursing Communication: ______________________________________________________
____________________________________________________________________________
☐ Nursing Communication: _____________________________________________________
___________________________________________________________________________
____________________________________________________________________________
Interventional Radiology Post Order Sets
Page 3 of 9
PO0140.0021 (9/23/15)
Patient Label
☐ Venous Sheath Management
☐ Remove venous sheath following arterial sheath removal and hemostasis
☐ Remove venous sheath now and hold manual pressure
☐ Cover site with dressing after hemostasis achieved
☐ Ambulate with assistance first time after ________ hours then resume usual activity level
Tubes and Drains
☐ Record drain output every shift, minus flush
☐ Flush drain q shift with 10 cc NS
☐ Tubes and Drains GI
☐ Insert nasogastric tube to low wall suction intermittent
☐ Insert nasogastric tube to low wall suction continuous
☐ Tubes and Drains GU
☐ Insert urinary catheter (indwelling)
☐ Insert urinary catheter (straight cath)
☐ Irrigate urinary catheter
☐ Irrigate bladder: continuous
☐ Irrigate bladder: manual PRN to maintain urinary catheter function
☐ Chest tubes
☐ Place chest tube to continuous suction
☐ Place chest tube to water seal
Arterial Sheath Management
☐ Sheath Management w/Closure Device
 Communications: Nursing hemostasis patch PRN for oozing or suboptimal hemostasis.
Apply to groin for 24 hours. Cover site with Bio-Occlusive dressing after hemostasis is
obtained
 Position Patient: Maintain Head of Bed not greater than 30 degrees continuous
starting today for 6 hours
 Ambulate with assistance first time after bedrest complete then resume usual activity level
 Communications: Nursing resume activity, after bedrest with BRP for 12 hours
 Ambulate ______ hours AFTER PROCEDURE
 Communications: Nursing remove dressing after 24 hours
☐ Sheath Management Without Closure, No Anticoagulation
☐ Remove Sheath: Arterial Now
☐ Remove Sheath: Arterial at ________________________
 Connect A-Line to pressure bag and invasive monitor until sheath removed
 Immobilize leg while sheath in place
 Bedrest, strict, with head of bed no higher than 30 degres and affected leg straight for
______ hours after sheath removed
 Ambulate with assistance first time after bedrest complete then resume usual activity level
 Apply manual pressure to obtain hemostasis
☐ Vasovagal Protocol
 Apply pressure dressing with hemostasis patch PRN for capillary bleeding
☐ Femostop Protocol PRN bleeding
 Notify physician for major arterial bleeding, SBP less than 90mmHg
 Communications: Nursing remove dressing after 24 hours
Interventional Radiology Post Order Sets
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PO0140.0021 (9/23/15)
Patient Label
☐ Sheath Management Without Closure, Heparin
☐ Remove Sheath: Arterial Now
☐ Remove Sheath: Arterial when Activated Clotting Time (ACT) is less than 150 seconds
☐ Remove Sheath: Arterial at ________________________
 Connect A-Line to pressure bag and invasive monitor until sheath removed
 Communications: Nursing Bedside ACT (I-STAT) PRN starting today
 Immobilize leg while sheath in place
 Bedrest, strict, with head of bed no higher than 30 degrees and affected leg straight for
______ hours after sheath removed
 Ambulate with assistance first time after bedrest complete then resume usual activity level
 Apply manual pressure to obtain hemostasis
☐ Vasovagal Protocol
 Apply pressure dressing with hemostasis patch PRN for capillary bleeding
☐ Femostop Protocol PRN bleeding
 Notify physician for major arterial bleeding, SBP less than 90mmHg
 Communications: Nursing remove dressing after 24 hours
☐ Sheath Management – Radial Access
☐ Leave arterial sheath in place, and connect to pressure line until further orders
☐ Bedrest for ___________ hours after procedure
☐ Ambulate wi th assitance first time after bedrest complete then resume usual activity level
☐ TR Band Management
 After 2 hrs, withdraw 2ml slowly and observe site for oozing or bleeding
 If no oozing/bleeding noted continuing aspirating 2 ml of air every 2 minutes until
device bladder is empty
 If bleeding occurs at any time during air removal, reinflate with 2ml and wait 30 minutes
before attempting removal
 If bleeding is again noted, re-inflate with 2ml of air for an additional 20 minutes and then
deflate 2ml every 15 minutes
 Immobilize wrist, no lifting or pushing with access arm for ______ hours
IV Fluids
☐ Lactated Ringers IV at _______ mL/hr
☐ Sodium Chloride 0.9% IV at __________mL/hr
☐ Sodium Chloride 0.9% with Potassium Chloride 20 meq/L IV at _________ mL/hr
☐ Sodium Chloride 0.9% with Potassium Chloride 40 meq/L IV at _________ mL/hr
☐ Sodium Chloride 0.45% IV at ___________ mL/hr
☐ Sodium Chloride 0.45% with Potassium Chloride 20 meq/L IV at _______ mL/hr
☐ Sodium Chloride 0.45% with Potassium Chloride 40 meq/L IV at _________ mL/hr
☐ Dextrose 5% in Lactated Ringers IV at ________ mL/hr
☐ Dextrose 5% in Lactated Ringers with Potassium Chloride 20meq/L IV
at _________ mL/hr
☐ Dextrose 5% in Lactated Ringers with Potassium Chloride 40meq/L IV
at__________ mL/hr
☐ Dextrose 5% in Sodium Chloride 0.45% IV at _________ mL/hr
☐ Dextrose 5% in Sodium Chloride 0.45% with Potassium Chloride with 20meq/L IV
at _________ mL/hr
☐ Dextrose 5% in Sodium Chloride 0.45% with Potassium Chloride 40meq/L IV
at_________ mL/hr
Interventional Radiology Post Order Sets
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PO0140.0021 (9/23/15)
Patient Label
Medications
☐ Vasoopressin 20 units in 100ml Sodium Chloride 0.9% via arterial catheter at
☐ 0.1 unit/minute via arterial catheter
☐ 0.2 unit/minute via arterial catheter
☐ 0.3 unit/minute via arterial catheter
☐ 0.4 unit/minute via arterial catheter
☐ Thrombolysis Medication Orders (drip catheter)
☐ tPA (Alteplase) 10mg/250ml NS infused through angiocatheter at ___ml/hr
 tPA Sliding Scale:
 If fibrinogen >200, no changes to tPA rate
 If fibrinogen >100 and <200, reduce tPA to half current rate
 If fibrinogen <100, stop tPA and call IR MD
 Sodium Chloride 0.45% at 30ml/hr if fibrinogen <100
☐ Heparin 2000 units/1000ml NS infused through sideport of sheath at 15 ml/hr
Antiemetics
☐ Metoclopramide (Reglan) 10 mg IV Q6H PRN nausea/vomiting
☐ Ondansetron (Zofran) 4 mg IV Q6H PRN nausea/vomiting
☐ Ondansetron (Zofran) 4 mg PO Q6H PRN nausea/vomiting
☐ Prochlorperazine (Compazine) 10 mg IV Q6H PRN nausea/vomiting
☐ Prochlorperazine (Compazine) 25 mg suppository per rectum Q12H PRN nausea/vomiting
☐ Promethazine (Phenergan) 12.5 mg IV Q6H PRN nausea/vomiting
☐ Promethazine (Phenergan) 25 mg IM Q6H PRN nausea/vomiting
Constipation
☐ Docusate (Colace) 100mg PO BID PRN constipation
Anti-anxiety
☐ Lorazepam (Ativan) 1 mg PO Q4H PRN anxiety/agitation
Insomnia
☐ Zolpidem (Ambien) 5 mg PO HS PRN insomnia. May repeat X 1 after 60 minutes if
ineffecive
Fever
☐ Acetaminophen (Tylenol) 650 mg PO Q4H PRN greater than 100F
☐ Acetaminophen (Tylenol) 650 mg suppository fever greater than 100F and patient unable to
tolerate PO
☐ Ibuprofen (Motrin) 400 mg PO Q4H PRN mild pain or fever greater than 100F
Mild Pain
 Acetaminophen (Tylenol) 650mg PO every 6 hours PRN mild pain
☐ Acetaminophen (Tylenol) 650mg/20.3 mL PO every 6 hours PRN mild pain
☐ Ibuprofen (Motrin) 600mg PO TID PRN mild pain
☐ Hydrocodone-Acetaminophen (Norco) 5/325mg PO every 6 hours PRN mild pain
☐ Morphine 2mg IV every 4 hours PRN mild pain
Interventional Radiology Post Order Sets
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PO0140.0021 (9/23/15)
Patient Label
Moderate Pain
 Hydrocodone-Acetaminophen (Norco) 7.5/325mg PO every 6 hours PRN moderate pain
☐ Morphine 4mg IV every 4 hours PRN pain moderate pain
Severe Pain
 Oxycodone/Acetaminophen 5/325 (Percocet) PO every 6 hours PRN severe pain
☐Hydromorphone (Dilaudid) 2mg IV every 6 hoursPRN severe pain
☐ PCA Management (Select Drug/Dose)
Please Reference Hospital-Recommended Dosing Parameters {insert link in electronic version}
☐ Morphine 30mg/30ml (Final concentration: 1mg/ml) NO BASAL RATE
☐ Loading dose: _______mg
 PCA dose _______mg every _______minutes
 Not to exceed ___________mg every 4 hours
☐ Morphine 30mg/30ml (Final concentration: 1mg/ml) BASAL RATE
 Basal rate: _____ mg/hour
☐ Loading dose: _______mg
 PCA dose _______mg every _______minutes
 Not to exceed ___________mg every 4 hours
☐ Hydromorphone (Dilaudid) 6mg/30ml (Final concentration: 0.2mg/ml)NO BASAL RATE
☐ Loading dose: _______mg
 PCA dose _______mg every _______minutes
 Not to exceed ___________mg every 4 hours
☐ Hydromorphone (Dilaudid) 6mg/30ml (Final concentration: 0.2mg/ml) BASAL RATE
 Basal rate: _____ mg/hour
☐ Loading dose: _______mg
 PCA dose _______mg every _______minutes
 Not to exceed ___________mg every 4 hours
 Sodium Chloride 0.9% at 20ml/hr while on PCA if no other maintenance IV fluids are
ordered.
 Naloxone 0.4mg IV PUSH STAT Q2MIN PRN decreased
mentation, unarousable, arousal score 5/5, respiratory rate less than 10 breaths/minute
Antiemetic
 Ondansetron (Zofran) 4mg IV PUSH Q6H PRN nausea/vomiting
 Promethazine (Phenergan) 25mg suppository per rectum Q4H PRN nausea/vomiting
Pruritus:
 Diphenhydramine (Benadryl) 25mg IV PUSH Q4H PRN itching
 Hydroxyzine (Atarax) 25mg IM Q4H PRN itching
Interventional Radiology Post Order Sets
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Patient Label
Nursing:
 PCA: Initiate PCA in PACU if patient is post-operative
 PCA: Discontinue all previously ordered opioid medication before PCA implementation
 PCA: Discontinue all previously ordered anti-emetic medications before PCA
implementation
 PCA: Discontinue all previously ordered anti-puritic medication before PCA implementation
 PCA: Educate family and patient PCA by proxy is NOT allowed
 PCA: Educate patient on proper administration and use of PCA management
 PCA: ETCO2 monitoring until PCA is discontinued
 PCA: Assess vital signs, pain, and sedation Q4H for Med-Surg
 PCA: Assess vital signs, pain, and sedation Q2H for ICU/Critical Care
 PCA: Assess vital signs before initiation or any dose/rate change. Reassess vital signs
every 15 minutes x2 then every 30 minutes x1 after any dose/rate change. Report
significant deviations from baseline to ordering physician.
 PCA: Excessive Sedation – Activate RRT
 PCA: Excessive Sedation – Stop PCA
 PCA: Excessive Sedation – Apply Oxygen
 PCA: Excessive Sedation – Notify MD Stat
☐ Discharge
☐ Discharge to home when pt is tolerating diet and pain is managed on PO meds
☐ Discharge to home after _________ hours AND when tolerating diet and pain is managed on
PO meds
☐ Call Interventional Radiologist before discharge
☐ Communicate discharge instructions and medication istructions
☐ Provide written copy of discharge instructions and medication list
Physician’s Signature: _____________________________ Date: __________ Time: _________
Interventional Radiology Post Order Sets
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Patient Label
Interventional Radiology Post Order Sets
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