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ADDRESSOGRAPH GREY BRUCE HEALTH NETWORK Page 1 of 3 SITE: __________________ Allergies: □ NKA or: __________________________ Weight (kg) _______________ Radical Prostatectomy Post-Operative Order Set Open Box indicates optional order, activated when checked . Checked Box indicates mandatory order unless crossed out. Diet ______ Sips to clear fluids ______ Regular Diet OR Energy controlled Diet _____ kcal when passing flatus ______ Activity as tolerated Activity Out of bed day of surgery Ambulate TID Post-Op Day 1 Vital Signs ______ VS + O2 sats Q4H x 24 hours, QID x 24 hours then BID when stable ______ Notify physician for temp greater than 38.5° C; systolic blood pressure less than 90 mmHg or greater than 160 mmHg; diastolic blood pressure greater than 100 mmHg; pulse less than 50 bpm or greater than 120 bpm; urine output less than 120 mL in 4 hours, or O2 sats less than 92% Patient Care ______ Direct Care: Height and Weight on admission Tubes/Drains ______ Urinary catheter to straight drainage ______ Manual irrigation PRN ______ NS bladder irrigation at a rate of 125 mL/h Or at a rate to maintain catheter patency. Decrease when urine clear or light pink ______ Catheter traction overnight. Discontinue catheter traction Post-Op Day 1 ______ Snyder drain to suction. Empty QSHIFT and PRN ______ If Tube/Drain ordered/present, select accompanying “Care” order Incision/Wound Care ______ Change Dressing 24 hours Post-Op, then PRN POC ______ POC Capillary Glucose: BID before meals or TID before meals or TID AC and QHS ______ If POC ordered, select accompanying “Reassessment” order – Physician to reassess after 72 hours ______ CBC, Electrolytes, Creatinine in PACU and Laboratory Daily x 1 day Daily x 2 days Physician’s Signature _________________________ Date ________________ Time ____________ Page 1/3 GBHN/Radical Prostatectomy Post op/MD/09-11/v3 Copyright © 2007-2012 Grey Bruce Health Network NOTE: this is a CONTROLLED document as are all files on this server. Any documents appearing in paper form are not controlled and should ALWAYS be checked against the server file versions (electronic version) prior to use. ADDRESSOGRAPH GREY BRUCE HEALTH NETWORK Page 2 of 3 SITE: __________________ Allergies: □ NKA or: __________________________ Weight (kg) _______________ Radical Prostatectomy Post-Operative Order Set IV Solutions ______ IV Fluid: ______ ______ Ringers Lactate 125 mL/h 2/3 1/3 NS With 20 mEq KCl per L of IV fluid With 40 mEq KCl per L of IV fluid Rate ___________________ mL/h ______ If IV ordered/present, select accompanying “Care” order ______ Saline lock IV when drinking well ______ Intake and Output with all continuous IV orders and/or if Tube/Drain present Medications ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ Belladonna and Opium suppository Rectally Q6H PRN bisaCODYL suppositories 10 mg Daily Rectally, starting Post-Op Day 1, until flatus Docusate Sodium 100 mg PO BID Hyoscine Butylbromide 20 mg IV or Subcutaneous Q4H PRN Acute Pain Service dimenhyDRINATE 25 – 50 mg IV or NG or PO Q4H PRN Antibiotic Prophylaxis Cephalexin 500 mg PO BID Nitrofurantoin SR 100 mg PO Daily Diabetes Management Hypoglycemia Clinical Protocol greater than or equal to 18 years Subcutaneous Insulin Order Set VTE Prophylaxis Management ______ Enoxaparin 40 mg Subcutaneous once Daily ______ Dalteparin 5,000 units Subcutaneous once Daily (HDH only) OR OR ______ ______ ______ Heparin 5,000 units Subcutaneous Q12H If Enoxaparin / Dalteparin / Heparin ordered, then CBC, INR, PTT, Creatinine prior to initiating therapy if not already ordered CBC day 1, 3, 7 ______ Reassess DVT prophylaxis therapy when patient is ambulating and on day of discharge ______ Intermittent Pneumatic Compression Device: Thigh High. Discontinue when ambulating. ______ If Pneumatic Compression Device ordered/present, select accompanying “Removal and Care” order Physician’s Signature _________________________ Date ________________ Time ____________ Page 2/3 GBHN/Radical Prostatectomy Post op/MD/09-11/v3 Copyright © 2007-2012 Grey Bruce Health Network NOTE: this is a CONTROLLED document as are all files on this server. Any documents appearing in paper form are not controlled and should ALWAYS be checked against the server file versions (electronic version) prior to use. ADDRESSOGRAPH GREY BRUCE HEALTH NETWORK Page 3 of 3 SITE: __________________ Allergies: □ NKA or: __________________________ Weight (kg) _______________ Radical Prostatectomy Post-Operative Order Set Admission/Discharge/Transfer ______ Plan for Post-Op Day 1 – 3 discharge ______ Follow up in 2 weeks for catheter removal after cystogram Consults ______ Chest Physiotherapy ______ CCAC for catheter care, wound care and supplies Other ______ Order Set Orderable – Radical Prostatectomy Post-Operative (Automatic order for statistical reports) Additional Orders ______ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ Physician’s Signature _________________________ Date ________________ Time ____________ Page 3/3 GBHN/Radical Prostatectomy Post op/MD/09-11/v3 Copyright © 2007-2012 Grey Bruce Health Network NOTE: this is a CONTROLLED document as are all files on this server. Any documents appearing in paper form are not controlled and should ALWAYS be checked against the server file versions (electronic version) prior to use.
