Download Craniotomy Postop

PHYSICIAN'S ORDERS
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Neuroscience Institute
Craniotomy - Neurosurgery Post-Operative Orders
Unit:
ICU
IMC
General Floor
Code Status:
Full Code
DNR
Allergies:
NKDA
List:_____________________________________________
________________________________
ICU - Every 15 minutes times 2 hours; then every 30 minutes times 2 hours; then every hour.
Vital Signs &
Neuro Checks: IMC - Upon arrival; @ 15 minutes times 1; every hour times 4; then every 4 hours.
General Floor - Upon arrival; every hour times 4; then every 4 hours.
Notify surgical team for:
Deterioration in neurological status
Drain output greater than 250 mL in 4 hours
Dressing saturation times 2 in less than 4 hours
Notify medical team for:
Systolic blood pressure greater than 200 mmHg or less than 80 mmHg
Heart rate greater than 125 or less than 50 beats per minute
Temperature greater than 101.5° F
IV Fluids:
(choose one)
Medications:
When multiple routes provided, order of preference is PO, gastric tube, IV then rectal.
Analgesia:
Severe Pain:
If not tolerating oral intake and no gastric tube:
Morphine 2 mg IV every 15 minutes PRN severe pain. Maximum of 30 mg per 4 hour period. Hold
for heart rate less than 60 beats per minute or respiratory rate of less than 10 per minute or systolic
blood pressure of less than 90 mmHg.
Morphine 1-2 mg IV every 1 hour PRN pain. Hold for heart rate less than 60 beats per minute
or respiratory rate of less than 10 per minute or systolic blood pressure of less than 90 mmHg.
Fentanyl 25 mcg IV every 10 minutes PRN pain. Hold for heart rate less than 60 beats per minute
or respiratory rate of less than 10 per minute or systolic blood pressure of less than 90 mmHg.
ONLY FOR USE IN THE ICU SETTING.
Meperidine (Demerol) ________mg IM every 3 hours PRN for pain.
If administering IV narcotic pain medications on the general floor, monitor patient with
continuous pulse oximetry with alarm set to 92% saturation.
(>7 pain scale)
(choose one)
Analgesia:
Oral
Continue IV bag from operating room at 80 mL per hour, then begin:
0.9% NaCl with __________ at _________ mL per hour.
Lactated Ringer's at ________ mL per hour.
Other: ___________________________ at __________ mL per hour.
Peripheral lock IV and discontinue maintenance IV fluids when oral intake greater than 500 mL per
day, then discontinue IV lock when antibiotic complete and no further need for IV medication.
When tolerating oral intake or has gastric tube, discontinue injectable opioid and begin:
Maximum daily dosage of Acetaminophen not to exceed 4000 mg from all sources.
Cepacol lozenge PO PRN throat irritation.
Prescriber's Signature
Scanned to pharmacy / entered into TDS by:
_______________________Date_____________Time______
TRINITY MOTHER FRANCES
*DT171*
HOSPITALS AND CLINICS
PHYSICIAN ORDERS
Craniotomy - Neurosurgery
Post-Operative Orders
E.F. 171-1282
Rev.10/12
Pg 1 of 5
Orders verified by:
_______________________Date_____________Time______
PHYSICIAN'S ORDERS
Mark X in for desired orders. If is blank, order is inactive. denotes standing active orders
Neuroscience Institute
Craniotomy - Neurosurgery Post-Operative Orders - Continued
Mild Pain:
(<4 pain scale)
Moderate Pain:
(4-7 pain scale)
Acetaminophen (Tylenol) 650 mg PO/gastric tube every 4 hours PRN, or patient refuses opioids
or if temperature > 100.5° F., or headache. If NPO, give Acetaminophen (Tylenol) 650 mg
rectally every 6 hours PRN pain.
Oxycodone/acetaminophen (Percocet) 5 mg/325 mg 1-2 tablets PO or per gastric tube every
4 hours PRN pain.
Oxycodone 5 mg 1-2 tablets PO or per gastric tube every 4 hours PRN pain.
Hydrocodone/acetaminophen (Norco) 5/500 1-2 tablets PO every 4-6 hours PRN pain.
Hydrocodone/acetaminophen (Norco) 7.5/500 1-2 tablets PO every 4-6 hours PRN pain.
Hydrocodone/acetaminophen (Norco) 10 mg/325 mg 1-2 tablets PO or per gastric tube every
4 hours PRN pain.
Other: _______________________________________________________________
Maximum daily dosage of Acetaminophen not to exceed 4000 mg from all sources.
Antispasmodic/
Anxiolytic:
(choose one)
Methocarbamol (Robaxin) 750 mg 1 tablet PO or per gastric tube every 12 hours PRN
muscle spasms.
Diazepam (Valium) 5 mg PO or per gastric tube every 6 hours PRN muscle spasms/anxiety.
Sedatives:
(choose one)
Zolpidem (Ambien) 5 mg PO or per gastric tube every bedtime PRN insomnia. May repeat once
after one hour if patient still awake.
Diphenhydramine (Benadryl) 25 mg PO, per gastric tube or IV every bedtime PRN insomnia.
May repeat once after one hour if patient still awake.
Antihypertensive:
Labetalol (Trandate) 10 mg IV every 10 minutes as needed for systolic blood pressure greater
than ____ mmHg. Hold for heart rate of less than ____ beats per minute. May repeat times
4 doses. If not effective notify consulting hospitalist. ONLY FOR USE IN ICU SETTING.
Clonidine (Catapres) 0.2 mg PO or per gastric tube every 4 hours PR, SBP greater than _______
mmHg or DBP > _______. If not effective notify consulting hospitalist.
Tachycardia:
Metoprolol (Lopressor) 5 mg IV every 15 minutes as needed for heart rate greater than _______
beats per minute. Hold for systolic blood pressure of less than ______ mmHg. May repeat times
4 doses. ONLY FOR USE IN ICU SETTING.
Antibiotic:
(choose one)
Cefazolin (Ancef) 1 gm (for patients < 80 kg) or 2 gm (for patients > 80 kg) IV every 8 hours
times 2 doses.
Clindamycin (Cleocin) 900 mg IV times 1 dose within 12 hours of surgery completion.
Vancomycin (Vancocin) _______ mg IV times 1 dose within 12 hours of surgery completion.
Prescriber's Signature
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_______________________Date_____________Time______
TRINITY MOTHER FRANCES
HOSPITALS AND CLINICS
*DT171*
PHYSICIAN ORDERS
Craniotomy / Neurosurgery
Post-Operative Orders
E.F. 171-1282
Rev. 10/12
Pg 2 of 5
Orders verified by:
_______________________Date_____________Time______
PHYSICIAN'S ORDERS
Mark X in for desired orders. If is blank, order is inactive. denotes standing active orders
Neuroscience Institute
Craniotomy - Neurosurgery Post-Operative Orders - Continued
Anticonvulsant:
Phenytoin (Dilantin) 300 mg PO or per gastric tube every bedtime.
Fosphenytoin (Cerebyx) 300 mg phenytoin equivalents IV every bedtime.
Other: _________________________________________________________________________
Slow Taper: Option 1
Steroid:
Dexamethasone (Decadron) 10 mg every 8 hrs times 3 days, then 8 mg every 8 hrs times 2 days,
IV, PO, PT, IM
then 6 mg every 8 hrs times 3 days, then 4 mg every 8 hrs times 2 days,
(choose one)
then 2 mg every 8 hrs times 3 days, then 1 mg every 8 hrs times 2 days,
then 1 mg every 12 hrs times 3 days, then 1 mg every day times 2 days, then discontinue.
Slow Taper: Option 2
Dexamethasone (Decadron) 4 mg four times daily for 2 days, then 3 mg four times daily for 2 days,
then 2 mg four times daily for 2 days, then 1 mg four times daily for 2 days, then discontinue.
Medium Taper: Dexamethasone (Decadron) 10 mg every 8 hrs times 2 days,
then 8 mg every 8 hrs times 2 days, then 6 mg every 8 hrs times 2 days,
then 4 mg every 8 hrs times 2 days, then 2 mg every 8 hrs times 2 days,
then 1 mg every 8 hrs times 2 days, then 1 mg every 12 hrs times 2 days,
then 1 mg every day times 2 days, then discontinue.
Rapid Taper: Option 1
Dexamethasone (Decadron) 10 mg every 8 hrs times 1 day, then 8 mg every 8 hrs times 1 day,
then 6 mg every 8 hrs times 1 day, then 4 mg every 8 hrs times 2 days,
then 2 mg every 8 hrs times 2 days, then 1 mg every 8 hrs times 1 day,
then 1 mg every 12 hrs times 1 day, then 1 mg every day times 1 day, then discontinue.
Rapid Taper: Option 2
Dexamethasone (Decadron) 4 mg four times daily for 1 day, then 3 mg four times daily for 1 day,
then 2 mg four times daily for 1 day, then 1 mg four times daily for 1 day, then discontinue.
Other: __________________________________________________________________
Antacid:
Antiemetic:
Pantoprazole (Protonix) 40 mg PO or IV daily.
Lansoprazole (Prevacid Solutab) soluble tablet 30 mg per gastric tube daily.
Famotidine (Pepcid) 20 mg PO or IV or per gastric tube twice daily.
Calcium carbonate (Tums) 500 mg PO or per gastric tube every 4 hours PRN indigestion or heartburn.
Ondansetron (Zofran) 4 mg IV every 6 hours PRN nausea and/or vomiting.
If Ondansetron ineffective after 2 doses, give Promethazine (Phenergan) 12.5 mg IV once for
nausea and/or vomiting. Reassess patient 30 minutes after dose. If nausea/vomiting persist, notify
consulting hospitalist.
Other: ___________________________________________________________________
Prescriber's Signature
Scanned to pharmacy / entered into TDS by:
_______________________Date_____________Time______
TRINITY MOTHER FRANCES
*DT171*
HOSPITALS AND CLINICS
PHYSICIAN ORDERS
Craniotomy / Neurosurgery
Post-Operative Orders
E.F. 171-1282 Rev. 10/12
Pg 3 of 5
Orders verified by:
_______________________Date_____________Time______
PHYSICIAN'S ORDERS
Mark X in for desired orders. If is blank, order is inactive. denotes standing active orders
Neuroscience Institute
Craniotomy - Neurosurgery Post-Operative Orders - Continued
Laxative:
Initiate Neuroscience Bowel Protocol Set.
Other: ___________________________________________________________________
Other Medications:
DRUG
DOSE
ROUTE
FREQ
INDICATION
Diet:
NPO
Oral fluids as tolerated
Advance diet to high fiber as tolerated
Other: ______________________________________________________________
Urinary:
Urinary catheter out now
Indwelling urinary catheter
Urinary catheter out 0600
day after surgery
POD # _______.
If urine is cloudy or malodorous, check urinalysis and culture with sensitivity. Notify hospitalist
if >100 WBC's, > 30 RBC's, many organisms on microscopy or > 100,000 CFU's on culture.
Initiate Neuroscience Urinary Retention Protocol.
Other: ________________________________________________________________
Activity:
Progress to ambulating one hour after PACU.
Ambulate with assistance; starting day after surgery a minimum of _____ times per day.
Out of bed to chair
Up to void at bedside
Bedrest
Other: ________________________________________________________________
Imaging:
None
Obtain MRI Head after surgery w/ and w/o gadoliniuim Date: ___________________
Date: ___________________
Obtain MRA of intracranial vasculature after surgery
Date: ___________________
Obtain CT Head after surgery w/o contrast
Date: ___________________
Obtain CT Head after surgery w/contrast
Other: _________________________________________________________________
Prescriber's Signature
Scanned to pharmacy / entered into TDS by:
_______________________Date_____________Time______
TRINITY MOTHER FRANCES
HOSPITALS AND CLINICS
*DT171*
PHYSICIAN ORDERS
Craniotomy / Neurosurgery
Post-Operative Orders
E.F. 171-1282 Rev. 10/12 Pg 4 of 5
Orders verified by:
_______________________Date_____________Time______
PHYSICIAN'S ORDERS
Mark X in for desired orders. If is blank, order is inactive. denotes standing active orders
Neuroscience Institute
Craniotomy - Neurosurgery Post-Operative Orders - Continued
None
Labs:
Misc Orders: Other: _______________________________________________________
Strictly record intake and output every 8 hours.
Incentive spirometry 10 times per hour when awake.
Fall precautions
Continue hospitalist consultation orders for medications. If any discrepancies, please follow
neuroscience order set.
Administer supplemental O2 (continue and adjust if from PACU) to keep SpO2 > 92%.
Check SpO2 every 4 hours and wean supplemental oxygen to off as able keeping SpO2 > 92%.
Respiratory: Assess and treat per protocol
Head of bed elevated _____ degrees. Other: ______________________________
Compression device to lower legs.
Dressing assessment every 4 hours times 2, then every 8 hours.
Discontinue dressing morning after surgery.
Drain output assessment every 4 hours.
Discontinue drain day after surgery after surgical team has assessed and output is less than 50 ml
in last eight hours.
Hospitalist/Intensivist Consult to co-manage patient post-operatively.
Endocrinology consult to endocrinologist on-call to see patient post-operatively.
Physical Therapy Occupational Therapy Speech Therapy:
consult, evaluate and treat as indicated on day of surgery.
Case Management/Social Work consult - assist with discharge planning.
Rehab
HHC
SNF
Hospice
Schedule Outpatient Physical Therapy to start _____ weeks from date of surgery.
Suture kit, 3-O Nylon, size 8 gloves, 4x4's, Betadine, alcohol swabs, 1% xylocaine with epinephrine
to bedside.
Time:
Date:
(Required)
(Required)
Prescriber's Signature
Service Pager:
Printed Name
Scanned to pharmacy / entered into TDS by:
_______________________Date_____________Time______
TRINITY MOTHER FRANCES
*DT171*
HOSPITALS AND CLINICS
PHYSICIAN ORDERS
Craniotomy / Neurosurgery
Post-Operative Orders
E.F. 171-1282
Rev. 10/12
Pg 5 of 5
Orders verified by:
_______________________Date_____________Time______
PHYSICIAN'S PROTOCOL
NEUROSCIENCE INSTITUTE BOWEL PROTOCOL
Protocol applies to adult Neuroscience patients (greater than 14 years of age).
Maintenance of patient's normal bowel pattern.
Production of soft, formed stool every 1-3 days
Patient's routine bowel habits should be recorded by nurse as well as any routine home medications utilized
to modify bowel habits.
Inclusion Criteria:
• Change in recent normal bowel pattern with decreasing stool frequency.
• Lack of bowel movement in prior three days.
• Recent spinal cord injury.
• Post-operative patients or patient receiving narcotic pain medication.
• Chronic neurogenic bowel.
Purpose:
Goal:
Data:
If any of above conditions met, proceed to Therapeutic Intervention section.
Therapeutic Intervention:
Diet: For patients able to tolerate a general diet without restrictions, a high fiber diet should be ordered (i.e. to include whole
whole grains, vegetables and fresh fruit).
If patient is receiving enteral tube feedings, fiber should be added to the formula. Obtain a nutritional consult.
Enteral feeding type, rate and fiber content supplementation as recommended by dietitian.
Fluid intake should be encouraged unless patient is on a fluid restriction order or present urine output is greater than
2000 mL per day.
Activity:
If patient is able and allowed to mobilize per primary physician's activity orders, encourage ambulation and use of either
a bedside commode or toilet.
Medication:
Senna and Docusate (8.6 mg/50 mg - Senokot-S) 2 tablets PO or per gastric tube every bedtime while
receiving opioids.
Bisacodyl (Dulcolax) 10 mg PO twice daily. May give rectally if unable to tolerate PO.
Milk of Magnesia 30 mL PO or per gastric tube daily PRN no bowel movement in over 24 hours.
Check serum magnesium level daily in patients with renal impairment (creatinine greater than 1.5).
If no bowel movement by third day of admission, initiate:
Polyethylene glycol 3350 (Miralax) 17 gm (1 heaping tablespoon) powder dissolved in 8 oz. beverage
PO daily PRN no bowel movement.
Initiate digital stimulation of rectum. If impaction, manually cleanse.
If incomplete impaction removal, or no bowel movement after above, give Sodium phosphate (Fleets)
enema rectally twice daily PRN no bowel movement.
If stools become liquid:
Discontinue Senna/Docusate and Bisacodyl.
Continue high-fiber diet, enteral feedings, fluid support and mobilization.
Collect and submit stool specimen for Clostridium difficile toxin (C. diff.) on two separate occasions.
Scanned to pharmacy / entered into TDS by:
_______________________Date_____________Time______
TRINITY MOTHER FRANCES
*DT171*
HOSPITALS AND CLINICS
PHYSICIAN ORDERS
TMFHS Neuroscience Institute
Bowel Protocol
E.F. 171-1205
Rev. 11/11
Pg 1 of 1
Orders verified by:
_______________________Date_____________Time______
PHYSICIAN'S PROTOCOL
NEUROSCIENCE INSTITUTE
URINARY RETENTION PROTOCOL
Protocol applies to adult Neuroscience patients (greater than 14 years of age).
Purpose: Maintenance of patient voiding capacity.
Goal:
Alleviation of urinary retention and reduction of urinary residuals to less than 250 mL.
Data:
Patient's routine urinary habits should be recorded by a nurse as well as any routine home medications utilized
to modify urination.
Inclusion Criteria:
• Change in recent voiding patterns and fluid balance (i.e. intraoperative intravenous fluids, blood loss, change in typical volume or
frequency of urination).
• Bladder distension by palpation.
• Presence of suprapubic pain.
• Post-operative patients having received general anesthetic or patient receiving narcotic pain medication.
• Recent spinal cord injury.
• Chronic neurogenic bladder.
• If any of the above conditions are met, proceed to Therapeutic Intervention section.
Therapeutic Intervention:
Utilize voiding measures to facilitate bladder emptying (privacy, relaxed environment, suprapubic massage, application of
suprapubic warm compress and trigger techniques).
If patient is able and allowed to mobilize per primary physician's activity orders, encourage frequent ambulation.
Measure and record time and amount of urine output.
Measure retention / post-void residual volumes via bladder scan.
Unless otherwise ordered by physician, obtain a in and out bladder catheterization for:
1) Estimated retention volume greater than or equal to 500 mL or greater than or equal to 250 mL and patient discomfort.
2) Estimated post-void residual volume greater than or equal to 250 mL.
If urine retention greater than or equal to 500 mL or symptomatic retention greater than or equal to 250 mL persists for greater
than 48 hours, start scheduled voiding attempts every 3 hours while awake with bladder scan after each attempt. In and out
catheterize for retention greater than or equal to 250 mL.
Lidocaine 2% gel may be applied to intermittent catheter as needed for urethral discomfort.
Discontinue intermittent catheterizations if urethral bleeding occurs or if hematuria. Notify hospitalist.
If signs / symptoms of a urinary tract infection are present (urinary frequency / urgency / burning pain / malodorous urine /
excessively cloudy), obtain a urinalysis with microscopic evaluation, Gram stain, and culture / sensitivity. A midstream urine
collection is desired, but if unable, collect urine by straight catheterization.
Once two consecutive bladder scans demonstrate an estimated post-void residual volume of less than 250 mL, bladder
scanning may be discontinued.
Educate patient on:
Bladder emptying techniques and procedures.
Signs and symptoms of urinary retention.
Scanned to pharmacy / entered into TDS by:
_______________________Date_____________Time______
TRINITY MOTHER FRANCES
HOSPITALS AND CLINICS
*DT171*
NEUROSCIENCE INSTITUTE
URINARY RETENTION PROTOCOL
E.F. 171-1278 Rev. 11/11 Pg. 1 of 1
Orders verified by:
_______________________Date_____________Time______