Download Pre Post Op Outpatient Surgery

1. ALLERGIES/REACTIONS:
2. † Inpatient
† Outpatient Surgery/Procedure
3. LEVEL OF CARE:
† Med/Surg
† Med/Surg Tele
† PCU
† ICU
4. PREFERRED LOCATION (UNIT/SERVICE):
5. PROCEDURE:
6. NUTRITION:
Progress diet to regular as tolerated; discontinue IV when taking fluids
7. ACTIVITY:
Up with assistance when able
8. LAB:
† HCT
† Other:
† BMP
† PT/INR
9. X-RAY:
10. GLUCOSE MANAGEMENT:
… Fingerstick blood glucose before meals and at bedtime or if NPO check every 6 hours
… See Glucose Correction Scale Protocol Orders (Physician Order #549)
11. MEDICATIONS:
6 Complete Medication Reconciliation Orders
† Nurse may initiate Over the Counter Patient Care Products Order
† If Prophylactic Antibiotics need to continue for 24 hours, use Inpatient General Surgical Post-Operative
(Physician Order #595)
[NOTE: Number only those medications desired. The nurse will select #1 as the first medication to be given. If
ineffective, #2 will be used next, and then #3, #4, etc. Number IV/IM Meds and Oral Meds separately. If orders
chosen are not numbered, the nurse will contact the prescriber for clarification.]
Analgesia
IV/IM Analgesia:
Morphine sulfate
mg IV every 1 hour or
mg IM every 3 hours PRN pain
Hydromorphone (Dilaudid)
mg IV every 1 hour or
mg IM every 3 hours PRN pain
(NOTE: 1 mg hydromorphone = 7 mg morphine. Usual starting dose for hydromorphone is 0.2 – 0.6 mg in
opiate naïve patients. Patients with prior opiate exposure may tolerate higher initial doses.)
Non Steroidal Anti-Inflammatory Medications:
† Ketorolac (Toradol) 15 mg IV/IM every 6 hours PRN pain. Discontinue Toradol 24 hours after order is initiated and
order a serum creatinine, further Toradol dosing requires a new physician order.
† Ketorolac (Toradol) 30 mg IV/IM every 6 hours PRN pain. Discontinue Toradol 24 hours after order is initiated and
order a serum creatinine, further Toradol dosing requires a new physician order. Not for use in patients age 65 and
over.
† Naproxen (Naprosyn) 250 mg PO every 6 hours with food or a snack PRN pain. First dose of Naproxen must be
given no sooner than 6 hours after last Toradol dose.
† Ibuprofen (Motrin) 400 mg 1-2 tablets PO every 6 hours PRN pain or fever. First dose of Ibuprofen must be given
no sooner than 6 hours after last Toradol dose.
Physician initial:
PATIENT INFORMATION
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Revision H
PHYSICIAN ORDERS
OUTPATIENT SURGERY POST-OP
11. MEDICATIONS: (Continued)
Oral Analgesia: (When pain is under control and patient tolerating oral intake, trial oral pain medications)
Oxycodone 5 mg with acetaminophen 325 mg (Percocet/Roxicet) 1-2 tablets every 4 hours PRN pain
Hydrocodone bitartrate 5 mg/acetaminophen 500 mg (Vicodin) 1-2 tablets PO every 4 hrs PRN pain
(Not to exceed 8 tablets per 24 hour)
Acetaminophen (Tylenol) 325 mg 1-2 tablets PO every 4 hours PRN mild discomfort
Acetaminophen (Tylenol) liquid
mg PO every 4 hours PRN mild discomfort
(LIMIT THE TOTAL DOSE OF ALL ACETAMINOPHEN CONTAINING PRODUCTS TO 4000 MG PER DAY)
Break Through Pain:
If above oral medications are ineffective after 1 hour minimum, use
… Oxycodone 5 mg 1-2 tablets PO every 3 hours PRN pain
[NOTE: Number only those medications desired. The nurse will select #1 as the first medication to be given. If
ineffective, #2 will be used next, and then #3, #4, etc. If orders chosen are not numbered, the nurse will contact
the prescriber for clarification.]
Nausea/Vomiting:
Ondansetron (Zofran) 4 mg IV every 8 hours PRN nausea/vomiting
If ondasetron ineffective, discontinue ondansetron and give promethazine (Phenergan) 12.5-25 mg IV
every 4 hours PRN nausea/vomiting. Use 6.25-12.5 mg IV for patients over 65.
Metoclopramide (Reglan) 10 mg IV every 6 hours PRN nausea/vomiting
Other Medications:
12. INTRAVENOUS FLUIDS:
… Follow current IV with
… Discontinue IV when tolerating oral intake
… Maintain saline lock
at
ml/hour
13. TREATMENT/DISCHARGE INSTRUCTIONS:
Routine vital signs until discharge
6 Patient may be discharged after discharge criteria are met. If not stable, call physician for additional orders.
Clarify patient status (Inpatient or Outpatient medical observation for documented symptoms and preferred
location)
… Please call MD with time of discharge
… Call MD office for follow-up appointment in
days / weeks
… Discharge prescriptions given preoperatively
… Discharge prescriptions in chart
… Straight cath PRN if unable to void
† Bladder scan after first void and/or first attempt to void. If residual urine greater than 150 ml, place catheter with
retention catheter and call MD with results.
† Patient may use home CPAP/BIPAP equipment and settings
… Walk regularly, no heavy lifting (15 lb limit times
)
… Remove dressing in
days, then may shower, leave steri-strips, skin glue and/or op-site on incision
… Ice bag to wound intermittently for 24 hours only, then intermittent heating pads as needed
Other:
NOTE: These orders should be reviewed by the attending physician, appropriately modified for the individual patient, dated,
timed and signed below.
DATE
TIME
PHYSICIAN’S SIGNATURE
Another brand of drug, identical in form and content, may be dispensed unless checked. …
PATIENT INFORMATION
Page 2 of 2
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Revision H
PHYSICIAN ORDERS
OUTPATIENT SURGERY POST-OP