CHN4100 Orthopedic Surgery Pre Operative Orders.pdf - Carondelet

USE BALL POINT PEN – PRESS FIRMLY
CARONDELET HEALTH NETWORK
HOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERS
STAT/NOW
(Check Box to Left)
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ORTHOPEDIC SURGERY PRE OPERATIVE ORDERS
PATIENT NAME:
DATE OF BIRTH:
DATE OF SURGERY: _______________________________________ Patient Time: ___________________________
* LIST ALL ALLERGIES: (Medication, food, latex and/or Contrast Dye) * Required on Admission Orders
PATIENT STATUS: Inpatient Outpatient
1. REASON FOR PROCEDURE/DIAGNOSIS:
2. VERIFY/WITNESS CONSENT FOR: (Physician to sign consent form and documents consenting process)
See consent from office
3. VTE PROPHYLAXIS
MECHANICAL PROPHYLAXIS
SCDs in place prior to anesthesia (caution in peripheral arterial insufficiency)
Ted Hose in place prior to anesthesia (except operative knee, if applicable) (caution in peripheral arterial
insufficiency)
4. ANTIBIOTIC PROPHYLAXIS: Patient Weight: ________kg
If patient is currently receiving scheduled antibiotics, indicate reason____________________________
NOTE: If patient is on therapeutic antibiotics for an unrelated infection, an appropriate prophylactic antibiotic must be
given pre-operatively OR patient should be evaluated for re-dosing of current antibiotic
All Antibiotics are to be administered 0-60 minutes prior to the first incision
(exception: within 120 minutes if using a fluoroquinolone or vancomycin)
SEE CHN ANTIMICROBIAL STEWARDSHIP PROGRAM: GUIDELINES FOR ANTIMICROBIAL PROPHYLAXIS
FOR SURGERY FOR PROCEDURES REQUIRING A PROPHYLACTIC ANTIBIOTIC
First Choice
CeFAZolin (KEFZOL)
● For patients less than 120 kg, CeFAZolin 2 grams IV push once
● For patients greater than or equal to 120 kg, CeFAZolin 3 grams IV push once
Cefuroxime (ZINACEF) 1.5 grams IVPB once
Alternative if Beta Lactam Allergy:
Clindamycin (CLEOCIN) 900 mg IVPB once
Vancomycin
● For patients less than 80 kg, Vancomycin 1 gram IVPB once
● For patients greater than or equal to 80 kg, Vancomycin 1.5 grams IVPB once
Physician Signature: Date Signed: Time Signed:
Physician Printed Name / License # / Telephone #:
PATIENT IDENTIFICATION
MEC Approval CSJ – 8/22/13 CSM – 9/26/13 CHC – 11/14/14
CHN4100 Expires – 09/2016
Page 1 of 2
UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED

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USE BALL POINT PEN – PRESS FIRMLY
CARONDELET HEALTH NETWORK
HOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERS
ORTHOPEDIC SURGERY PRE OPERATIVE ORDERS
5. For documented High Risk MRSA:
Vancomycin AND CeFAZolin (KEFZOL)
• For patients less than 80 kg, Vancomycin 1 gram IVPB once
• For patients greater than or equal to 80 kg, Vancomycin 1.5 grams IVPB once
AND
• For patients less than 120 kg, CeFAZolin (KEFZOL) 2 grams IV push once
• For patients greater than or equal to 120kg, CeFAZolin (KEFZOL) 3 grams IV push once
STAT/NOW
(Check Box to Left)
Vancomycin reasons: Must have physician/APN/PA documentation
Beta-lactam (penicillin or cephalosporin) allergy
MRSA colonization or infection
High risk due to acute inpatient hospitalization within last year prior to admission
High risk due nursing home or extended care facility within last year prior to admission
Facility wide or operation-specific increased MRSA rate
Chronic wound care or dialysis
Continuous inpatient stay of more than 24 hours prior to principal procedure
Transfer of patient following a 3-day inpatient hospitalization at another facility
Other Reason_____________________________________________
6. INITIATE PRE-OP ANESTHESIA PROTOCOL
7. Diagnostic Testing/Labs in addition to those requested on the Pre-Op Anesthesia Protocol for the following
medical conditions:
1) ______________________________________________________________
2) ______________________________________________________________
8. Blood Draw
CBC with diff
BUN/Creatinine
Liver Profile (BILI & BILC)
Potassium
Basic Metabolic Panel
Comprehensive Metabolic Panel
Type & Screen
Blood Bank Hold Clot
Type & Cross ______ units
PT/INR day of surgery
PTT
HgbA1C
POC
Urine Pregnancy Test
Other
UA, C&S if positive
MRSA Swab
CXR
ECG
9. For Total Joint Replacement Surgery: Pre Op Evaluation by CHN Surgical Nurse Practitioner, Pre Operative
Assessment Clinic
10. For Total Joint Replacement Surgery: Schedule patient for Joint Camp through Orthopedic Unit coordinator
11. Other Orders:
Physician Signature: Date Signed: Time Signed:
Physician Printed Name / License # / Telephone #:
PATIENT IDENTIFICATION
MEC Approval CSJ – 8/22/13 CSM – 9/26/13 CHC – 11/14/14
CHN4100 Expires – 09/2016
Page 2 of 2
UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED

USE BALL POINT PEN – PRESS FIRMLY
CARONDELET HEALTH NETWORK
HOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERS
TREATMENT PROTOCOL – PRE OP ANESTHESIA (CSJ/CSM)
1 Order to initiate PreOp Anesthesia Protocol was previously given by a Licensed Independent Practitioner and signed on
a separate Orders page unless box below is checked.
Initiate PreOp Anesthesia Protocol – checkmark here requires physician signature, date, time on bottom of page
2 NPO Status: Per table on page 2
3 Medications: Take all prescription medications on day of surgery with a sip of water EXCEPT:
• Metformin (Glucophage) and other oral diabetic
medications
• Any medication that needs to be taken with food
4 Other Special Medications:
• Anticoagulants as per surgeon, cardiologist or PCP
• Aspirin and Clopidogrel (Plavix) should be taken up to the
day of surgery unless specifically instructed by physician
• Insulin; unless given specific instructions by PCP,
attending or Hospitalist
• Diuretics
• Herbals, vitamins and supplements, and weight loss drugs:
Should be stopped 2 weeks prior to surgery
• Diabetics: If AM blood glucose low, may take clear liquids
with sugar
5. If patient is on a BETA BLOCKER at home, record time and date of last dose in Medication history
If patient is on a BETA BLOCKER and they have not taken it in the last 24 hours, notify anesthesia ASAP
6. Start IV in pre-op holding, Lactated Ringers at 25 mL/hour (TKO)
If renal dialysis and/or renal failure patient: Start IV with 0.9% Sodium Chloride at 25 mL/hour (TKO)
(may use 0.5 mL 1% Lidocaine for skin wheal)
Note: All testing must be based on known medical conditions, either documented in a physician’s H & P or the medical
record, or reported by a patient as an established diagnosis. Contact the anesthesiologist directly for any testing not indicated
by the protocol.
7. LAB: Lab testing may be obtained through Laboratory analysis, Point of Care, or Fingerstick testing
A checkmark in the box indicates that Lab test was done after Protocol was initiated
K+ (Potassium) within one week prior to surgery if on Digoxin or Diuretics
K+ (Potassium) day of surgery if renal dialysis and/or renal failure patient
PT/INR day of surgery if on Warfarin (COUMADIN) within the last 7 days prior to surgery
Pregnancy test if female of child bearing years (onset of menses to no menses for 1 year) and no hysterectomy
Hgb/Hct within one week (day of surgery with active bleeding) in patients with documented history of liver disease,
anemia or bleeding disorder or if indicated by type/invasiveness of surgery (see page 2).
Blood bank orders (if indicated on page 2): Hold Clot Type and screen Type and Cross 2 units PRBC’s
Blood glucose within 2 hours of surgery for diabetic patients
FOR CARDIOTHORACIC SURGERY ONLY:
ACT if patient is on Heparin infusion
Platelet Works if patient received Plavix or ASA within 1 week before cardiac surgery
8. ECG: Needed within 90 days for the following patients:
a) Patients undergoing cardiac or vascular surgical procedures
b) Patients with a pacemaker or AICD except those undergoing intraocular or endoscopic procedures
c) Patients with any of the following cardiovascular risk factors undergoing INPATIENT surgical procedures:
• coronary artery disease
(MI/PCI/stents/history of arrhythmia)
• cerebrovascular disease (TIA/CVA)
• diabetes mellitus
• peripheral artery disease
• heart failure
• renal insufficiency or failure
9. NOTIFY: Anesthesiologist of record, or on-call anesthesiologist, for abnormal values or for clarification of protocol
• K+ level less than 3.0 mmol/L or greater than 5.0 mmol/L
• INR greater than 1.5
• Positive pregnancy test
• Hgb less than 10 gram/dL or greater than 19 gram/dL
• Blood Glucose less than 60 mg/dL or greater than 200 mg/dL
10. CHG: 2% Chlorhexidine Gluconate (CHG) wipes per policy
CSM Only: 0.12% CHG mouthwash (PERIDEX) 15 mL to brush teeth, then 1 minute swish and spit
Nurse Signature per physician order: Nurse Printed Name: Date Signed: Time Signed:
Physician’s Signature if #1 box is checked Physician’s Printed Name if #1 box is checked PATIENT IDENTIFICATION
MEC Approval CSJ – 06/26/14 CSM – 06/26/14
CHN8215 Expires – 06/2017
Copy 08.11.14 Page 1 of 2
UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED

USE BALL POINT PEN – PRESS FIRMLY
CARONDELET HEALTH NETWORK
HOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERS
TREATMENT PROTOCOL – PRE OP ANESTHESIA (CSJ/CSM)
WILL BE APPENDED TO THE FOLLOWING PREPRINTED ORDERS THAT REFERENCE “ANESTHESIA PROTOCOL”:
SHOCK WAVE LITHOTRIPSY, GENERAL SURGERY PRE OPERATIVE ORDERS – CSJ / CSM, SLEEVE GASTRECTOMY PRE OPERATIVE ORDERS,VASCULAR SURGERY
PRE-OP ORDERS, PERI-OPERATIVE EXCISION OF PTERYGIUM ORDERS, PRE OPERATIVE E.N.T ORDERS, PRE-OP ORTHOPEDIC SURGERY ORDERS, RETINA
PERIOPERATIVE ORDERS – CSJ, TRABECULECTOMY PERI-OPERATIVE ORDERS,PODIATRY PERIOPERATIVE ORDERS, EAR/NOSE/THROAT (ENT) PERIOPERATIVE
ORDERS –CSJ, OPHTHALMOLOGY PERIOPERATIVE ORDERS-CSJ, GYN PREOPERATIVE ORDERS – CSJ
NPO Status Instructions to Patient Minimum Period
Clear liquids (black coffee, apple juice, grape juice) Up to 4 hours pre-op 2 hours
Breast milk Up to 4 hours pre-op 4 hours
Infant formula Up to 6 hours pre-op 6 hours
Light meal (Dry toast and clear liquids) None after midnight 6 hours
Fried or fatty food and meat (includes milk products) None after midnight 8 hours
Solids in high risk patients (e.g.: diabetes, pregnancy, obesity) None after midnight 8 hours
PRE-OPERATIVE HGB/HCT and BLOOD BANK REQUIREMENTS
Surgery
MAJOR ABDOMINAL:
Whipple
Splenectomy
Gastrectomy
Abdominal perineal resection
Bleeding ulcer
Adrenalectomy
Esophagogastrectomy
Hysterectomy
Colectomy
VASCULAR:
AAA, open abdominal
AAA, endovascular
Any bypass case
Any endarterectomy
Aneurysmal repairs
Repair/excision of infected grafts
BKA/AKA
CARDIOTHORACIC:
Cardiac Surgeries
Thoracic Surgeries
ORTHOPAEDIC:
Total Hip/Knee Arthroplasty
Hip Fracture/Revision
Spine surgery (2 or more levels)
Other Total Joints
UROLOGICAL:
Nephrectomy
Cystectomy
Prostatectomy
TURP
NEUROLOGIC:
Craniotomy
Spine surgery (2 or more levels)
Aneurysm repair/clipping
PLASTICS:
TRAM
Pressure ulcers
Type & Cross
2 units PRBCs
And HGB/HCT
X
X
X
Type & Screen
And HGB/HCT
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
HGB/HCT & Hold Clot
(if HGB/HCT