CHN4100 Orthopedic Surgery Pre Operative Orders.pdf - Carondelet

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P H Y S I C I A N ‘ S O R D E R 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
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CHN4100 Orthopedic Surgery Pre Operative Orders.pdf - Carondelet

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