CHN4623 ENT Pre Op Orders.pdf - Carondelet

PHYSICIAN‘SORDERUSE BALL POINT PEN – PRESS FIRMLYCARONDELET HEALTH NETWORKHOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERSEAR/NOSE/THROAT PRE OPERATIVE ORDERSPhysician Signature: Date Signed: Time Signed:STAT/NOW(Check Box to Left)PATIENT NAME:DOB:DATE OF SURGERY: ________________________________________ Patient Time: _________________* LIST ALL ALLERGIES: (Medication, food, latex and/or Contrast Dye) * Required on AdmissionOrdersPATIENT STATUS: Inpatient Outpatient (check if applicable)1. Diagnosis:2. VERIFY/WITNESS CONSENT for:TonsillectomyAdenoidectomyTonsillectomy and AdenoidectomyBilateral Tympanostomies with tubesThyroidectomy Right Left Right and LeftParathyroidectomyEndoscopic Sinus SurgerySeptoplasty with submucous resection inferior turbinatesOther: ____________________________3. VTE Prophylaxis:TEDs Knee high Thigh high SCDs4. ANTIBIOTIC PROPHYLAXIS: Patient Weight: ________kgIf patient is currently receiving scheduled antibiotics, indicate reason___________________________________NOTE: A pre-operative prophylactic antibiotic must be given regardless of the patient being on therapeuticantibiotics.All Antibiotics are to be administered 0-60 minutes prior to the first incision(exception: within 120 minutes if using a fluoroquinolone or vancomycin)CLEAN-CONTAMINATED (OROPHARYNGEALMUCOSA IS COMPROMISED):CeFAZolin (KEFZOL) AND MetroNIDAZOLE (FLAGYL)• For patients less than 120 kg, CeFAZolin (KEFZOL) 2 grams IV push once AND MetroNIDAZOLE(FLAGYL) 500 mg IVPB once• For patients greater than or equal to 120 kg, CeFAZolin (KEFZOL) 3 grams IV push once ANDMetroNIDAZOLE (FLAGYL) 500 mg IVPB onceClindamycin (CLEOCIN) 900 mg IVPB once AND Gentamicin 5 mg/kg IVPB once5. Initiate Pre Op Anesthesia Protocol6. Diagnostic Testing/Labs in addition to those requested on the Anesthesia Protocol for the following medicalconditions:_________________________________________________________________________________________CBC with diff CBC without diff PT w/INR PTT Basic Metabolic PanelUA/C&S if indicated Other: ___________________________________Please FAX this requisition to Pre-Admission TestingPhysician Printed Name / License # / Telephone #:PATIENT IDENTIFICATIONMEC Approval CSJ – 08/22/13 CSM -09/26/13CHN4623 Expires – 09/2016UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED

USE BALL POINT PEN – PRESS FIRMLYCARONDELET HEALTH NETWORKHOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERSTREATMENT PROTOCOL – PRE OP ANESTHESIA (CSJ/CSM)1 Order to initiate PreOp Anesthesia Protocol was previously given by a Licensed Independent Practitioner and signed ona separate Orders page unless box below is checked.Initiate PreOp Anesthesia Protocol – checkmark here requires physician signature, date, time on bottom of page2 NPO Status: Per table on page 23 Medications: Take all prescription medications on day of surgery with a sip of water EXCEPT:• Metformin (Glucophage) and other oral diabeticmedications• Any medication that needs to be taken with food4 Other Special Medications:• Anticoagulants as per surgeon, cardiologist or PCP• Aspirin and Clopidogrel (Plavix) should be taken up to theday 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 liquidswith sugar5. If patient is on a BETA BLOCKER at home, record time and date of last dose in Medication historyIf patient is on a BETA BLOCKER and they have not taken it in the last 24 hours, notify anesthesia ASAP6. 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 medicalrecord, or reported by a patient as an established diagnosis. Contact the anesthesiologist directly for any testing not indicatedby the protocol.7. LAB: Lab testing may be obtained through Laboratory analysis, Point of Care, or Fingerstick testingA checkmark in the box indicates that Lab test was done after Protocol was initiatedK+ (Potassium) within one week prior to surgery if on Digoxin or DiureticsK+ (Potassium) day of surgery if renal dialysis and/or renal failure patientPT/INR day of surgery if on Warfarin (COUMADIN) within the last 7 days prior to surgeryPregnancy test if female of child bearing years (onset of menses to no menses for 1 year) and no hysterectomyHgb/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’sBlood glucose within 2 hours of surgery for diabetic patientsFOR CARDIOTHORACIC SURGERY ONLY:ACT if patient is on Heparin infusionPlatelet Works if patient received Plavix or ASA within 1 week before cardiac surgery8. ECG: Needed within 90 days for the following patients:a) Patients undergoing cardiac or vascular surgical proceduresb) Patients with a pacemaker or AICD except those undergoing intraocular or endoscopic proceduresc) 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 failure9. 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/dL10. CHG: 2% Chlorhexidine Gluconate (CHG) wipes per policyCSM Only: 0.12% CHG mouthwash (PERIDEX) 15 mL to brush teeth, then 1 minute swish and spitNurse 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 IDENTIFICATIONMEC Approval CSJ – 06/26/14 CSM – 06/26/14CHN8215 Expires – 06/2017Copy 08.11.14 Page 1 of 2UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED

USE BALL POINT PEN – PRESS FIRMLYCARONDELET HEALTH NETWORKHOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERSTREATMENT 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 SURGERYPRE-OP ORDERS, PERI-OPERATIVE EXCISION OF PTERYGIUM ORDERS, PRE OPERATIVE E.N.T ORDERS, PRE-OP ORTHOPEDIC SURGERY ORDERS, RETINAPERIOPERATIVE ORDERS – CSJ, TRABECULECTOMY PERI-OPERATIVE ORDERS,PODIATRY PERIOPERATIVE ORDERS, EAR/NOSE/THROAT (ENT) PERIOPERATIVEORDERS –CSJ, OPHTHALMOLOGY PERIOPERATIVE ORDERS-CSJ, GYN PREOPERATIVE ORDERS – CSJNPO Status Instructions to Patient Minimum PeriodClear liquids (black coffee, apple juice, grape juice) Up to 4 hours pre-op 2 hoursBreast milk Up to 4 hours pre-op 4 hoursInfant formula Up to 6 hours pre-op 6 hoursLight meal (Dry toast and clear liquids) None after midnight 6 hoursFried or fatty food and meat (includes milk products) None after midnight 8 hoursSolids in high risk patients (e.g.: diabetes, pregnancy, obesity) None after midnight 8 hoursPRE-OPERATIVE HGB/HCT and BLOOD BANK REQUIREMENTSSurgeryMAJOR ABDOMINAL:WhippleSplenectomyGastrectomyAbdominal perineal resectionBleeding ulcerAdrenalectomyEsophagogastrectomyHysterectomyColectomyVASCULAR:AAA, open abdominalAAA, endovascularAny bypass caseAny endarterectomyAneurysmal repairsRepair/excision of infected graftsBKA/AKACARDIOTHORACIC:Cardiac SurgeriesThoracic SurgeriesORTHOPAEDIC:Total Hip/Knee ArthroplastyHip Fracture/RevisionSpine surgery (2 or more levels)Other Total JointsUROLOGICAL:NephrectomyCystectomyProstatectomyTURPNEUROLOGIC:CraniotomySpine surgery (2 or more levels)Aneurysm repair/clippingPLASTICS:TRAMPressure ulcersType & Cross2 units PRBCsAnd HGB/HCTXXXType & ScreenAnd HGB/HCTXXXXXXXXXXXXXXXXXXXXXHGB/HCT & Hold Clot(if HGB/HCT