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CHN4623 ENT Pre Op Orders.pdf - Carondelet

CHN4623 ENT Pre Op Orders.pdf - Carondelet

CHN4623 ENT Pre Op Orders.pdf - Carondelet

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USE BALL POINT PEN – PRESS FIRMLYCARONDELET HEALTH NETWORKHOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERSTREATM<strong>ENT</strong> PROTOCOL – PRE OP ANESTHESIA (CSJ/CSM)1 Order to initiate <strong>Pre</strong><strong>Op</strong> Anesthesia Protocol was previously given by a Licensed Independent Practitioner and signed ona separate <strong>Orders</strong> page unless box below is checked.Initiate <strong>Pre</strong><strong>Op</strong> 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 surgery<strong>Pre</strong>gnancy 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 INPATI<strong>ENT</strong> 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 PATI<strong>ENT</strong> ID<strong>ENT</strong>IFICATIONMEC 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 EQUIVAL<strong>ENT</strong> MEDICATION MAY BE DISPENSED

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