Page 1 of 25

Plastic Surgery Postoperative [30400771]

(2/25/16)

PATIENT INFORMATION

Plastic Surgery Post-Operative [30400771] If appropriate for patient condition, please consider the following order sets:

Glycemic Control - Subcutaneous Addendum #825 Postoperative Continuous Epidural Analgesia #551 On-Q Pain Pump #722 Patient Controlled Analgesia (PCA) #564 Alcohol Withdrawal, Mild/Moderate #822 Alcohol Withdrawal, Severe (for ICU/PCU only) #823 Height_____________________ Weight_____________________ Allergies____________________

General

Level of Care [195028]

[ ] Admit to Inpatient [ADT1] ___________________________________REQUIRED Diagnosis: Estimated length of stay: Certification: I reasonably expect the patient will require inpatient services that span a period of time over two-midnights. (See Rationale Section in the order for options) Additional documentation will be found in progress notes and admission history and physical. Must be completed by Physician for Inpatient Admissions: Rationale for Inpatient Admission: Plans for post hospital care: See Discharge Summary/ Progress Note Level of Care:

[ ] Refer to Observation [ADT12] ___________________________________REQUIRED Diagnosis: Monitor for: Notify provider when: Level of Care:

[ ] Continue Outpatient Services (including extended recovery) [NUR151]

Outpatient Options: Diagnosis:

Provider’s Initial:

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Plastic Surgery Postoperative [30400771] (2/25/16)

PATIENT INFORMATION

SAH, SCH, SFH, SJMC & Highline Code Status (Single Response) [123416]

( ) Full code [COD2] ___________________________________REQUIRED This code status was determined by: Post-op

( ) Full treatment WITH intubation but WITHOUT ACLS [COD3]

___________________________________REQUIRED This code status was determined by: Post-op, - Initiate Code Blue for management of airway in the presence of a primary respiratory event - Therapeutic plan is otherwise unaltered - Transfer to critical care if indicated

( ) Full treatment WITHOUT intubation and WITHOUT ACLS [COD4]

___________________________________REQUIRED This code status was determined by: Post-op, - Do NOT initiate Code Blue - Therapeutic plan is otherwise unaltered - Transfer to critical care if indicated.

( ) Comfort Care [COD1] ___________________________________REQUIRED This code status was determined by: Post-op, 1) Provider must complete comfort care orders #668 2) RN or designee to place a purple wristband on Patient 3) Do NOT initiate Code Blue 4) Do NOT transfer to higher level of care

SAH, SCH, SFH, SJMC & Highline Code Status (Single Response) [132250]

( ) Full code [COD2] ___________________________________REQUIRED This code status was determined by: Post-op

( ) Full treatment WITH intubation but WITHOUT ACLS [COD3]

___________________________________REQUIRED This code status was determined by: Post-op, - Initiate Code Blue for management of airway in the presence of a primary respiratory event - Therapeutic plan is otherwise unaltered - Transfer to critical care if indicated

( ) Full treatment WITHOUT intubation and WITHOUT ACLS [COD4]

___________________________________REQUIRED This code status was determined by: Post-op, - Do NOT initiate Code Blue - Therapeutic plan is otherwise unaltered - Transfer to critical care if indicated.

Provider’s Initial:

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Plastic Surgery Postoperative [30400771] (2/25/16)

PATIENT INFORMATION

( ) Comfort Care [COD1] ___________________________________REQUIRED This code status was determined by: Post-op, 1) Provider must complete comfort care orders #668 2) RN or designee to place a purple wristband on Patient 3) Do NOT initiate Code Blue 4) Do NOT transfer to higher level of care

Harrison Code Status (Single Response) [171271]

( ) Full code [COD2] ___________________________________REQUIRED This code status was determined by: Post-op

( ) Full treatment WITH intubation but WITHOUT ACLS [COD3]

___________________________________REQUIRED This code status was determined by: Post-op, - Initiate Code Blue for management of airway in the presence of a primary respiratory event - Therapeutic plan is otherwise unaltered - Transfer to critical care if indicated

( ) Full treatment WITHOUT intubation but WITH ACLS [COD9]

___________________________________REQUIRED This code status was determined by: Post-op, -Initiate Code Blue for management of cardiac arrhythmias in the presence of a primary cardiac event - Therapeutic plan is otherwise unaltered - Transfer to critical care if indicated

( ) Full treatment WITHOUT intubation and WITHOUT ACLS [COD4]

___________________________________REQUIRED This code status was determined by: Post-op, - Do NOT initiate Code Blue - Therapeutic plan is otherwise unaltered - Transfer to critical care if indicated.

( ) Comfort Care [COD1] ___________________________________REQUIRED This code status was determined by: Post-op, 1) Provider must complete comfort care orders #668 2) RN or designee to place a purple wristband on Patient 3) Do NOT initiate Code Blue 4) Do NOT transfer to higher level of care

Provider’s Initial:

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Plastic Surgery Postoperative [30400771] (2/25/16)

PATIENT INFORMATION

Harrison Code Status (Single Response) [171272]

( ) Full code [COD2] ___________________________________REQUIRED This code status was determined by: Post-op

( ) Full treatment WITH intubation but WITHOUT ACLS [COD3]

___________________________________REQUIRED This code status was determined by: Post-op, - Initiate Code Blue for management of airway in the presence of a primary respiratory event - Therapeutic plan is otherwise unaltered - Transfer to critical care if indicated

( ) Full treatment WITHOUT intubation but WITH ACLS [COD9]

___________________________________REQUIRED This code status was determined by: Post-op, -Initiate Code Blue for management of cardiac arrhythmias in the presence of a primary cardiac event - Therapeutic plan is otherwise unaltered - Transfer to critical care if indicated

( ) Full treatment WITHOUT intubation and WITHOUT ACLS [COD4]

___________________________________REQUIRED This code status was determined by: Post-op, - Do NOT initiate Code Blue - Therapeutic plan is otherwise unaltered - Transfer to critical care if indicated.

( ) Comfort Care [COD1] ___________________________________REQUIRED This code status was determined by: Post-op, 1) Provider must complete comfort care orders #668 2) RN or designee to place a purple wristband on Patient 3) Do NOT initiate Code Blue 4) Do NOT transfer to higher level of care

Vital Signs [127304]

[X] Vital signs [NUR2069] Q15 minutes x (# of occurrences): Q30 minutes x (# of occurrences): Q1 hour x (# of occurrences): 4 Q2 hours x (# of occurrences): Q4 hours x (# of occurrences): 6 Then: Per unit routine Post-op, Until discontinued, Starting S

Provider’s Initial:

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PATIENT INFORMATION

Cardiac Monitoring [149575]

[ ] Cardiac monitoring [NUR436] Routine, Until discontinued, Starting S, PACU only (Anesthesia)

Notify Provider [121842]

[ ] Notify provider [NUR183] Routine, Until discontinued, Starting S Pulse greater than: Respiratory rate less than: Respiratory rate greater than: Temperature greater than (celsius): Urine output less than (mL/hr): Systolic BP greater than: Systolic BP less than: Diastolic BP greater than: Diastolic BP less than: Other: For changes in the flap condition., Post-op

Activity [127612]

[ ] Ambulate Progressive [NUR804] Routine, Until discontinued, Starting S, Post-op

[ ] Up with assistance when able [NUR131] Routine, As needed, Post-op

[ ] Up in chair [NUR130] Routine, As needed, Post-op

[ ] Activity as tolerated [NUR129] Routine, Until discontinued, Starting S, Post-op

[ ] Bed rest [NUR162] Routine, Until discontinued, Starting S, Post-op

[ ] Patient may shower [NUR550] Routine, Until discontinued, Starting S, Post-op

[X] Elevate HOB 30 degrees [NUR51] ___________________________________REQUIRED Routine, Until discontinued, Starting S, Post-op

[ ] Elevate extremity [NUR52] Routine, Until discontinued, Starting S Extremity: Post-op

[ ] Ambulate patient [NUR11] Routine, Every shift, Post-op

[ ] Stand and walk day of surgery [NUR185] Routine, Until discontinued, Starting S, Post-op

[ ] Dangle at bedside in 0-6 hours [NUR44] Routine, Once, Post-op

[ ] No pressure on flap [NUR185] Routine, Until discontinued, Starting S, Post-op

[ ] Keep patient flexed at waist 30 degrees at all times [NUR185]

Routine, Until discontinued, Starting S, Post-op

Provider’s Initial:

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PATIENT INFORMATION

Diet [129623]

[ ] Diet NPO [DIET41] Diet effective now, Starting S NPO Except: Diet Comments: Post-op

[ ] Diet Liquid [DIET42] Diet effective now, Starting S Diet: Clear Diet: Additional Modifiers: Viscosity/Liquids: Post-op

[ ] Advance diet as tolerated [DNS10] ___________________________________REQUIRED Once Target Diet: Post-op

[ ] Diet General [DIET24] ___________________________________REQUIRED Diet effective now, Starting S Select/Nonselect: Additional Modifiers: Viscosity/Liquids: Texture: Mech Soft Fluid Restriction / day: Sodium Modifiers: Supplements: No chew. Post-op

[ ] Diet Diabetic [DIET16] ___________________________________REQUIRED Diet effective now, Starting S Diet, Diabetic: Select/Nonselect: Additional Modifiers: Viscosity/Liquids: Texture: Fluid Restriction / day: Supplement: Diet Comments: Post-op

SCIP Urinary Catheter Orders (Single Response) [205085] ___________________________________REQUIRED

( ) Discontinue existing retention catheter [NUR2055] Routine, Once For 1 Occurrences Post Op Day: POD #1 Post-op

( ) Continue Catheter [NUR697] Routine, Until discontinued, Starting S, Initiate Medical Staff Approved Urinary Catheter Protocol

( ) Catheter was not placed Intra-Operatively [NUR172585] Routine, Until discontinued, Starting S

Provider’s Initial:

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Plastic Surgery Postoperative [30400771] (2/25/16)

PATIENT INFORMATION

Nursing Interventions [121850]

[ ] Retention catheter to gravity [NUR375] Routine, Until discontinued, Starting S, Post-op

[ ] Bladder Scan [122007] ___________________________________REQUIRED

[X] Bladder scan [NUR374] Routine, Once, If unable to void in 8 hours, Post-op

[X] Insert Foley catheter [NUR380] ___________________________________REQUIRED Routine, As needed Type of Catheter: if bladder scan is greater than 300 ml. initiate Medical Staff Approved Urinary Catheter Protocol, Post-op

[ ] Apply device [NUR812] Routine, Once Device: Abdominal binder Type: Extremity: Extremity: Length: Post-op

[ ] Mechanical vent - noninvasive [RT87] ___________________________________REQUIRED Routine, Continuous Use protocol: Defer to RT for Settings: Type of ventilation: Spontaneous/CPAP Backup Rate: IPAP min: IPAP max: EPAP: FiO2: CPAP: May use home CPAP? Yes APAP min: APAP max: Initiate CPAP - Patient Owned Medical Equipment Use protocol #908.00, Post-op

[ ] Nursing communication [NUR185] Routine, Until discontinued, Starting S, Home medical equipment waiver must be signed by the patient., Post-op

[ ] Intake and Output [NUR467] Routine, Every shift, Discontinue when IVs, drains, and catheters discontinued., Post-op

[ ] Flap checks with Doppler, color assessment, and temperature [NUR406]

___________________________________REQUIRED Routine, Every shift, Flap type: *** and flap location: *** , needing assessment. Every *** hours., Post-op

[ ] Strip bulb suction [NUR122] Routine, Once, Jackson Pratt drain care., Post-op

Provider’s Initial:

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Plastic Surgery Postoperative [30400771] (2/25/16)

PATIENT INFORMATION

[X] Empty and record drain output [NUR399] Routine, Every shift, Every shift and PRN, Post-op

[ ] Daily weights [NUR450] Routine, Daily, Post-op

Education [121858]

[ ] Routine drain care teaching [NUR2059] Routine, Until discontinued, Starting S, Post-op

[ ] Provide smoking cessation information and document on education record [NUR502]

Routine, Once, Post-op

Respiratory Assessments [121848]

[ ] RT Communication [RT101] Routine, Once For 1 Occurrences Please add additional info: Respiratory Therapy/Nursing to assess patient's ability to self-administer CPAP Respiratory Therapy/Nursing to assess patient's ability to self-administer CPAP, Post-op

[ ] Mechanical vent - noninvasive [RT87] ___________________________________REQUIRED Routine, Continuous Use protocol: Defer to RT for Settings: Type of ventilation: Spontaneous/CPAP Backup Rate: IPAP min: IPAP max: EPAP: FiO2: CPAP: May use home CPAP? APAP min: APAP max: Post-op

Respiratory Interventions [121853]

[X] Incentive spirometry [NUR361] Routine, As needed, Every 1 hour while awake and every 2 hours at night PRN, Post-op

[X] Oxygen therapy [RT83] ___________________________________REQUIRED Routine, Continuous O2 Delivery Method: Titrate to saturation of: 93% Indications for O2: Hypoxemia Indicate LPM/FiO2: Titrate oxygen for O2 saturation greater than 93%, Post-op

[X] Turn cough deep breathe [NUR371] Routine, Now then every 2 hours, Every 2 hours until ambulating independently., Post-op

Provider’s Initial:

Page 9 of 25

Plastic Surgery Postoperative [30400771] (2/25/16)

PATIENT INFORMATION

Ancillary Consults [129624]

[ ] PT eval and treat [PT4] ___________________________________REQUIRED Routine, Once For 1 Occurrences Reason for PT? Post-op

[ ] OT eval and treat [OT1] ___________________________________REQUIRED Routine, Once For 1 Occurrences Reason for OT? Post-op

[ ] Speech and language pathology eval and treat - dysphagia evaluation [SLP2]

___________________________________REQUIRED Routine, Once For 1 Occurrences Type? Post-op

[ ] Speech and language pathology eval and treat- communication evaluation [SLP2]

Routine, Once For 1 Occurrences Type? Communication/Cognition Post-op

[ ] IP consult to Care Management [CON583] ___________________________________REQUIRED Reason for Consult? RN/Secretary to contact the consulting provider? Yes Post-op

[ ] Inpatient consult to Wound Care/ET Nurse [CON506] ___________________________________REQUIRED Reason for Consult? RN/Secretary to contact the consulting provider? Yes Post-op

[ ] Inpatient consult to IV therapy [CON582] ___________________________________REQUIRED Reason for Consult? RN/Secretary to contact the consulting provider? Yes Post-op

[ ] Inpatient consult to IV therapy - PICC placement [CON582]

Reason for Consult? For PICC line placement RN/Secretary to contact the consulting provider? Yes Post-op

[ ] Inpatient consult to Spiritual Care [CON22] Reason for Consult? Post-op

[ ] Pharmacy general consult [CON100] Routine, Once

[ ] Inpatient consult to Nutrition Services [CON34] ___________________________________REQUIRED Reason for Consult? Post-op

Provider’s Initial:

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PATIENT INFORMATION

Discharge Instructions [127616]

[ ] Call physician office for follow up appointment [NUR163] Routine, Clinic Performed, Post-op

[ ] Discharge appointment made preoperatively [NUR185] Routine, Clinic Performed, Post-op

[ ] Discharge prescriptions given preoperatively [NUR185] Routine, Clinic Performed, Post-op

[ ] Walk regularly, no heavy lifting [NUR185] Routine, Clinic Performed, Post-op

[ ] Remove dressing after [NUR543] ___________________________________REQUIRED Routine, Clinic Performed, Post-op

[ ] Ice bag to wound intermittently for 24 hours only, then intermittent heating pads as needed [NUR810]

Routine, Clinic Performed

Labs

Chemistry [121045]

[ ] Basic metabolic panel [LAB15] Morning draw For 1 Occurrences, Post-op

Hematology [121862]

[ ] CBC and differential [LAB293] Morning draw For 1 Occurrences, Post-op

[ ] CBC and differential [LAB293] Once, PACU only (Anesthesia)

Coagulation [127615]

[ ] Activated partial thromboplastin time [LAB325] Once, Starting S For 1 Occurrences, Post-op

[ ] PT / INR [LAB320] Once, Starting S For 1 Occurrences, Post-op

VTE Prophylaxis

SAH, SCH, SFH, SJMC & Harrison Post-op VTE Prophylaxis Mechanical [129681]

[ ] Apply sequential compression device [NUR563] ___________________________________REQUIRED Routine, Until discontinued, Starting S Apply sequential compression device: Ensure correct VTE choices, need mechanical VTE prophylaxis if no pharmacologic prophylaxis, please see SCIP guidelines, Post-op

[ ] Place TED hose [NUR560] ___________________________________REQUIRED Routine, Until discontinued, Starting S Stocking type: Leg choice: Post-op

Provider’s Initial:

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Plastic Surgery Postoperative [30400771] (2/25/16)

PATIENT INFORMATION

[ ] Reason for No VTE Prophylaxis (Mech) [COR101] ___________________________________REQUIRED Reason for no VTE prophylaxis (mechanical): Note to provider: Reason required to be in in compliance with CMS SCIP guidelines.

Highline Post-op VTE Prophylaxis Mechanical [171228]

[ ] Place sequential compression device [NUR563] ___________________________________REQUIRED Routine, Until discontinued, Starting S Apply sequential compression device: Both Legs Ensure correct VTE choices, need mechanical VTE prophylaxis if no pharmacologic prophylaxis, please see SCIP guidelines, PACU & Post-op (Surgeon)

[ ] Reason for No VTE Prophylaxis (Mech) [COR101] ___________________________________REQUIRED Reason for no VTE prophylaxis (mechanical): Note to provider: Reason required to be in in compliance with CMS SCIP guidelines

Post-op VTE Prophylaxis Pharmacological [408129682] If mechanical prophylaxis contraindicated, MUST order pharmacologic prophylaxis. <br>IF PATIENT HAS

INDWELLING EPIDURAL CATHETER IN PLACE AND HEPARIN OR ENOXAPARIN IS ORDERED, REFER TO EPIDURAL ORDERS

[X] heparin (porcine) injection 5,000 units/mL [10181] 5,000 Units, SubCutaneous, Every 8 hours, Starting S+1 Pharmacy: Time of first dose of enoxaparin, Heparin, or other anticoagulant to be given within 18 hours after anesthesia end time

[ ] enoxaparin (LOVENOX) injection 40 mg [105900] 40 mg, SubCutaneous, Daily, Starting S+1 Pharmacy: Time of first dose of enoxaparin, Heparin, or other anticoagulant to be given within 18 hours after anesthesia end time

[ ] Reason for No VTE Prophylaxis (Pharm) [COR100] ___________________________________REQUIRED Reason for no VTE prophylaxis (pharmacological): Note to provider: Reason required to be in in compliance with CMS SCIP guidelines.

Provider’s Initial:

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PATIENT INFORMATION

IV Fluids

IV Fluids [408129626]

[ ] Saline Flush and Lock Panel [408128747]

[X] sodium chloride 0.9 % syringe [7319] 2 mL, IntraVENous, Every 8 hours, Post-op

[X] Saline lock IV [IVT11] Routine, Continuous, Post-op

[ ] dextrose 5 % and sodium chloride 0.45 % infusion [9814]

125 mL/hr, IntraVENous, Continuous, Post-op

[ ] dextrose 5 % and sodium chloride 0.45 % with KCl 20 mEq/L infusion [9801]

125 mL/hr, IntraVENous, Continuous, Post-op

[X] lactated ringers infusion [4318] 100 mL/hr, IntraVENous, Continuous, Post-op

Medications

Over the Counter [130872]

[ ] Nurse may initiate OTC Pt Care Products [NUR2066] Routine, As needed, Post-op

Harrison Pharmacy Consult - SCIP antibiotics [171242]

[ ] Pharmacy Consult: Antibiotics [CON100] Routine, Once For 1 Occurrences

Antibiotic Prophylaxis [408129627] Administer first dose in PACU. If continued greater than 18 hours, must document suspected or actual infection (see

above).

[ ] ceFAZolin (ANCEF) IV [420006] 1 g, IntraVENous, Every 8 hours, Starting S, For 2 Doses, PACU & Post-op (Surgeon) Administer first dose in PACU. Please choose an indication . Surgical Prophylaxis

[ ] ceFAZolin (ANCEF) IV [420006] 2 g, IntraVENous, Every 8 hours, Starting S, For 2 Doses, PACU & Post-op (Surgeon) For patients greater than 80 kg. Administer first dose in PACU. Please choose an indication . Surgical Prophylaxis

[ ] clindamycin (CLEOCIN) IV syringe [420108] 600 mg, IntraVENous, Every 8 hours, Starting S, For 2 Doses, PACU & Post-op (Surgeon) Administer first dose in PACU. Please choose an indication . Surgical Prophylaxis

Provider’s Initial:

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Plastic Surgery Postoperative [30400771] (2/25/16)

PATIENT INFORMATION

[ ] clindamycin (CLEOCIN) IV syringe [420108] 900 mg, IntraVENous, Every 8 hours, Starting S, For 2 Doses, PACU & Post-op (Surgeon) For patients greater than 100 kg. Administer first dose in PACU. Please choose an indication . Surgical Prophylaxis

[ ] vancomycin (VANCOCIN) IVPB 250 mL (base) [420024] 1,000 mg, IntraVENous, Every 12 hours, Starting S, For 1 Doses, PACU & Post-op (Surgeon) Administer 12 hours after pre-op dose times one dose. Please choose an indication (trough goal in parenthesis): Surgical Prophylaxis - increased MRSA rate either facility wide or operation specific

Antibiotic Treatment [122866]

[ ] clindamycin (CLEOCIN) capsule [1740] 450 mg, Oral, Every 6 hours, Starting S, PACU & Post-op (Surgeon) 1st dose to be given in the PACU. Please choose an indication . Skin/Soft Tissue Infection

[ ] clindamycin (CLEOCIN) IV syringe [420108] 600 mg, IntraVENous, Every 8 hours, Starting S, PACU & Post-op (Surgeon) 1st dose to be given in the PACU. Please choose an indication . Skin/Soft Tissue Infection

[ ] ceFAZolin (ANCEF) IV [420006] 1 g, IntraVENous, Every 8 hours, Starting S, PACU & Post-op (Surgeon) 1st dose to be given in the PACU. Please choose an indication . Skin/Soft Tissue Infection

[ ] cephalexin (KEFLEX) capsule [9500] 500 mg, Oral, 4 times daily, Starting S, PACU & Post-op (Surgeon) 1st dose to be given in the PACU. Please choose an indication . Skin/Soft Tissue Infection

[ ] Pharmacy to dose vancomycin [PHA205] ___________________________________REQUIRED STAT, Once

Provider’s Initial:

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Plastic Surgery Postoperative [30400771] (2/25/16)

PATIENT INFORMATION

Medications: Pain [197434]

[ ] Analgesics: FIRST CHOICE (Single Response) [195052]

( ) HYDROMORPHONE IV ORDERABLE [420079] IntraVENous, For 7 Days, Post-op Give this medication 1st. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 1st. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) MORPHINE SULFATE IV ORDERABLE [420065] 2 mg, IntraVENous, Every 4 hours PRN, severe pain, Post-op Give this medication 1st. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 1st. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) ketorolac (TORADOL) injection [22473] 15 mg, IntraVENous, For 5 Days, Post-op Give this medication 1st. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 1st. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) oxyCODONE-acetaminophen (PERCOCET) 5-325 mg per tablet [5940]

1 tablet, Oral, Every 4 hours PRN, moderate pain, Post-op Give this medication 1st. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 1st. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) oxyCODONE (ROXICODONE) immediate release tablet [10814]

5 mg, Oral, Post-op Give this medication 1st. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 1st. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) HYDROmorphone (DILAUDID) tablet [3760] 2 mg, Oral, Every 4 hours PRN, severe pain, For 7 Days, Post-op Give this medication 1st. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 1st. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

Provider’s Initial:

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PATIENT INFORMATION

( ) HYDROcodone-acetaminophen (NORCO) 7.5-325 mg per tablet [34544]

1 tablet, Oral, Every 6 hours PRN, moderate pain, severe pain, Post-op Give this medication 1st. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 1st. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) HYDROcodone-acetaminophen (NORCO) 5-325 mg per tablet [34505]

1 tablet, Oral, Every 6 hours PRN, moderate pain, severe pain, Post-op Give this medication 1st. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 1st. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) ibuprofen (ADVIL,MOTRIN) tablet [3843] 400 mg, Oral, Every 6 hours PRN, mild pain, Post-op Start 6 hours after last ketorolac [TORADOL] dose, if given. Give this medication 1st. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 1st. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) acetaminophen (TYLENOL) tablet [101] Oral, Post-op Give this medication 1st. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 1st. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

[ ] Analgesics: SECOND CHOICE (Single Response) [195053]

( ) HYDROMORPHONE IV ORDERABLE [420079] IntraVENous, For 7 Days, Post-op Give this medication 2nd if first medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 2nd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) MORPHINE SULFATE IV ORDERABLE [420065] 2 mg, IntraVENous, Every 4 hours PRN, severe pain, Post-op Give this medication 2nd if first medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 2nd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

Provider’s Initial:

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PATIENT INFORMATION

( ) ketorolac (TORADOL) injection [22473] 15 mg, IntraVENous, For 5 Days, Post-op Give this medication 2nd if first medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 2nd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) oxyCODONE-acetaminophen (PERCOCET) 5-325 mg per tablet [5940]

1 tablet, Oral, Every 4 hours PRN, moderate pain, Post-op Give this medication 2nd if first medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 2nd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) oxyCODONE (ROXICODONE) immediate release tablet [10814]

5 mg, Oral, Post-op Give this medication 2nd if first medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 2nd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) HYDROmorphone (DILAUDID) tablet [3760] 2 mg, Oral, Every 4 hours PRN, severe pain, For 7 Days, Post-op Give this medication 2nd if first medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 2nd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) HYDROcodone-acetaminophen (NORCO) 7.5-325 mg per tablet [34544]

1 tablet, Oral, Every 6 hours PRN, moderate pain, severe pain, Post-op Give this medication 2nd if first medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 2nd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) HYDROcodone-acetaminophen (NORCO) 5-325 mg per tablet [34505]

1 tablet, Oral, Every 6 hours PRN, moderate pain, severe pain, Post-op Give this medication 2nd if first medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 2nd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

Provider’s Initial:

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PATIENT INFORMATION

( ) ibuprofen (ADVIL,MOTRIN) tablet [3843] 400 mg, Oral, Every 6 hours PRN, mild pain, Post-op Start 6 hours after last ketorolac [TORADOL] dose, if given. Give this medication 2nd if first medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 2nd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) acetaminophen (TYLENOL) tablet [101] Oral, Post-op Give this medication 2nd if first medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 2nd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

[ ] Analgesics: THIRD CHOICE (Single Response) [195054]

( ) HYDROMORPHONE IV ORDERABLE [420079] IntraVENous, For 7 Days, Post-op Give this medication 3rd if second medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 3rd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) MORPHINE SULFATE IV ORDERABLE [420065] 2 mg, IntraVENous, Every 4 hours PRN, severe pain, Post-op Give this medication 3rd if second medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 3rd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) ketorolac (TORADOL) injection [22473] 15 mg, IntraVENous, For 5 Days, Post-op Give this medication 3rd if second medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 3rd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) oxyCODONE-acetaminophen (PERCOCET) 5-325 mg per tablet [5940]

1 tablet, Oral, Every 4 hours PRN, moderate pain, Post-op Give this medication 3rd if second medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 3rd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

Provider’s Initial:

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PATIENT INFORMATION

( ) oxyCODONE (ROXICODONE) immediate release tablet [10814]

5 mg, Oral, Post-op Give this medication 3rd if second medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 3rd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) HYDROmorphone (DILAUDID) tablet [3760] 2 mg, Oral, Every 4 hours PRN, severe pain, For 7 Days, Post-op Give this medication 3rd if second medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 3rd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) HYDROcodone-acetaminophen (NORCO) 7.5-325 mg per tablet [34544]

1 tablet, Oral, Every 6 hours PRN, moderate pain, severe pain, Post-op Give this medication 3rd if second medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 3rd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) HYDROcodone-acetaminophen (NORCO) 5-325 mg per tablet [34505]

1 tablet, Oral, Every 6 hours PRN, moderate pain, severe pain, Post-op Give this medication 3rd if second medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 3rd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) ibuprofen (ADVIL,MOTRIN) tablet [3843] 400 mg, Oral, Every 6 hours PRN, mild pain, Post-op Start 6 hours after last ketorolac [TORADOL] dose, if given. Give this medication 3rd if second medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 3rd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) acetaminophen (TYLENOL) tablet [101] Oral, Post-op Give this medication 3rd if second medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 3rd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

Provider’s Initial:

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PATIENT INFORMATION

Sedative/Hypnotic [122874]

[ ] diphenhydrAMINE (BENADRYL) capsule [2509] 25 mg, Oral, Nightly PRN, itching, sleep, Post-op May repeat times one dose.

[ ] zolpidem (AMBIEN) tablet [11701] 5 mg, Oral, Nightly PRN, sleep, Post-op May repeat times one dose for patients under age 65 only.

Bowel Management [122870]

[ ] docusate sodium (COLACE) capsule [2566] 100 mg, Oral, 2 times daily PRN, constipation, Post-op

[ ] bisacodyl (DULCOLAX) EC tablet 5 mg [1079] 5-10 mg, Oral, Daily as needed, constipation, Post-op

[ ] bisacodyl (DULCOLAX) suppository 10 mg [1080] 10 mg, Rectal, Daily as needed, constipation, Post-op

[ ] magnesium hydroxide (MILK OF MAGNESIA) suspension 400 mg/5mL [116887]

30 mL, Oral, Daily as needed, constipation, Post-op

Antiemetic [197437]

[ ] Antiemetic: FIRST CHOICE (Single Response) [195061]

( ) ondansetron (ZOFRAN) 4 mg/2 mL injection [106348] IntraVENous, Post-op Give this medication 1st. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 1st. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) promethazine (PHENERGAN) IV for patients 65 years & over (6.25-12.5 mg) [6618]

6.25-12.5 mg, IntraVENous, Post-op Give this medication 1st. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 1st. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) promethazine (PHENERGAN) IV for patients under 65 years (12.5-25 mg) [6618]

IntraVENous, Post-op Give this medication 1st. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 1st. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

Provider’s Initial:

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PATIENT INFORMATION

( ) metoclopramide (REGLAN) injection [5002] 5-10 mg, IntraVENous, Every 6 hours PRN, nausea, vomiting, Post-op Give this medication 1st. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 1st. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

[ ] Antiemetic: SECOND CHOICE (Single Response) [195062]

( ) ondansetron (ZOFRAN) 4 mg/2 mL injection [106348] IntraVENous, Post-op Give this medication 2nd if first medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 2nd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) promethazine (PHENERGAN) IV for patients 65 years & over (6.25-12.5 mg) [6618]

6.25-12.5 mg, IntraVENous, Post-op Give this medication 2nd if first medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 2nd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) promethazine (PHENERGAN) IV for patients under 65 years (12.5-25 mg) [6618]

IntraVENous, Post-op Give this medication 2nd if first medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 2nd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) metoclopramide (REGLAN) injection [5002] 5-10 mg, IntraVENous, Every 6 hours PRN, nausea, vomiting, Post-op Give this medication 2nd if first medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 2nd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

[ ] Antiemetic: THIRD CHOICE (Single Response) [195063]

( ) ondansetron (ZOFRAN) 4 mg/2 mL injection [106348] IntraVENous, Post-op Give this medication 3rd if second medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 3rd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

Provider’s Initial:

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PATIENT INFORMATION

( ) promethazine (PHENERGAN) IV for patients 65 years & over (6.25-12.5 mg) [6618]

6.25-12.5 mg, IntraVENous, Post-op Give this medication 3rd if second medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 3rd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) promethazine (PHENERGAN) IV for patients under 65 years (12.5-25 mg) [6618]

IntraVENous, Post-op Give this medication 3rd if second medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 3rd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

( ) metoclopramide (REGLAN) injection [5002] 5-10 mg, IntraVENous, Every 6 hours PRN, nausea, vomiting, Post-op Give this medication 3rd if second medication is ineffective. Nurse to call provider to clarify if multiple orders with the same therapeutic indication are numbered to give 3rd. If duplicative therapeutic orders are NOT numbered, nurse to call the prescriber for clarification.

Beta-Blocker [408122951] For patients on prior beta-blocker therapy, order appropriate beta-blocker now.

[ ] Reason for no beta-blocker during perioperative period [COR2]

___________________________________REQUIRED Reason for no beta blocker prescribed at discharge?

Nicotine Replacement Therapy [408123734] Nicotine Replacement therapy will be avoided if possible in patient with unstable acute coronary syndrome for 72

hours. After 72 hours if chest pain, arrhythmias, and/or blood pressure have stabilized, Nicotine replacement may be considered at ONE STEP below the calculated replacement dose. NOTE: 1/2 pack = 10 cigarettes

The nicotine products listed below may be used as monotherapy or in combination therapy. Combination therapy should include a nicotine patch plus either nicotine gum or nicotine lozenges. Smoking History Recommended Starting Dose

Step down therapy after initial nicotine replacement for 6-7 weeks: patch, 7mg 10 Cigarettes per Day or less, past history of cardiovascular disease, or weight under 45 kg: Nicotine patch, 14 mg

Heavy smokers (More than 10 cigarettes/day): Nicotine patch, 21 mg

Smokeless tobacco users, pipe smokers or at patient request: Nicotine Gum, 2mg

Note to provider: Insulin requirements may change - monitor blood sugars. Topical Steroids and oral antihistamines may be recommended to treat less severe skin irritations.

Provider’s Initial:

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PATIENT INFORMATION

[ ] Patient uses tobacco [206892]

[ ] nicotine (NICODERM CQ) 7 mg/24 hr [27860] 1 patch, TransDermal, for 24 Hours, Daily, Post-op

[ ] nicotine (NICODERM CQ) 14 mg/24 hr [27862] 1 patch, TransDermal, for 24 Hours, Daily, Post-op

[ ] nicotine (NICODERM CQ) 21 mg/24 hr [27863] 1 patch, TransDermal, for 24 Hours, Daily, Post-op

[ ] nicotine polacrilex (NICORETTE) gum [10717] 2 mg, Buccal, Every 1 hour PRN, smoking cessation, Post-op

[ ] buPROPion (WELLBUTRIN SR) 12 hr tablet [18385] 100 mg, Oral, 2 times daily, Post-op

[ ] varenicline (CHANTIX) tablet [76444] 0.5 mg, Oral, 2 times daily with meals, Post-op

[ ] Patient refuses nicotine replacement medication [COR406]

Details

[ ] Patient does not use tobacco [COR405] Details

[ ] Nicotine replacement contraindicated [COR407] ___________________________________REQUIRED Reason for contraindication:

Antipruritics [122869]

[ ] diphenhydrAMINE (BENADRYL) capsule [2509] 25 mg, Oral, Every 6 hours PRN, itching, Post-op

[ ] hydrOXYzine (VISTARIL) capsule [3777] 25-50 mg, Oral, Every 6 hours PRN, itching, Post-op Do not use for patients age 65 and over Is this related to a chemo treatment?

Glucose Management Post-Op [408127889]

[ ] Hemoglobin A1c [LAB90] Once, Post-op

[ ] POCT glucose [POC10] Routine, 4 times daily before meals and at bedtime, Post-op

[ ] Hypoglycemia Protocol Panel Post-Op [408122980]

[X] Hypoglycemia Protocol (Blood glucose less than 70 mg/dL) [NUR185]

Routine, As needed, Starting S, 1. If patient awake and able to take PO-give 4 oz of clear regular soda (i.e. Sprite) 2. If patient awake and unable to take PO-give 25 ml 50% dextrose in water (D50W) IV push 3. If patient obtunded (due to hypoglycemia)-give 50 ml 50% dextrose in water (D50W) IV push 4. Recheck blood glucose in 15 minutes. If blood glucose less than 70 mg/dL, repeat above treatment. Recheck blood glucose every 30 minutes until greater than or equal to 80 mg/dL. 5. If glucose remains less than 70 mg/dL after 2 doses of soda/dextrose, then notify provider, Post-op

Provider’s Initial:

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PATIENT INFORMATION

[X] dextrose 50 % IV [119654] 25-50 mL, IntraVENous, As needed, low blood sugar, see below, Post-op 1. If patient awake and unable to take PO-give 25 ml 50% dextrose in water (D50W) IV push. 2. If patient obtunded (due to hypoglycemia)-give 50 ml 50% dextrose in water (D50W) IV push.

[X] glucagon (human recombinant) (GLUCAGEN) injection [126497]

1 mg, IntraMuscular, Once, when indicated (remains on MAR), low blood sugar, For blood sugar less than 70 If patient unable to take PO AND no IV access. Give glucagon 1 mg IM x 1 dose only. Turn patient on side as nausea and vomiting frequently occur. Notify provider. Obtain IV access and start D5W if deem appropriate by provider.

[ ] Insulin Regular Correction Scale (Novolin R) Post-op (Single Response) [408127109]

CHOOSE ONE

( ) insulin regular (NOVOLIN R) injection (LOW DOSE SUB-Q SCALE) [10289]

2-10 Units, SubCutaneous, See admin instructions, Post-op If fingerstick blood glucose over 180 mg/dL for 2 consecutive checks increase correction insulin scale to next higher dose. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL] Low Dose - Total Daily Dose Under 40 Units/Day 150-200 2 units 201-250 4 units 251-300 6 units 301-350 8 units Over 350-Notify MD 10 units Will this be administered via an insulin pump?

( ) insulin regular (NOVOLIN R) injection (MEDIUM DOSE SUB-Q SCALE) [10289]

3-15 Units, SubCutaneous, See admin instructions, Post-op If fingerstick blood glucose over 180 mg/dL for 2 consecutive checks increase correction insulin scale to next higher dose. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL] Medium Dose - Total Daily Dose 40 - 80 Units/Day 150-200 3 units 201-250 6 units 251-300 9 units 301-350 12 units Over 350-Notify MD 15 units Will this be administered via an insulin pump?

Provider’s Initial:

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PATIENT INFORMATION

( ) insulin regular (NOVOLIN R) injection (HIGH DOSE SUB-Q SCALE) [10289]

4-18 Units, SubCutaneous, See admin instructions, Post-op If fingerstick blood glucose over 180 mg/dL for 2 consecutive checks increase correction insulin scale to next higher dose. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL] High Dose - Total Daily Dose Over 80 Units/Day 150-200 4 units 201-250 8 units 251-300 11 units 301-350 15 units Over 350-Notify MD 18 units Will this be administered via an insulin pump?

[ ] Insulin Aspart Correction Scale (Novo Log) Post-op (Single Response) [408127110]

CHOOSE ONE

( ) insulin aspart (NovoLOG) injection ( LOW DOSE SUB-Q SCALE) [28534]

2-10 Units, SubCutaneous, As needed, high blood sugar, Post-op If fingerstick blood glucose over 180 mg/dL for 2 consecutive checks increase correction insulin scale to next higher dose. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL] Low Dose - Total Daily Dose Under 40 Units/Day 150-200 2 units 201-250 4 units 251-300 6 units 301-350 8 units Over 350-Notify MD 10 units Will this be administered via an insulin pump?

( ) insulin aspart (NovoLOG) injection (MEDIUM DOSE SUB-Q SCALE) [28534]

3-15 Units, SubCutaneous, As needed, high blood sugar, Post-op If fingerstick blood glucose over 180 mg/dL for 2 consecutive checks increase correction insulin scale to next higher dose. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL] Medium Dose - Total Daily Dose 40 - 80 Units/Day 150-200 3 units 201-250 6 units 251-300 9 units 301-350 12 units Over 350-Notify MD 15 units Will this be administered via an insulin pump?

Provider’s Initial:

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PATIENT INFORMATION

( ) insulin aspart (NovoLOG) injection ( HIGH DOSE SUB-Q SCALE) [28534]

4-18 Units, SubCutaneous, As needed, high blood sugar, Post-op If fingerstick blood glucose over 180 mg/dL for 2 consecutive checks increase correction insulin scale to next higher dose. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL] High Dose - Total Daily Dose Over 80 Units/Day 150-200 4 units 201-250 8 units 251-300 11 units 301-350 15 units Over 350-Notify MD 18 units Will this be administered via an insulin pump?

DATE TIME ORDERING PROVIDER PRINT NAME

PROVIDER SIGNATURE DATE TIME RN ACKNOWLEDGED