Admit to Orthopaedics. MRP is ______

Code Status: Full Code No-CPR see further written orders regarding CPR/DNR MRP to determine

Consults

Hospitalist Dr______aware____

Anaesthesiologist Dr______aware____

Geriatric medicine Dr______aware____

Other Dr______aware____

Diet

·  Universal Swallow Screen

Clear fluids up to 2 hours pre-op (water, pulp-free juice, coffee and tea without milk or broth)

Light meal and other liquids for up to 6 hours pre-op (e.g. milk, toast, or cereal, not meat or nut butters)

Meal up to 8 hours pre-op

Diabetic Renal Other ______

NPO 2h before surgery

Pre-Operative Preparation

·  Follow Pre-Operative Skin Prep Clinical Standard

·  Do not remove cast or splint

·  Patient to brush teeth & tongue within 4h of OR

Activity Bedrest Elevate extremity Buck’s traction ______kg

·  Reposition q2h

·  Ensure heels and sacrum are checked q2h and pressure is off loaded

·  Head of bed elevated minimum 30 degrees

Vitals

·  Vital signs q4h and prn

·  Neurosensory assessments of affected limb(s) q2h q4h as per Unit Guidelines

Tubes/Respiratory

Urinary Catheter

·  If patient normally continent but unable to void using a bedpan, insert silver alloy catheter and affix securement device on unaffected leg as per surgical services urinary catheter guidelines

Respiratory

·  Titrate O2 to maintain SpO2 92% or greater

·  Incentive spirometer q1h while awake

·  Clean teeth and tongue BID

Investigations (If not already done)

Hematology profile

Sodium, potassium, chloride, carbon dioxide total, creatinine, phosphate, magnesium, glucose

INR, PTT

Macroscopic and Microscopic

Culture if pyuria or nitrite present

Blood Group and Antibody Screen

ECG

Other______

Medical Imaging

X-ray______

IV Fluids

Solution

0.9% sodium chloride D5W and 0.9% sodium chloride

2/3 + 1/3 Ringer’s Lactate

D5W + 0.45% sodium chloride

Additive

KCl 20 mmol/L

Rate

75 mL/h 125 mL/h

100 mL/h 150mL/h

Or ______mL/h

Bolus 500 mL Ringer’s Lactate over 90 minutes X 1 PRN when urine output less than 30mL/h for 2 hours and if no increase in urine output notify surgeon

Bolus 500 mL 0.9% sodium chloride over 90 minutes X 1 PRN when urine output less than 30mL/h for 2 hours and if no increase in urine output notify surgeon

Antibiotic Prophylaxis

ceFAZolin 2g IV to be given at induction of anesthesia

For patients with severe beta-lactam (penicillin/cephalosporin) allergy eg. anaphylaxis, angioedema

clindamycin 900 mg IV 30 minutes pre-op

Or

vancomycin 1 g IV 90 minutes pre-op infused over 60 minutes

Bowel Management

·  Ensure fluids/adequate hydration within prescribed limits, frequent/encourage mobility within prescribed limits, regular bowel routine

Acute care: Bowel Intervention – Adult Non-ICU

if NPO:______

·  RN, RPN and/or Pharmacist to complete thorough assessment of bowel function including review of Pre-Hospital Functional Screening Tool to determine if regularly scheduled laxatives are required

Laxatives as indicated RN, RPN and/or Pharmacist based on assessment above and Best Possible Medication History

Contact MRP to discuss

docusate 100 mg PO BID; hold if patient develops. Reassess need for docusate

Delirium

·  CAM assessment Q shift

·  If CAM positive, notify MD to investigate/ address underlying cause within 12 hours

Medication orders only for persistent agitation with risk of harm or injury

·  Notify MD if agitation medication given

QUEtiapine 6.25 mg to 12.5 mg PO Q____h PRN to a maximum of 18.75 mg in 24h

loxapine 2.5 to 5 mg q2h PO PRN to a maximum of 10 mg in 24h

If unable to use oral route give

loxapine 2.5 to 5 mg q2h subcutaneously PRN to a maximum of 10 mg in 24h

Insomnia

zopiclone 3.75 mg PO at bedtime as required for sleep

If patient has been taking another sleeping pill regularly, continue the same:______

Diabetes Management:

Follow either IV or Subcut Insulin Order Set – MRP to complete Other:______

Pain and Nausea Management

Pain

·  acetaminophen 650 mg PO or RECTAL suppository QID to a max of 4,000 mg per 24 hours

Other: ______

***Do not use IV/subcutaneous and PO simultaneously***

HYDROmorphone 0.5 mg PO q4h

Or

HYDROmorphone 1 mg PO q4h

For patients unable to tolerate oral route

HYDROmorphone 0.25 mg subcutaneously q4h

Or

HYDROmorphone 0.5mg subcutaneously q4h

·  Hold opioid dose if frequently drowsy (or per sedation scale).

·  May hold opioid if sleeping.

Breakthrough pain

HYDROmorphone 0.5 to 1 mg PO Q2h PRN

Or

HYDROmorphone 0.25 to 0.5 mg subcutaneously Q2h PRN

For patients unable to tolerate oral route

Nausea and Vomiting

ondansetron 4 mg IV/PO Q8h PRN

metoclopramide 10 mg IV/PO Q6h PRN if ondansetron ineffective

Other: ______

VTE Prophylaxis

·  Complete VTE Risk Assessment (page 6)

·  Consult Anaesthesia if patient requires dalteparin q12h

No Anticoagulation required ______(reason)

dalteparin 5,000 units subcut q24h

Patients less than 40 kg or age greater than 85 years

dalteparin 2,500 units subcut q24h

Patients greater than 100 kg Or at very high risk of VTE (DVT/PE)

dalteparin 5,000 units subcut q 12h (not recommended in patients with epidural)

heparin 5,000 units subcut £q12h £ q8h (not recommended in patients with epidural)

·  Hematology profile q4days while on heparin

Mechanical: Specify

Warfarin Reversal (See Page 7)

**In patients with high risk of stroke (eg atrial fibrillation with CHADS2 score greater than 3, previous stroke/TIA, mechanical heart valve) or thrombosis (eg VTE within past 3 months, cancer-associated thrombosis, thrombophilia, antiphospholipid antibody syndrome), algorithm may not be appropriate; Hematology/ Internal Medicine consultation is recommended**

Consult

Hematology/ Internal Medicine Dr______aware____

·  Hold warfarin

vitamin K : 2 mg PO STAT if INR between 1.2 and 5.0 and surgery is in more than 24 hours

2 mg in 50 mL NS IV STAT if INR between 1.2 and 5.0

5 mg in 50 mL NS IV STAT if INR greater than 5.0 or on-going major bleeding

***Prothrombin Complex Concentrate is appropriate only if emergent surgery is required. ***

Prothrombin Complex Concentrate______units IV x 1 as per protocol in Blood Product Monograph

STAT (active bleeding)

Within 1 hour of booked surgery time

At ______hours

(Consult hematopathologist for appropriate dose)

STAT INR 15 minutes after Prothrombin Complex Concentrate infusion. Notify ordering physician STAT if INR greater than 1.5

Additional Laboratory Testing:

INR at 0600 morning of surgery. Call MD STAT if INR greater than 1.5

INR at ______H (within 6 hours of surgery). Call MD STAT if INR greater than 1.5

STAT INR 12 hours after Prothrombin Complex Concentrate infusion if ongoing bleeding. Notify ordering physician of result

Ortho8308 Hip Fracture Preoperative Orthopaedic Orders_Mar2015 new.doc C/8/HipFracture/MD/01-14/V1/Pre-op

Clinical Regimen

Note: not for use in patients who have had bowel surgery in the last year

·  Newly-admitted patients experiencing constipation longer than 4 days or those unable to identify date of last bowel movement start at step 2

·  All other patients requiring bowel care per protocol including those where assessment not possible begin at baseline

·  Notify physician if vomiting and abdominal pain develop

·  Discontinue protocol and notify MRP if step 4 reached more than once in 10 days

Intervention for Constipation

Medication
Baseline / ·  No medication
Step 2: Last BM more than 48 hours ago / ·  lactulose 30 mL PO x 1 today and
If no results by next AM proceed to next step
Step 3: Last BM more than 72 hours ago / ·  Increase lactulose to 30 mL PO BID today, and
·  sennosides 24 mg PO after breakfast today, and
If no results in 24 hours proceed to next step
Step 4: Last BM more than 96 hours ago / ·  Continue with lactulose 30 mL PO BID
AND sennosides 24 mg PO after breakfast today, and
·  glycerine suppository (2.65 g) PR after breakfast today x 1
·  If no results after 3 hours give sodium citrate enema (Microlax) 5 mL PR x 1 today
·  If no results from sodium citrate enema perform rectal examination for presence or absence of stool and inform physician
Return to baseline once desired results are achieved

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Step One

-  assess all patients admitted to hospital for level of mobility (tick one box). All surgical patients and all medical patients with significantly reduced mobility, should be considered for further risk assessment

Step Two

-  review patient-related factors against thrombosis risk, ticking each box that applies (more than one box can be ticked)

-  any tick for thrombosis risk should prompt thromboprophylaxis according to NICE guidance. Risk factors identified are not exhaustive. Clinicians may consider additional risks in individual patients and offer thromboprophylaxis as appropriate

Step Three

-  review the patient-related factors against bleeding risk and tick each box that applies (more than one box can be ticked)

-  any tick should prompt clinical staff to consider if bleeding risk is sufficient to preclude pharmacological intervention

Balancing risk/benefit is at the discretion of the ordering physician

Mobility – all patients (tick one box) / Tick / Tick / Tick
Surgical patient / Medical patient expected to have ongoing reduced mobility relative to normal state / Medical patient NOT expected to have significantly reduced mobility relative to normal state
Assess for thrombosis and bleeding risk below / Risk assessment now complete

Thrombosis Risk

Patient related / Tick / Admission related / Tick
Active cancer or cancer treatment / Significantly reduced mobility for 3 days or more
Age greater than 60 / Hip or knee replacement
Dehydration / Hip fracture
Known thrombophilias / Total anaesthetic + surgical time greater than 90 min
Obesity (BMI greater than 30 kg/m2) / Surgery involving pelvis or lower limb with a total anaesthetic + surgical time greater than 60 minutes
One or more significant medical comorbidities (eg heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions) / Acute surgical admission with inflammatory or intra-abdominal condition
Personal history or first-degree relative with a history of VTE / Critical care admission
Use of hormone replacement therapy / Surgery with significant reduction in mobility
Use of estrogen-containing contraceptive therapy
Varicose veins with phlebitis
Pregnancy or less than 6 weeks post partum (see NICE guidance for specific risk factors)

Bleeding Risk

Patient related / Tick / Admission related / Tick
Active bleeding / Neurosurgery, spinal surgery or eye surgery
Acquired bleeding disorders (such as acute liver failure) / Other procedure with high bleeding risk
Concurrent use of anticoagulants known to increase risk of bleeding (eg warfarin with INR greater than 2.0) / Lumbar puncture/epidural/spinal anaesthesia expected within the next 12 hours
Acute stroke / Lumbar puncture/epidural/spinal anaesthesia within the previous 4 hours
Thrombocytopaenia (platelets less than 75)
Uncontrolled systolic hypertension (230/120 mmHg or higher)
Untreated inherited bleeding disorders (such as haemophilia and von Willebrand’s disease)

Reference: Risk Assessment for Venous Thromoboembolism (VTE). National Institute for Health and Clinical Excellence, London UK. March

2010. See http://www.nice.org.uk/guidance

Ortho8308 Hip Fracture Preoperative Orthopaedic Orders_Mar2015 new.doc C/8/HipFracture/MD/01-14/V1/Pre-op

y ordering physician of result.XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

Warfarin Reversal for Invasive Procedures/ Surgery / Clinical Decision Support

**In patients with high risk of stroke (e.g. atrial fibrillation with CHADS2 score greater than 3, previous stroke/TIA, mechanical heart valve) or thrombosis (e.g. VTE within past 3 months, cancer-associated thrombosis, thrombophilia, antiphospholipid antibody syndrome), algorithm may not be appropriate and Hematology/ Internal Medicine consultation is recommended**

References

Activity

Bone & Joint Canada Hip Fracture Tool Kit 2011 Wasdell ed.

Handoll HH SCMJ. Interventions aimed at improving and restoring mobility after hip fracture. Cochrane Database Syst Rev. 2011;3.

Kristensen MT, Andersen L, Bech-Jensen R, et al. High intertester reliability of the cumulated ambulation score for the evaluation of basic mobility in patients with hip fracture. Clin Rehabil. Dec 2009;23(12):1116-1123.

Overgaard J, Kristensen MT. Feasibility of progressive strength training shortly after hipfracture surgery. World journal of orthopedics. 2013;4(4):248-258.

Sherrington C, Lord SR, Herbert RD. A randomized controlled trial of weight-bearing versus non-weight-bearing exercise for improving physical ability after usual care for hip fracture. Arch Phys Med Rehabil. May 2004;85(5):710-716.

Pashikanti, L., Von Ah, D. Impact of Early Mobilization Protocol on the

Medical-Surgical Inpatient Population: An Integrated Review of Literature. Clinical Nurse Specialist, Lippincott 2012.

Laboratory

Flesher, M.E. Archer K.A., Leslie, B.D. McCollom, R. Martinka, G. P. Assessing the Metabolic and Clinical Consequences of Early Enteral Feeding in the Malnourished Patient JPEN J Parenter Enteral Nutr March 2005 vol. 29 no. 2 108-117 .

Holidk, M. F., Binkley, N.C., Bischoff-Ferrairi H. A. , Gordon C.M., Hanley D. A., Heaney R. P. Hassan, M. H., Weaver, C. M. Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline. DOI: http://dx.doi.org/10.1210/jc.2011-0385 Received: February 14, 2011

Laulund AS, Lauritzen JB, Duus BR, Mosfeldt M, Jørgensen HL.

Routine blood tests as predictors of mortality in hip fracture patients. Injury. 2012 Jul;43(7):1014-20. doi: 10.1016/j.injury.2011.12.008. Epub 2012 Jan 10.

Portsmouth Hospital NHS Trust. Guidelines for the management of patients at risk for refeeding syndrome.

References continued

Diet Type

Björkelund,K., Hommel,A., Thorngren K.G. Lundberg, D., Larrson, S. The Influence of Perioperative Care and Treatment on the 4-Month Outcome in Elderly Patients With Hip Fracture AANA Journal ß, February 2011, ß Vol. 79, No. 1

Hearing, S. D. Refeeding syndromeIs underdiagnosed and undertreated, but treatable BMJ. 2004 April 17; 328(7445): 908–909. doi: 10.1136/bmj.328.7445.908

Hommel, A., Hertz K. & Mainz, H. Personal communication: International Collaboration of Nursing Hip Fracture Working Group. Feb 16th, 2014.

Eneroth M, Olsson UB, Thorngren KG. Insufficient fluid and energy intake in hospitalised patients with hip fracture. A prospective randomised study of 80 patients. Clin Nutr 2005; 24: 297–303.

Fossi B, Jensen P & Kehlet H. Risk factors for insufficient perioperative oral nutrition after hip fracture surgery within a multi-modal rehabilitation programme Age and Ageing 2007; 36: 538–543

Lawson RM, Doshi MK, Ingoe LE, Colligan JM, Barton JR, Cobden I. Compliance of orthopaedic patients with postoperative oral nutritional supplementation. Clin Nutr 2000;

19: 171–5.

Radtke, F. M; Franck, M.; MacGuill, M.; Seeling, M.; Lütz, A.; Westhoff, S.; Neumann, U.; Wernecke, K. D; Spies, C. Duration of fluid fasting and choice of analgesic are modifiable factors for early postoperative delirium. European Journal of Anaesthesiology: May 2010 - Volume 27 - Issue 5 - p 411–416