PLACE LABEL HERE

KNEE REPLACEMENT

POST-OP ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

1. Do you expect that the patient’s condition will require a hospital stay that will cross two midnights (includes the time spent in outpatient- ED, surgery, OBS) and the patient has medical necessity for an inpatient admission?

Yes, admit as inpatient, proceed to # 2No, place in observation

2.If admitted as inpatient, Inpatient Physician Certification:

Diagnosis:Atrial Fibrillation

Level of Care: Critical  Intermediate  Acute Care Location/Specialty Unit Preference______

  1. Telemetry: If patient Medical/Surgical, must complete form # 36084, for Tikosyn Administration
  2. Isolation:  Contact  Droplet  Airborne For: ______

PACU

5. X-Ray affected knee AP/ lateral

6.No pillow(s) under operative knee (popliteal area)

7.Neurovascular checks q 15 mins

8.Ice to operative site

9.Orthopedic Autotransfusion. Convert to wound drain after transfusion

10.Epidural: See orders (form # 1825)

11.Nucynta (tapentadol) 100 mg po x 1 dose or 50 mg po x 1 dose

12.Ofirmev (acetaminophen) 1 gm IV x 1 dose(if not given in OR)

POST-OP

13. Neurovascular checks q 4 hrs x 24 hrs

14.Consult Physical Therapy (Physical Therapy to consult Occupational Therapy if indicated), Weight bearing activity: WBAT PWB Toe touch WB NWB

15.Consult Social Worker for placement

16.Consult Occupational Therapy

17. Consult Pain Service

18.Hospitalist consult for medical management

19.Labs: H&H in AM on first and second day of post-op (notify physician if HGB ≤ 7.0)

Platelet count on POD # 3 or prior to discharge (notify physician if abnormal)

20. Diet:  Regular diet as tolerated Other: ______

21.Oral Nutrition Supplement Standing Orders (form # 31417), initiate if patient meets criteria

22.Incentive spirometry qone hr while awake

23.O2 Protocol (form # 34431)

24.CPM: Range of motion at ______for knee replacement,increase as tolerated

25. Knee immobilizer when up until 3/5 quadriceps strength  Knee brace locked in extension at night

26.If on CPM, increase as tolerated

May D/C at nightArrange for home CPM use D/C CPM when reach 90° passive flexion

27.Surgical drain: D/C no sooner than the POD #1 when drainage 25 ml for 8 hrs

28.Dressing:  Reinforce prn  Change: ______ Other: ______

29.Foley catheter to bedside bag. D/CFoley catheter on POD # 1 by11am.

30.Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)

31. Monitor urine output q2 hrs x 24 hrs. Call physician if urine output is 0.5ml/kg/hr over 4 hrs.

Copy to pharmacy Order writer’s initials ______

*3-18298*FORM 3-18298 REV. 02/2017 Page 1 of 3

PLACE LABEL HERE

KNEE REPLACEMENT

POST-OP ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

SCHEDULED MEDICATIONS

32. IVF: D5 ½ NS IV at 100 ml/hr D5½ NS IV at ______ml/hr Other: ______

 Discontinue IVF when tolerating oral fluids

33. Antibiotic:  Ancef (cefazolin) 2 gm IV q 8 hrs x 2 doses

Post-op antibiotic will be automatically stopped within 24 hrs unless indication documented

Document indication for > 24 hrs: ______

OR beta lactam allergy only:

 Vancomycin (give 12 hrs from initial dose)

If patient weight < 90 kg, 1 gm IV x 1 dose (infuse over 1 hr)

If patient weight 90 kg, 1.5 gm IV x 1 dose (infuse over1.5 hrs)

REQUIRED: Rationale for using Vancomycin as an antimicrobial prophylaxis

History of MRSA/positive screen

Allergy to penicillin and cephalosporins

Post-op antibiotic will be automatically stopped within 24 hrs unless indication documented

Document indication for > 24 hrs: ______(Pharmacy to dose)

OR

Cleocin (clindamycin) 900 mgIV q 8 hrs x 2 doses

Post-op antibiotic will be automatically stopped within 24 hrs unless indication documented

Document indication for > 24 hrs: ______

34. VTE Prophylaxis: (Do not begin anticoagulant therapy until epidural catheter out for 4 hrs):

Foot pumps

Apply/maintain antiembolic stockings

Surgery end time:______

 Coumadin (warfarin) ____ mg po q day at 1700, start today.

 Aspirin, enteric coated, 325 mg po bid, First dose in AM POD # 1

 Lovenox (enoxaparin)

 30 mg SQ q 12 hrs x 2 doses, First dose 12 hrs post-op, then 40 mg SQ q 24 hrs

 40 mg SQ q 24 hrs, First dose in AM POD 1, If CrCl < 30, 30 mg SQ daily

 Arixtra (fondaparinux), if CrCl < 30 or weight < 50 kg, Arixtra will be therapeutically interchanged to Lovenox

 2.5 mg SQ q 24 hrs, start 8 hrs post-op

 2.5 mg SQ q 24 hrs, First dose in AM POD # 1

 Xarelto (rivaroxaban), if CrCl < 30, Xarelto will be therapeutically interchanged to Lovenox

 10 mg po q 24 hrs, First dose 8 hrs post-op

 10 mg po q 24 hrs, First dose in AM POD # 1

 Eliquis (apixaban) 2.5 mg po q 12 hrs,First dose 12 hours post op, if CrCl < 30, Eliquis will be therapeutically interchanged to Lovenox

 No Pharmacological Prophylaxis (Documented Reason Required):

 Bleeding Risk  Patient Refusal  Thrombocytopenia

 Active Bleeding (GI Bleed, Cerebral Hemorrhage, Hemorrhage, Retroperitoneal Bleed)

 Other: ______

Case Manager to coordinate anticoagulant therapy for home

35. Bowel Management / Constipation:

Senokot-S (docusate/senna) 2 tablets po at bedtime nightly

POD # 2, if no BM: Dulcolox (bisacodyl) 10 mg po x 1 dose on POD # 2

POD # 3, if no BM: Dulcolax (bisacodyl) 10 mg suppository per rectum x 1 dose, on POD # 3

If no BM 4 hrs post suppository, give Fleets Enema (sodium phosphate) per rectum x 1 bottle

Copy to pharmacyOrder writer’s initials ______

FORM 3-18298 REV. 02/2017 Page 1 of 3

PLACE LABEL HERE

KNEE REPLACEMENT

POST OP ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

36. PCA:  PCA (orders # 2119)  Sleep Apnea PCA (orders # 21261)  Epidural: Per Anesthesia

Discontinue PCA or Epidural on POD #2. If patient has epidural hold all other sedatives/narcotics unless ordered/approved by anesthesia until epidural discontinued.

37. If not on PCA, OxyCONTIN (oxyCODONE, Extended Release) 10 mg 20 mg po q 12 hrs x 4 doses

PRN MEDICATIONS (See policy 520-06 for range orders and pain intensity guidelines)

(if not ordered by Anesthesia during peri-operative phase)

  1. Electrolyte Replacement Protocol (form # 21340)
  2. Mild Pain, Temp>100.5F, HA:Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
  3. Moderate Pain:

Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered.

or If patient cannot take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po q 4 hrs prn instead of Norco. DC if Percocet ordered.

or Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Norco ordered.

and/or  Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (15 mg if CrCl 31-50, > 65 y/o old or <50 kg) or 10 mg po q 6 hrs prn (max combined duration of IV and po ketorolac is 5 days). DC if CrCl < 30.

  1. Severe Pain (Begin when Epidural or PCA has been discontinued)

Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered.

or  Dilaudid (HYDROmorphone) 0.25-0.5 mg IV q 3 hrs prn. If CrCl < 30, dose at 0.25 mg. Hold for excessive sedation. DC if Morphine ordered.

  1. Nausea/Vomiting: Zofran (ondansetron) 4 mg IV or po q 6 hrs prn

If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)

  1. Sleep: Melatonin 5 mg po q HS prn

or Ambien (zolpidem)5 mg (female or males ≥ 65 y/o) or 5-10mg (male < 65 y/o) po at HS prn

  1. Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn

45.Cough:Robitussin (guaifenesin) 15 ml po q 4 hrs prn

46.Sore Throat:Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn

ADDITIONAL ORDERS:

______

______

______

______

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-18298 REV. 02/2017 Page 3 of 3