PLACE LABEL HERE
GYN SURGERY
POST-OP ORDERS
The following orders will be implemented. Orders with a “q” 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?
q Yes, admit as inpatient, proceed to # 2 q No, place in observation
2. If admitted as inpatient, Inpatient Physician Certification:
Diagnosis: ________________________________________________________________________________
Level of Care: q Critical q Intermediate q Acute Care Location/Specialty Unit Preference___________
3. q Telemetry: If patient Medical/Surgical, must complete form # 36084
4. q Isolation: q Contact q Droplet q Airborne For: _________________
5. Consult: _________________________, Reason ___________________________ q Notified
Consult: _________________________, Reason ___________________________ q Notified
6. Diagnostics: In PACU: q H&H q CBC q Chem 7 q CMP q Other: ______________
POD # 1: q H&H q CBC q Chem 7 q CMP q Other: ______________
7. Vital signs per routine
8. Notify physician for temp > 101°F, urine output < 0.5 ml/kg/hr over 4 hrs, BP > 160/100 or < 90/60, RR > 30, P > 130 or excessive bleeding
9. O2 per Protocol (form # 34431)
10. Foley catheter to drainage bag
11. Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)
12. Discontinue Foley catheter in AM POD #1 at 0600
q Straight cath if unable to void q 4-6 hrs OR if bladder scan reads > _________ mls
q Do NOT discontinue (document reason): _________________ q Other: ______________
13. q Vaginal packing: RN to remove in AM q physician to remove
14. q Ice packs to incisions x 48 hrs q Other: ______________________________________
15. Incentive spirometer 10 repetitions q 1 hr while awake
16. Remove dressing POD #1 q Other: ________________________
17. Diet: Clear liquid, advance as tolerated q Other: _______________________________________
q No carbonated beverages, straws, or gum
18. Initiate Nutrition Supplement Orders (form # 31417), if patient meets criteria
19. Activity: Progressive ambulation: Dangle @ 4 hrs post-op with assist; Ambulate @ 6 hrs post-op with assist. Advance ambulation to 4-6 times a day starting POD # 1, then progressing to up ad lib.
q Bed rest until AM q May shower q Other: ________________________
SCHEDULED MEDICATIONS:
20. IVF: D5 ½ NS at ___ ml/hr q Other: _________________ q Add KCI 20 mEq to each liter of IVF
Convert to INT if tolerating diet and temp < 100.5°F
21. Pain: q See PCA orders (form # 2119) q See Sleep Apnea PCA orders (form # 21261)
q Toradol (ketorolac) 30 mg IV q 6 hrs x ____ doses (15 mg if > 65 y/o or < 50 kg, max duration is 5 days)
22. Colace (docusate) 100 mg po bid
23. q Dulcolax (bisacodyl) 10 mg per rectum in AM of POD#1
Copy to pharmacy Order writer’s initials _______
*3-16013* FORM 3-16013 REV. 03/2016 Page 1 of 2
PLACE LABEL HERE
GYN SURGERY
POST-OP ORDERS
The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
24. Antibiotic:
q Ancef (cefazolin) 2 gm IV q 8 hrs x 2 doses or q continue > 24 hrs for ___________ (Reason REQUIRED)
q If allergic to Penicillin:
Cleocin (clindamycin) 600 mg IV q 8 hrs x 2 doses or q continue > 24 hrs for _______ (Reason REQUIRED)
and
Gentamicin 5 mg/kg IV x 1 dose or q continue > 24 hrs for _______ (Reason REQUIRED), Pharmacy to dose
25. VTE prophylaxis, Initiate Venous Thromboembolism (VTE) Prophylaxis Orders (form # 33058)
q Heparin 5,000 units SQ q 8 hrs (q 12 hrs if wt < 50 kg or age > 75)
or q Lovenox (enoxaparin) 40 mg SQ daily, begin in am on POD # 1 (30 mg if CrCl < 30 ml/min)
(if pt has an epidural, do not begin enoxaparin until epidural has been out for 12 hrs)
and/or q Mechanical devices: SCDs
PRN MEDICATIONS (If > one drug is ordered for the same indication, clinical assessment will be used per policy 520-06)
26. q Electrolyte Replacement Protocol (form # 21340)
27. Mild Pain, Temp >100.5°F, HA: q Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
28. Moderate Pain:
q Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered.
or q 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 q Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Norco ordered.
29. Severe Pain (Begin when Epidural or PCA has been discontinued)
q Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered.
or q 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.
30. Nausea/Vomiting: q Zofran (ondansetron) 4 mg IV or po q 6 hrs prn
q If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)
31. Sleep: q Melantonin 5 mg po q HS prn
q Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn
32. Indigestion: q Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
33. Cough: q Robitussin (guaifenesin) 15 ml po q 4 hrs prn
34. Sore Throat: q Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn
35. Gastric Bloating: q Mylicon (simethicone) 80 mg po at meals and at bedtime prn
_____________ _______________ _________________________________ ___________
Date Time Physician Signature PID Number
Copy to pharmacy
FORM 3-16013 REV. 03/2016 Page 2 of 2