PLACE LABEL HERE
HEPATIC INTRA-ARTERIAL THERAPY
POST-PROCEDURE 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 q No, outpatient, DC home
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. Check vital signs, distal pulses and entrance site for evidence of bleeding:
Every 15 min x 4 times, then q 30 min x 4 times, then q 1 hr x 4 times
6. If entrance site bleeds or develops a hematoma:
Hold pressure for 15 min
Reassess site and distal pulses.
If bleeding or hematoma swelling continues, hold pressure again.
Notify Radiologist or Hospitalist for assistance to stabilize bleeding/hematomas.
7. Notify Radiologist if distal pulses change to non-palpable
8. Diet: Advance as tolerated
9. Foley Catheter to bedside bag. D/C in a.m.
10. CBC, CMP in am
11. Activity: bedrest with ______leg straight for ______hrs, then:
q Up with assistance for the first time and then up as tolerated or q ______
SCHEDULED MEDICATIONS:
12. IV: D5½ NS at 150 ml/hr for 6 hrs after procedure, then convert to INT.
13. Hold medications containing Metformin 48 hrs post procedure.
14. q Sandostatin (Octreotide) infusion 1 mcg/ml, 100mcg/hr IV (Do not D/C until ordered by Radiologist)
15. q Decadron (dexamethasone) 8mg IV q 8 hrs x 2 doses, then 4 mg IV q 8 hrs
16. Antibiotics:
q Ancef 1 gm IV q 8 hrs x 24 hrs, to be given at ______
q Flagyl 500mg IV q 8 hrs x 24 hrs, to be given at ______
q Avelox 400mg IV q 24 hrs x 24hrs, to be given at ______
*3-2767* FORM 3-2767 REV. 02/2016 WHITE: Medical Record CANARY: Pharmacy Page 1 of 2
PLACE LABEL HERE
HEPATIC INTRA-ARTERIAL THERAPY
POST-PROCEDURE 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).
PRN MEDICATIONS See policy 520-06 for range orders and pain intensity guidelines.
17. q Electrolyte Replacement Protocol (form # 21340)
18. Mild Pain, Temp >100.5°F, HA: q Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
19. 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 can not take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po q 4 hrs prn intead 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.
20. 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.
21. 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)
22. Sleep: q Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn
23. Indigestion: q Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
24. Stool Softener: q Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
25. Constipation: q Milk of Magnesia (MOM) 30 ml po daily prn
If no BM after 48 hrs, q Dulcolax (biscodyl) 10 mg per rectum daily prn
and/or q Senokot-S (docusate/senna) 2 tablets po at bedtime nightly
26. Cough: q Robitussin (guaifenesin) 15 ml po q 4 hrs prn
27. Sore Throat: q Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn
ADDITIONAL ORDERS:
______
______
Call ______with any problems at ______(after hours, page interventional radiologist on call)
______
Date Time Physician Signature PID Number
FORM 3-2767 REV. 02/2016 WHITE: Medical Record CANARY: Pharmacy Page 2 of 2