PLACE LABEL HERE

ORTHOPEDIC

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.Status was addressed pre-procedure and has NOT CHANGED.

or

Status order was addressed pre-procedure and HAS CHANGED to  Admit as Inpatient, expected stay will cross two midnights

Place in Observation  Outpatient, DC home

2. Diagnosis: ______

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

3. Telemetry: If patient Medical/Surgical, must complete form # 36084

4. Isolation:  Contact  Droplet  Airborne For: ______

5.Consults: Hospitalist consult for medical management  Notified

Occupational Therapy consult on POD # ___: Shoulder exercises, OT may consult PT for mobility  Other: ____

 Physical Therapy consult on POD # ____Transfer to training bed to chair Gait training Therapeutic exercises

Weight bearing status: WBAT______LE  TDWB______LEPWB  TTWB

 NWB______LE  ______% WB______LE

Case Manager to arrange: Anticoagulant therapy for home Referral to rehab facility: ______

 Equipment for home use: ______ Home health services: ______ Other: ______

6. X-Rays:

Exam / Laterality Option / Ordered Views / Priority / Reason for Exam / Location of Exam
Chest / N/A / AP / Stat or
Routine / Portable
Done in OR
Clavicle / Left Right  Bilateral / AP / Stat or
Routine / Portable
Done in OR
Scapula / Left Right  Bilateral / AP AP/Lateral / Stat or
Routine / Portable
Done in OR
Shoulder / LeftRight  Bilateral / AP/Y/Axillary
AP/Y/Valpeau / Stat or
Routine / Portable
Done in OR
Humerus / Left Right  Bilateral / APLateral / Stat or
Routine / Portable
Done in OR
Elbow / LeftRight  Bilateral / APLateral / Stat or
Routine / Portable
Done in OR
Forearm / LeftRight  Bilateral / APLateral / Stat or
Routine / Portable
Done in OR
Wrist / LeftRight  Bilateral / APLateral Oblique / Stat or
Routine / Portable
Done in OR
Hand / LeftRight  Bilateral / APLateral Oblique / Stat or
Routine / Portable
Done in OR
Pelvis / N/A / APInlet/Outlet
Judet / Stat or
Routine / Portable
Done in OR
Hip / LeftRight  Bilateral / AP/Lateral
AP/Cross Table / Stat or
Routine / Portable
Done in OR
Femur / LeftRight  Bilateral / AP/Lateral / Stat or
Routine / Portable
Done in OR
Knee / LeftRight  Bilateral / AP/Lateral  Sunrise
45° PA Standing / Stat or
Routine / Portable
Done in OR
Tibia / LeftRight  Bilateral / AP/Lateral / Stat or
Routine / Portable
Done in OR
Ankle / LeftRight  Bilateral / AP/Lateral/Mortise / Stat or
Routine / Portable
Done in OR
Calcaneus / LeftRight  Bilateral / Lateral Harris / Stat or
Routine / Portable
Done in OR
Foot / LeftRight  Bilateral / APLateral Oblique / Stat or
Routine / Portable
Done in OR
Patella / LeftRight  Bilateral / APLateral / Stat or
Routine / Portable
Done in OR

Copy to pharmacyOrder writier’s initials ______

*3-18111*FORM 3-18111 REV. 03/2016 Page 1 of 4

PLACE LABEL HERE

ORTHOPEDIC

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).

7.Labs:  Chem 7  CMP  CBC  H&H  PT/PTT  Other: ______

Acetabular/Pelvic Fracture patients: H&H in am and POD # 2 (notify physician if HGB ≤ 7.0)

8. Vital signs per routine

9.Neurovascular checks q 1 hr x 4 hrs, then q 2 hrs x 4 hrs, then q 4 hrs, or  Other: ______

Left lower extremity or Right lower extremity

10.Elevate affected extremity and apply ice or  Cold therapy pad  Other: ______

11. Brace/Immobilizer: Patient already has brace

Shoulder Sling With abductor pillow

 Shoulder immobilizerWith abductor pillow

Leg brace:  At all times  Except when CPM in useCPM (settings) ______

 Knee immobilizer Cam Boot Post Op Shoe

Knee Hinge: Locked at ___° or Unlocked and adjusted for freedom between_____°

Elbow Hinge: Locked at __° or Unlocked and adjusted for freedom between_____°

12.Dressing:  Keep intact unless saturated  Reinforce prn (notify physician after 2 times) Change: ______

13. Drains: Hemovac  JP  NPWT (Wound Vac), consult Wound Care

Acetabular/Pelvic Fracture patients: Surgical drain to self suction. Record output q 8 hrs.

DC no sooner than POD # 1 when drainage < 25 ml for 8 hrs

DC Drain:______

14.Instruct patient in use of: Sling  Knee immobilizer  Hinge Knee  Hinge elbow  shoulder brace

Instruct for crutchesROM Quad rehabWBAT PWB

Instruct (q 15 min while awake)Straight leg lifts QUAD sets Ankle pumps

 Other: ______

Shoulder Surgery:

 Start pendulum swings tomorrow x 3 day. Otherwise, stay in sling at all times/no other shoulder motion

 Start elbow flexion and extension exercises tomorrow

15.Acetabular/Pelvic Fracture Patients: Monitor urine output q 2 hrs x 48 hrs

Call physician if urine output is < 0.5 ml/kg over 4 hrs

Hip precautions

Abduction pillow while in bed

16.  Incentive spirometry q one hr while awake

17.  Foley catheter to bedside bag. D/C Foley catheter on POD # 1 by 11am.

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

19.O2per Protocol (form # 34431)

20. Diet: Clear liquids; advance as tolerated to:  Regular Cardiac  Diabetic ______calorie  Renal

or  npo

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

22.Activity: Bedrest x ___ hrs

Bedrest with BRP (affected leg elevated) With crutches: WBAT PWB NWB

 Ambulate with assistance

23. Notify physician if:Temp > 102FDBP < 50 or > 100

RR less than 10 or > 30Changes in neurovascular status

HR less than 50 or > 140Excessive drainage from incision

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

24.IVF:  D5 ½ NS  D5 NS  ½ NS  D5 LR  LR at ______ml/hr IV 

 Discontinue IVF when tolerating oral fluids

25.Antibiotic:(1st dose due at: ______)

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

 Ancef (cefazolin) 2 gm IV q 8 hrs x2 doses

or  x 48 hrsfor______(Reason) or  > 48 hrs for______(Reason)

 Rocephin (ceftriaxone) 1 gm IV q 24 hrs x 1 dose

or  x 48 hrsfor______(Reason) or  > 48 hrs for______(Reason)

 Zosyn (piperacillin/tazobactrim) 3.375 gm IV q 8 hrs x 2 doses

or  x 48 hrsfor______(Reason) or  > 48 hrs for______(Reason)

 Cleocin (clindamycin) 600 mg IV q 8 hrs x 2 doses

or  x 48 hrsfor______(Reason) or  > 48 hrs for______(Reason)

Vancomycin, pharmacy to dose x 24 hrs

or  x 48 hrsfor______(Reason) or  > 48 hrs for______(Reason)

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

 Apply/maintain antiembolic stockings

 Sequential compression device Foot compression device (document reason): ______

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: ______

27.Bowel Management:

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

28.PCA:  See PCA orders (form # 2119)  See Sleep Apnea PCA orders (form # 21261)

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

30. Indocin (indomethacin) 25 mg po three times daily. Start in AM of ______

31. CeleBREX (celecoxib) 100 mg or 200 mg 400 mg po q day or bid

32. Ultram (tramadol) 50 mg or 100 mg po q 6hr or q 8 hrs or q 12 hrs (CrCl < 30)

Copy to pharmacyOrder writer’s initials ______

FORM 3-18111 REV. 03/2016 Page 1 of 4

PLACE LABEL HERE

ORTHOPEDIC

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).

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

  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

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

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

ADDITIONAL ORDERS:

______

______

______

______

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-18111 REV. 03/2016 Page 1 of 4