PLACE LABEL HERE

ORTHOPEDIC SURGERY

PRE-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).

ALLERGIES: ______

SURGICAL PROCEDURE: ______

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 # 3 No, outpatient

2. Is this an inpatient only procedure? Yes, admit as inpatient, proceed to # 3 No, outpatient

3. Diagnosis: ______

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

  1. Telemetry: If patient Medical/Surgical, must complete form # 36084
  2. Isolation: Contact  Droplet Airborne For: ______
  3. Consult: IMPACT Evaluation: ______

Pulmonologist Notified

Physical Therapy, Reason______

 Other: ______

  1. Diagnostics: Per Anesthesia form # 33644

 CBC  H&H Platelet count U/A  Chem 7 CMP

 PT  PTT  Platelet Function Screen (if PT or PTT abnormal)

 Urine hCG for any menustrating female ≥ 12 years of age

 Other: ______

 CXR, Reason: ______

 EKG, Reason: ______, Read by: ______

Type and Screen  Hold #units _____

  1. MRSA & MSSA nasal swab:

All Total Joint Replacement Surgeries

Unicompartmental Knee Replacement Surgery

Spinal Fusion Surgery

Laminectomy

Microdiscectomy

  1. For all MRSA/MSSA positive results, nurse to initiate form # 2645, Positive MRSA/MSSA Screen Prior to Surgical Procedure Protocol
  1. Pre-op teaching: Chlorhexidine 4% shower at home  Surgical Procedure does not require 4% Chlorhexidine preop

 NPO past midnight (unless otherwise ordered by anesthesia)

 Crutch walking:  WBAT  NWB  Walker  Other: ______

  1. Chlorhexidine 2% wipes to be done in pre-op Surgical Procedure does not require 2% wipes preop
  1. Regional Anesthesia:  Femoral Block  Scalene Block  Bier Block  Adductor canal block  Other: _____

For Total Knee: Adductor canal block, 20 ml 0.25% bupivacaine with epinephrine 1:200

  1. Apply antiembolic device:  Sequential compression device  Plexi pulse (FCDs)

 Antiembolic stockings    Other: ______

  1. Clip surgical site for procedure as indicated
  1. Cast in pre-op:  Split or  Bivalve

Order writer’s initials ______

*3-28584* FORM 3-28584 REV. 10/2017 WHITE: Medical Record CANARY: Pharmacy Page 1 of 2

PLACE LABEL HERE

ORTHOPEDIC SURGERY

PRE-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).

PRE-OP MEDICATIONS

16. Antibiotic: Ancef (cefazolin) 2 gm (or 3 gm if weight > 120 kg) IV pre-op to be administered by anesthesia

or If Pediatric (wt ≤50 kg & ≤ 12 y/o): Ancef (cefazolin) 25 mg/kg to a max of 1 gm x 1 dose

OR beta lactam (penicillin and cephalosporin) allergy only,

Cleocin (clindamycin) 900 mg IV pre-op to be administered by anesthesia

OR

Vancomycin IV to be administered 1-2 hrs preoperatively

 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 over 1.5 hrs)

REQUIRED: Rationale for using Vancomycin as an antimicrobial prophylaxis

History of MRSA/positive screen

Allergy to penicillin and cephalosporins

HOLD PREOP ANTIBIOTIC UNTIL INTRA OP CULTURES OBTAINED

For Total Hip and Knee Patients

17. CeleBREX (celecoxib) 200 mg po x 1 dose or  100 mg  400 mg po x 1 dose in pre-op. DC if CrCl <30

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

19. Scopolamine patch 1.5 mg, apply behind the ear just prior to surgery. DC if > 65 y/o, h/o of glaucoma, BPH, or post op urinary retention. Remove the next day.

20. Decadron (dexamethasone) 10 mg IV x 1 dose (to be administered by anesthesia intra-op)

______

DateTimePhysician SignaturePID Number

FORM 3-28584 REV. 10/2017 WHITE: Medical Record CANARY: Pharmacy Page 2 of 2