PLACE LABEL HERE

PHYSICIAN ORDERS

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

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

Diagnostics (day of surgery):______

PRE-OP ORDERS:

1. Fetal Heart Tones check preoperatively if > 12 weeks gestation

2. Intraoperative TEE, Reason: Cardiac Surgery, Read by: Anesthesia

PRE-OP MEDICATION ORDERS:

3.Antiemetic:  Scopolamine 1.5 mg transdermal patch, apply behind ear x 1 dose

Zofran (ondansetron) 4 mg IV x 1 dose

Other: ______x 1 dose in pre-op

4.Antacid:Pepcid (famotidine) 20 mgIV x 1 dose or po x 1 dose

Bicitra (citric acid/sodium citrate) 30 ml po x 1 dose

5.Anxiety: Versed (midazolam) ______mg IV x 1 dose or  po x 1 dose

6.Pain:Morphine 1 mg IVP x 1 dose now, may repeat x 1 dose if needed

orMorphine 2 mg IVP x 1 dose now, may repeat x 1 dose if needed

or Dilaudid (HYDROmorphone) 0.25 mg IVP x 1 dose now, may repeat x 1 dose if needed

or Dilaudid (HYDROmorphone) 0.5 mg IVP x 1 dose now, may repeat x 1 dose if needed

  1. Bilateral myringotomies/tubes:

Tylenol (acetaminophen) suppository 30-40 mg/kg x 1 dose in OR (may round, max dose 650 mg)

8. Lopressor (metoprolol) 5 mg IV x 1 dose OR  25 mg po x 1 dose OR  50 mg po x 1 dose

9. Atenolol 25 mg po x 1 dose OR  50 mg po x 1 dose

10.Albuterol 2.5 mg respiratory treatment pre-op x ______

11. Hydrocortisone 100 mg IV x 1 dose

12.Initiate Perioperative Glucose Control Orders (form # 21383)

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DateTimePhysician SignaturePID Number