PLACE LABEL HERE
ROBOTIC PROSTATECTOMY
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 q No, outpatient, DC
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. Diagnostics: q CBC STAT in PACU
q CBC, BMP in am
q Other: ______
6. Vital signs per unit routine
7. Strict I & O: q 2 hrs x 2, then q 4 hrs
8. Foley to Bedside Bag. Do Not Remove Foley, Reason: Surgical Procedure
9. Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)
10. Turn, cough, deep breath
11. Activity: Ambulate with assistance as needed today, then up ad lib on POD #1
12. Notify physician for: Temp > 101° F, urine output < 30 ml/hr for two consecutive hrs, BP > 180/90 or < 90/60, RR > 30 or < 10, or excessive bloody drainage.
13. Nothing per rectum
14. Diet: q Clear liquids, advance as tolerated to ______
q Other: ______
15. q JP Drain to Bulb Suction
16. q Instruct patient on Foley care and leg bag for home use
17. q Incentive spirometer 10 repetitions q one hr while awake
18. 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 at 1700 (30 mg if CrCl < 30 ml/min)
and/or q Mechanical devices: SCDs
SCHEDULED MEDICATIONS:
19. IV Fluids: q NS q LR q D5NS q D5 ½ NS with 20 KCl at ______ml/hr
Discontinue IVF when patient tolerating PO fluids
20. Antibiotics: Post-op antibiotic will be automatically stopped within 24 hrs unless indication is documented
q Ancef (cefazolin) 1 gm IV q 8 hrs x 2 doses or q continue > 24 hrs for ______(Reason REQUIRED)
Copy to pharmacy Order writer’s initials ______
*3-27026* FORM 3-27026 REV. 07/2015 Page 1 of 2
PLACE LABEL HERE
ROBOTIC PROSTATECTOMY
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).
PRN MEDICATIONS: See policy 520-06 for range orders and pain intensity guidelines.
21. Bladder Spasm: q Detrol LA (tolterodine) 4 mg po daily prn
22. q Electrolyte Replacement Protocol (form # 21340)
23. Mild Pain, Temp >100.5°F, HA: q Tylenol (acetaminophen) 650 mg po q 4 hrs prn
24. 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.
and/or q 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.
25. 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.
26. 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)
27. Sleep: q Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10mg (male < 65 y/o) po at HS prn
28. Indigestion: q Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
29. Stool Softener: q Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
30. 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
31. Cough: q Robitussin (guaifenesin) 15 ml po q 4 hrs prn
32. Sore Throat: q Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn
ADDITIONAL ORDERS:
______
______
______
Date Time Physician Signature PID Number
Copy to pharmacy
FORM 3-27026 REV. 07/2015 Page 2 of 2