PLACE LABEL HERE
SPINE SURGERY NON-FUSION
Lumbar Laminectomy / Microdiskectomy / Kyphoplasty
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
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. q Hospitalist consult for medical management q Notified
6. Vital signs per unit routine
7. Dressing: q Change dressing PRN if saturated q Change POD 1 q Change POD 2 q Remove dressing POD 2,
leave open to air
8. TED hose and SCDs while in bed.
9. q Foley catheter to bedside bag. Reason: Surgical Procedure, DC within 12 hrs post-op.
10. Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)
11. Drain Type: ______q 1/2 suction q Full suction q gravity
Discontinue drain: ______
12. Diet: NPO except ice chips for 4 hrs. Advance as tolerated to ______
13. Oral Nutrition Supplement Orders (form # 31417), initiate if patient meets criteria
14. Activity: Logroll. Out of bed with assistance within 6 hrs.
Ambulate in hall on DOS OR q Activity: ______
15. q Consult Physical Therapy Reason: strength training/post-op spine surgery
16. q RN May Consult PT if indicated
17. Muscle strength/sensory check q 1 hr x 4 hrs, then q 4 hrs
18. Incentive spirometry q 1 hr while awake
SCHEDULED MEDICATIONS
19. IV Fluids: q NS q LR q D5NS q D5 ½ NS with 20 KCl at ______ml/hr
Decrease to KVO when tolerating po
20. Antibiotic: Post-op antibiotic will be automatically stopped within 24 hrs unless indication is documented
q Ancef (cefazolin) 2 gm IV q 8 hrs x 2 doses or q continue > 24 hrs for ______(Reason REQUIRED)
q Other______x 24 hrs or q continue > 24 hrs for ______(Reason REQUIRED)
21. Pain: q See PCA orders (form # 2119) q See Sleep Apnea PCA orders (form # 21261)
and
q Percocet (oxyCODONE/acetaminophen) 5/325 mg, 1 to 2 tabs po q 6 hrs NOT prn x 3 doses
22. 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 q 24 hrs, in am on POD # 1 (30 mg if CrCl < 30 ml/min)
and/or q Mechanical devices: SCDs
23. Bowel management: Colace (docusate) 100 mg po twice daily
24. No Nicotine patches, No Toradol (ketorolac)
Copy to pharmacy Order writer’s Initials______
*3-9416* FORM 3-9416 REV. 11/2016 Page 1 of 2
PLACE LABEL HERE
SPINE SURGERY NON-FUSION
Lumbar Laminectomy / Microdiskectomy / Kyphoplasty
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)
25. Muscle relaxant: q Flexeril (cyclobenzaprine) 10 mg po q 8 hrs prn
or q Zanaflex (tizanidine) 4 mg po q 8 hrs prn
or q Robaxin (methocarbamol) 500 mg po tid prn
or q Valium (diazePAM) 5 mg po q 8 hrs prn
26. q Electrolyte Replacement Protocol (form # 21340)
27. Mild Pain, Temp >100.5°F, HA: q Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
28. Moderate Pain: Do not order these if Percocet is ordered as scheduled med.
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.
29. 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.
30. 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)
31. Sleep: q Melatonin 5 mg po q HS prn
or q Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn
32. Indigestion: q Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
33. 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
34. Cough: q Robitussin (guaifenesin) 15 ml po q 4 hrs prn
35. 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 3-9416 REV. 11/2016 Page 2 of 2