WRITE WITH BLACK BALL POINT INK ONLY USING FIRM PRESSURE.
DOCTOR WRITING ORDER IS TO RECORD DATE AND TIME WITH EACH SET OF ORDERS WRITTEN. AUTHENTICATE WITH FULL SIGNATURE AND BEEPER NUMBER.
MR FORM 1C
8/96
PHYSICIAN ORDERS
DIAGNOSIS:
DRUG SENSITIVITY:
Patient Identification
THORACIC SURGERY
POST-OPERATIVE/TRANSFER ORDERS
LOCATION: Transfer to monitored bed - 4 North
DIAGNOSIS: _______________________________________________________________________________________
RESPONSIBLE SERVICE/PHYSICIAN: __________________________________________________________________
CONDITION:
G stable G guarded G severe G critical
VITALS: Routine new post-op arrival vitals per unit protocol, then measure and record vitals and I/O’s q4hrs
Call thoracic service for:
• Decrease in oxygen saturation less than 90%
• Increase in oxygen requirement greater than 2 liters in 8 hours or for requirement of greater than 5 Lpm oxygen per nasal cannula
• HR > 100 or < 50
• Temp > 38.5°C
• Systolic BP > 180 or < 90 or Diastolic BP ≥ 110
• Urine output < 30 ml/hr for greater than 2 hr or < 120 ml per 4 hour period
• Chest tube output of greater than 500mL in first 2 hours post-op
• Change in character of chest tube drainage (i.e., increasing air leak, increasing blood tinge, milky appearance)
• Call Team managing pain (i.e., APMS) for patient pain score of equal to or greater than 5
• Call the Primary Service for patient complaints of ongoing uncontrolled pain
ACTIVITY:
G Ambulate on ward AT LEAST TID/Qshift with assistance.
G Out of bed to chair AT LEAST TID for 1 hour.
G Out of bed to chair AT 90° for ALL meals.
NURSING ORDERS:
1. Head of bed to 30°
2. K-pad to shoulder for arm pain PRN
3. Foley to dependent drainage. May D/C Foley 6 hours after epidural catheter is removed.
4. DVT prophylaxis:
a. Sequential Compression Device (SCD’s) to be worn while in bed, day/night until fully ambulatory then may be worn at night time only.
5. Document STRICT I&O’s. Q 4 hours (see above for UOP guidelines).
6. Chest tubes:
G Water seal G Suction _______cm G Balanced Pneumonectomy Pleural Drain
7. NG Tube:
G Continuous low wall suction
G Clamped G None
G FLUSH NG TUBE 30ML NS Q 4hrs
G Do not place anti-reflux valve
8. Incentive spirometry (x10/hr) and cough and deep breathe exercise to be done and reinforced by nursing every hour while awake, Q2hrs at night.
9. G Feeding Jejunostomy
G Flush 30m NS Q 4hrs and after all medications
G May give liquids medications via Jejunostomy tube. Do not administer crushed medications via Jejunostomy tube.
____________________
Date
Rev. 6/10
____________________
Time
sr 6/29/10 Page 1 of 4
_______________________________________________
Physician Signature
Distribution: White - Chart Copy
WRITE WITH BLACK BALL POINT INK ONLY USING FIRM PRESSURE.
DOCTOR WRITING ORDER IS TO RECORD DATE AND TIME WITH EACH SET OF ORDERS WRITTEN. AUTHENTICATE WITH FULL SIGNATURE AND BEEPER NUMBER.
MR FORM 1C
8/96
PHYSICIAN ORDERS
DIAGNOSIS:
DRUG SENSITIVITY:
Patient Identification
THORACIC SURGERY
POST-OPERATIVE/TRANSFER ORDERS
DIAGNOSTIC ORDERS:
PACU STAT Orders: G CXR; RE: s/p lung surgery
G CBC, e-group, BUN, Creatinine, Magnesium
AM Orders: G CXR PA/Lateral
G CXR portable RE: s/p lung surgery
G CBC, G e-group, G BUN, G Creatinine, G Magnesium, G PT/INR, PTT
Other: __________________________________________________________________________________________________
MEDICATIONS:
Antibiotics
G Cefuroxime 1.5 grams IV every 8 hours for 23 hours, dc.
• Pre-op dose given at:______________ (see anesthesia record)
• First post op dose to be given at: ___________
• Second post op dose to be given at: _________
• Third post op dose to be given at: ___________
• Discontinue after third post-op dose.
*IF Beta-lactam allergy then,
G Vancomycin 1 gram IV every 12 hours x 23 hours
• Pre-op dose given at:______________ (see anesthesia record)
• First post op dose to be given at: ___________
• Second post op dose to be given at: _________
• Discontinue after second post op dose.
G Other: ________________________________________________________________________________________________
Pain Management
If epidural is present, call Anesthesia (APMS) for management of epidural and pain control. (If ongoing uncontrolled pain, then
contact the primary service as well as APMS).
IF epidural is discontinued or NOT present, then: (select only one of the items in numbers 2-5 for breakthrough pain)
1. G See PCA orders
2. G Hydrocodone 5 mg/Acetaminophen 325mg 1 tablet PO Q6hrs (scheduled). For breakthrough pain, give one
additional tablet every 4-6 hours for a maximum of two tablets every six hours.
3. G Hydrocodone 10 mg/Acetaminophen 325mg (Norco 10)1 tablet PO Q6hrs (scheduled). For breakthrough pain, give one
additional tablet every 4-6 hours for a maximum of two tablets every six hours.
4. G Oxycodone 5mg/Acetaminophen 325mg (Percocet) 1 tablet PO Q6hrs (scheduled). For breakthrough pain, give one
additional tablet every 4-6 hours for a maximum of two tablets every six hours.
5. G Oxycodone 5mg PO Q4hrs PRN breakthrough moderate pain
G Oxycodone 10mg PO Q4hrs PRN breakthrough severe pain.
6. Ketorolac (Toradol)
G 30mg IV Q6hrs (scheduled) x 2 days
G 15mg IV Q6hrs (scheduled) x 2 days [If age >65 years or weight is <50kg]
7. For breakthrough pain not relieved by above medications (and no epidural is present), then:
G Fentanyl __________mcg IV Q__________hours.
G Morphine__________mg IV Q__________hours.
____________________
Date
Rev. 6/10
____________________
Time
sr 6/29/10 Page 2 of 4
______________________________________________
Physician Signature
Distribution: White - Chart Copy
WRITE WITH BLACK BALL POINT INK ONLY USING FIRM PRESSURE.
DOCTOR WRITING ORDER IS TO RECORD DATE AND TIME WITH EACH SET OF ORDERS WRITTEN. AUTHENTICATE WITH FULL SIGNATURE AND BEEPER NUMBER.
MR FORM 1C
8/96
PHYSICIAN ORDERS
DIAGNOSIS:
DRUG SENSITIVITY:
Patient Identification
THORACIC SURGERY
POST-OPERATIVE/TRANSFER ORDERS
DVT Prophylaxis: (No Lovenox or Arixtra with epidural patients.)
G Heparin 5000 units SQ TID
G Enoxaparin (Lovenox) 30 mg SQ BID (1st dose 12 hours post surgery)
G Fondaparinux (Arixtra) 2.5 mg SQ daily (1st dose 12 hours post surgery)
Scheduled Medications:
Surfak 240 mg PO Qdaily
Stress Ulcer Prophylaxis:
G Not currently indicated.
G Ranitidine 50 mg IVPB every 8 hours
G Pantoprazole 40 mg PO daily
G Pantoprazole 40 mg IVPB once a day
G Prevacid solutab 30 mg NGT/OGT daily
G Other:_________________________________________________________________________________________________
Medications as needed (PRN):
1. Ondansetron (Zofran) 4mg IV Q4hrs PRN nausea.
2. Mylanta 30 ml PO Q4hrs PRN heartburn or indigestion
3. Milk of Magnesia 30ml gms PO Q12hrs PRN constipation
4. Simethicone 80 mg PO Q4hrs PRN gas or bloating
7. Dulcolax suppository 1 PR daily as needed for constipation. May repeat x 1 if needed.
(Note: maximum dose of acetaminophen = 4 gm/24 hours)
Atrial Fibrillation Prophylaxis :
G Not currently indicated.
G Metoprolol 5mg iv Q6 hours, Hold for SBP <100, HR<60
G Metoprolol 5mg iv Q6 hours, PRN HR>120 Hold for SBP <100, HR<60
G When tolerating PO well, DC iv scheduled metoprolol and begin Metoprolol 12.5mg po Q12 hours, Hold for SBP <100, HR<60
G Other:__________________________________________________________________________
IV FLUIDS:
D5 ___ NS with ___ mEq Potassium Chloride at ____ ml/hr.
G Post-operative day 1 check with thoracic service to HepLock IV if patient tolerates PO fluids/diet>400ml/shift or if PCA is
present decrease rate to 30ml/hour IV if patient tolerates PO fluids/diet>400ml/shift.
MISCELLANEOUS ORDERS:
Respiratory Care:
1. Respiratory Therapy to call thoracic service if:
• Decrease in oxygen saturation <90%
• Increase in oxygen requirement greater than 2 liters in 8 hours
• Increase in oxygen requirement for >5Lpm nasal cannula
2. Wean O2 per protocol.
____________________
Date
Rev. 6/10
____________________
Time
sr 6/29/10 Page 3 of 4
______________________________________________
Physician Signature
Distribution: White - Chart Copy
WRITE WITH BLACK BALL POINT INK ONLY USING FIRM PRESSURE.
DOCTOR WRITING ORDER IS TO RECORD DATE AND TIME WITH EACH SET OF ORDERS WRITTEN. AUTHENTICATE WITH FULL SIGNATURE AND BEEPER NUMBER.
MR FORM 1C
8/96
PHYSICIAN ORDERS
DIAGNOSIS:
DRUG SENSITIVITY:
Patient Identification
THORACIC SURGERY
POST-OPERATIVE/TRANSFER ORDERS
3. Administer respiratory medications as indicated below:
G Albuterol 2.5mg/0.5mL in 3ml NS q4h nebulizer
G 200 mg mucomyst (acetylcysteine) q6h nebulizer preceded by albuterol 2.5 mg/0.5mL in 3 mL NS q6h nebulizer X 48 hours
G DuoNeb (albuterol/ipratropium) 2.5mg/0.5mg per 3 mL q6h nebulizer
G Ipratropium Bromide 0.5 mg in 2.5 ml NS q6h nebulizer
G Combivent MDI (albuterol/ipratropium 120/21mcg spray 2 puffs Q4hours and PRN wheezes
4. G Acapela / PEP therapy Q4hrs
5. Incentive spirometry (x10 per hour) cough and deep breathe exercises. Repiratory therapy to provide teaching with treatments.
6. O2 tank for ambulation PRN
DIET
G NPO except sips of water and ice chips on day of operation
Post-operative day 1:
G Clear liquids, advance to regular for lunch as tolerated
G Regular diet
G ADA regular diet
MISCELLANEOUS
1. ______________________________________________________________________________________________________
2. ______________________________________________________________________________________________________
3. ______________________________________________________________________________________________________
4. ______________________________________________________________________________________________________
5. ______________________________________________________________________________________________________
6. ______________________________________________________________________________________________________
7. ______________________________________________________________________________________________________
8. ______________________________________________________________________________________________________
9. ______________________________________________________________________________________________________
10. _____________________________________________________________________________________________________
11. _____________________________________________________________________________________________________
12. _____________________________________________________________________________________________________
_________/_________/_________
Date
_________________________________
Physician Last Name (Print)
Rev. 6/10
_____________________
Time
____________________
Pager
____________________________________________
Physician Signature
sr 6/29/10 Page 4 of 4
Distribution: White - Chart Copy