Height Weight Allergies If appropriate for patient condition, please consider the following order sets: Hydration Order for Reducing Risk of Radiocontrast Induced Nephrotoxicity Physician Order #683 In addition, if appropriate for this patient: -Stop heparin infusion 4 to 6 hours prior to surgery -Hold prophylactic LMWH for at least 12 hours before anticipated neuraxial anesthetic -Hold LMWH for 24 hours if therapeutic dose being used prior to neuraxial anesthetic General: Inpatient Case Request [ ] Case request operating room Primary Provider: Location: SJMC OR, Procedure: ESOPHAGECTOMY, Case Request, Case Request Diagnosis risk screen completed? Required Visit Type? [ ] Case request operating room Primary Provider Location: SJMC OR, Procedure: JEJUNOSTOMY, Case Request, Case Request Diagnosis risk screen completed? Required [ ] Case request operating room Primary Provider Location Procedure: LAPAROSCOPY REPAIR HIATAL HERNIA (HIATAL HERNIA - EGD), Case Request, Case Request Diagnosis risk screen completed? Required Vital Signs [ ] Vital signs, Per unit routine, Starting today, [ ] Frequent vital signs Indication: Q15 minutes x (# of occurrences): Q30 minutes x (# of occurrences): Q1 hour x (# of occurrences): Q2 hours x (# of occurrences): Q4 hours x (# of occurrences): Then: Per unit routine, Until discontinued, Starting today SAH, SCH, SFH, SJMC & Harrison Cardiac Pulse Monitoring (Pre-Op) [ ] Pulse Oximetry, Once, Starting today Keep O2 saturation greater than or equal to: [ ] Continuous Pulse Oximetry, Until discontinued, Starting today Keep O2 saturation greater than or equal to: [ ] Cardiac monitoring, Until discontinued, Starting today, Activity: Pre-Op Page 1 of 6
[X] Activity as tolerated, Until discontinued, Starting today, Consent: Pre-Op [ ] Verify hosptial consent is completed and signed, Once, Starting today Indicate one of the following to confirm the patient/representative has given informed consent for blood products. [ ] Verify informed consent, Once, Starting today Indicate one of the following to confirm the patient/representative has given informed consent for blood products. [ ] Obtain blood transfusion consent, Once, Starting today Indicate one of the following to confirm the patient/representative has given informed consent for blood products. Education: Pre-Op [X] Patient education [X] Patient education, Once, Starting today, Instruct on incentive spirometry,, Once, Starting today, Instruct on PCA machine, Physician Consults [X] Inpatient consult to Anesthesiology Reason for Consult? Pre-anesthesia evaluation RN/Secretary to contact the consulting provider? Ancillary Consults [ ] Inpatient consult to Transfusion Free Program Reason for Consult? Patient Prep: Pre-Op [ ] Retention Catheter Panel [ ] Insert urinary retention catheter, As needed, Starting today, Insert as needed for inability to void or feelings of discomfort or distention. Initiate Medical Staff Approved Urinary Catheter Protocol, [ ] Urinalysis with culture, if indicated, upon insertion Daily, Starting today with First Occurrence Include Now For 2 Occurrences Obtain a UA-R upon insertion and repeat UA-R prior to 48 hours postinsertion., Inpatient Orders: Used to have test done pre-operatively the day of surgery Pre-Anesthesia Testing Protocol [X] Initiate Pre-Anesthesia Testing Protocol Physician Order #009, Once, Starting today For 1 Occurrences, Chemistry: Pre-Op Testing [ ] Comprehensive metabolic panel Once, Starting today, [ ] Basic metabolic panel Once, Starting today, Hematology: Pre-Op Testing [ ] CBC and differential Once, Starting today, Page 2 of 6
Coagulation: Pre-Op Testing [ ] Protime-INR Once, Starting today, [ ] Activated partial thromboplastin time Once, Starting today, Microbiology: Pre-Op Testing [ ] MRSA by PCR Once, Starting today, Required Blood: Pre-Op Testing Use General Blood Administration # 632 for all type and crossmatch orders [ ] Type and screen Once, Starting today For 1 Occurrences, Has the patient been transfused with in the past 90 days?: Has the patient been pregnant with in the past 90 days? [ ] Type and Crossmatch Once, Starting today For 1 Occurrences, Number of units to prepare Required Reason for Blood Blood Product Type needed Required Patient has predonated autologous prbcs? Required Has the patient been transfused within the past 90 days? Has the patient been pregnant within the past 90 Days? Imaging: [ ] X-ray chest PA and lateral, 1 time imaging, Starting today For 1 Occurrences Reason for Exam: Is the patient pregnant? Reason for Exam (USE SIGNS AND SYMPTOMS): Transport Mode: Transport Mode: Bed Cardiac Studies: [ ] ECG 12 lead, Once, Starting today Reason for Exam (Signs & Symptoms): Other Ambulatory PAT Orders: Used to have tests done prior to day of surgery Pre-Anesthesia Testing Protocol [ ] Initiate Pre-Anesthesia Testing Protocol Physician Order #009, Clinic Performed, Pre-Admit Testing Chemistry: Pre-Admission Testing [ ] CMP, Lab Collect, Expires: 6/3/15, Pre-Admit Testing [ ] BMP, Lab Collect, Expires: 6/3/15, Pre-Admit Testing Hematology: Pre-Admission Testing [ ] CBC and differential, Clinic Collect, Expires:6/3/15 Auto,Count:2, Pre-Admit Testing Page 3 of 6
Coagulation: Pre-Admission Testing [ ] Protime-INR, Lab Collect, Expires: 6/3/15, Pre-Admit Testing [ ] Activated partial thromboplastin time, Lab Collect, Expires: 6/3/15, Pre-Admit Testing Blood: Pre-Admit Testing Use General Blood Administration # 632 for all type and crossmatch orders [ ] Type and screen ASAP, Lab Collect, Expires: 6/3/15, Pre-Admit Testing Has the patient transfused within the past 90 days? Has the patient been pregnant within the past 90 days? [ ] Type and Crossmatch, Lab Collect, Expires: 6/3/15, Pre-Admit Testing Number of units to prepare Required Reason for Blood Blood Product Type needed Required Patient has predonated autologous prbcs? Required Has the patient been transfused within the past 90days? Has the patient been pregnant within the past 90days? SAH, SCH, SFH, SJMC & Harrison Pre-Admission Testing Imaging / Tests [ ] ECG 12 lead unit performed Expires: 6/3/15,, Ancillary Performed, Pre-Admit Testing [ ] X-ray chest PA and lateral Expires: 6/3/15,, Ancillary Performed, Pre-Admit Testing Harrison IP Pre-admission Testing Imaging [ ] X-ray chest PA and lateral Expires: 6/3/15,, Ancillary Performed, Pre-Admit Testing HH IP Labs Preadmit Testing Use order set #632 - General Blood Administration for blood orders. Complete tests if not done within 48 hours of Admission. [ ] Pro Brain Natriuretic Peptide, Lab Collect, Expires: 6/3/15 [ ] CMP, Lab Collect, Expires: 6/3/15, Pre-Admit Testing [ ] Hemoglobin A1c, Lab Collect, Expires: 6/3/15, Pre-Admit Testing [ ] hcg, serum, qualitative, Lab Collect, Expires: 6/3/15, Pre-Admit Testing [ ] Lipid panel, Lab Collect, Expires: 6/3/15, Pre-Admit Testing [ ] TSH, Lab Collect, Expires: 6/3/15, Pre-Admit Testing [ ] CBC, no diff (hemogram), Lab Collect, Expires: 6/3/15, Pre-Admit Testing [ ] Blood gas, arterial, Lab Collect, Expires: 6/3/15, Pre-Admit Testing [ ] Protime-INR, Lab Collect, Expires: 6/3/15, Pre-Admit Testing [ ] Urinalysis with culture, if indicated, Clinic Collect, Expires: 6/3/15, Pre-Admit Testing [ ] C-reactive protein, Lab Collect, Expires: 6/3/15, Pre-Admit Testing Education: Pre-Admit Testing [ ] Patient education (specify), Clinic Performed, Pre-Admit Testing Page 4 of 6
VTE Prophylaxis: VTE Prophylaxis Mechanical [X] Place sequential compression device, Until discontinued, Starting today Stocking Type: Knee high Apply SCD's: Both legs [ ] Place TED hose, Until discontinued, Starting today Stocking type: Leg choice: [ ] Reason for No VTE Prophylaxis (Mech) Reason for no VTE prohphylaxis (mechanical): Note to provider: Reason required to be in in compliance with CMS SCIP guidelines VTE Prophylaxis Pharmacological [ ] heparin (porcine) injection 5,000 units/ml 5,000 Units, SubCutaneous, Once, For 1 Doses, On admission to surgical unit [ ] enoxaparin (LOVENOX) syringe 30 mg 30 mg, SubCutaneous, Once, For 1 Doses, On admission to surgical unit [ ] enoxaparin (LOVENOX) syringe 40 mg 40 mg, SubCutaneous, Once, For 1 Doses, On admission to surgical unit [ ] Reason for No VTE Prophylaxis (Pharm) Reason for no VTE prophylaxis (pharmacological): High risk of bleeding Note to provider: Reason required to be in in compliance with CMS SCIP guidelines IV Fluids: Pre-Op IV Fluids [ ] Per Pre-Anesthesia Testing Protocol, Until discontinued, Starting today, Physician Order # 009, [ ] Insert peripheral IV, Continuous, Starting today, [ ] dextrose 5 % and sodium chloride 0.45 % infusion 75 ml/hr, IntraVENous, Continuous,, [ ] sodium chloride 0.9% (NS) infusion 100 ml/hr, IntraVENous, Continuous, If renal failure patient use 0.9% sodium chloride (Normal Saline) [X] lidocaine (XYLOCAINE) 1 % local injection 0.5-10 ml, SubCutaneous, As needed, local anesthetic for IV access, May use local anesthetic for IV access Medications: Harrison phamacy consult- SCIP antibiotics [ ] Pharmacy Consult: Antibiotics, Once, Starting today For 1 Occurrences Antibiotics [X] cefazolin (ANCEF) IV [X] gentamicin < 120mg/ 50 ml IVPB (standard dosing) Page 5 of 6 2 g, IntraVENous, Every 8 hours, To be given by Anesthaesia within 60 minutes of incision 1.5 mg/kg, IntraVENous, for 30 Minutes, Every 8 hours interval, To be given by Anesthaesia within 60 minutes of incision
Other Meds [ ] magnesium citrate oral solution Oral, Once, Give 2 bottles PO for bowel prep. Call physician if unable to complete in start time. [ ] metoclopramide (REGLAN) tablet Frequency: 10 mg, Oral, 4 times daily PRN, nausea / vomiting,, Date: Time: Printed Name of Ordering Provider: Provider Signature: Date: Time: RN Acknowledged: Page 6 of 6