PLACE LABEL HERE

SHOULDER SURGERY

POST-OP ORDERS

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

Initial all handwritten order modification sand 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?

Yes, admit as inpatient, proceed to # 2No, place in observation No, outpatient, DC home

2. If admitted as inpatient, Inpatient Physician Certification:

Diagnosis: ______

Level of Care:  Critical  Intermediate  Acute Care Location/Specialty Unit Preference______

3. Telemetry: If patient Medical/Surgical, must complete form # 36084

4. Isolation:  Contact  Droplet  Airborne For: ______

  1. Vital signs per PACU routine, then vital signs per post-op care routine
  2. Shoulder X-Ray, Reason:______
  3. Cold therapy:  Right shoulder  Left shoulder  Ice bag Cold therapy
  4.  Sling to shoulder ______ Shoulder immobilizer
  5. Straight cath if unable to void
  6. Dressing:  Reinforce prn  Change ______ Other: ______
  7. Regular diet as tolerated
  8. Ambulate ad lib
  9. Consult Occupational Therapy: Shoulder exercises

(Occupational Therapy to consult Physical Therapy if indicated for mobility)

  1. Hospitalist consult for medical management

SCHEDULED MEDICATIONS

15 IVF: D5½ NS at 100 ml/hr IV D5 ½ NS at ______ml/hr IV

 Other: ______

 Discontinue IVF when tolerating oral fluids

16.Antibiotics: Ancef (cefazolin) 1 gm IV q 8 hrs x 2 doses

 Other: ______

For antibiotic > 24 hrs, document indication REQUIRED:______

Post-op antibiotic will be automatically stopped within 24 hrs unless indication is documented above

17. VTE prophylaxis, Initiate Venous Thromboembolism (VTE) Prophylaxis Orders (form # 33058)

(Do not begin anticoagulant therapy until epidural catheter out for 4 hrs):

Lovenox (enoxaparin) 40 mg SQ q 24 hrs at 0900 POD # 1; if CrCl < 30, give 30 mg SQ q 24 hrs

Arixtra (fondaparinux) 2.5 mg SQ, give 8 hrs post-op (1st dose due at ______hrs)

then 2.5 mg SQ q 24 hrs for ______days

If CrCl < 30 or weight < 50 kg, Arixtra will be therapeutically interchanged to Lovenox

Case Manager to coordinate anticoagulant therapy for home

18.Bowel Management:

Senokot-S (docusate/senna) 2 tablets po at bedtime nightly

POD # 2, if no BM: Dulcolox (bisacodyl) 10 mg po x 1 dose on POD # 2

POD # 3, if no BM: Dulcolax (bisacodyl) 10 mg suppository per rectum x 1 dose, on POD # 3

If no BM 4 hrs post suppository, give Fleets Enema (sodium phosphate) per rectum x 1 bottle

19. Pain:  PCA: Initiate PCA orders (form # 2119)  Sleep Apnea PCA (form # 21261)  Epidural: Per Anesthesia

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

Initial all handwritten order modification sand the bottom of each page when indicated (multipage).

PRN MEDICATIONS See policy 520-06 for range orders and pain intensity guidelines.

If not ordered by Anesthesia during peri-operative phase:

  1. Electrolyte Replacement Protocol (form # 21340)
  2. Mild Pain, Temp>100.5F, HA:Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
  3. Moderate Pain:

Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered.

or 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 Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Norco ordered.

and/or  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.

  1. Severe Pain (Begin when Epidural or PCA has been discontinued)

Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered.

or  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.

  1. Nausea/Vomiting: Zofran (ondansetron) 4 mg IV or po q 6 hrs prn

If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)

  1. Sleep: Ambien (zolpidem)5 mg (female or males ≥ 65 y/o) or 5-10mg (male < 65 y/o) po at HS prn
  2. Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
  3. Stool Softener: Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
  4. Constipation: Milk of Magnesia (MOM) 30 ml po daily prn

If no BM after 48 hrs, Dulcolax (biscodyl) 10 mg per rectum daily prn

and/or Senokot-S (docusate/senna) 2 tablets po at bedtime nightly

29.Cough:Robitussin (guaifenesin) 15 ml po q 4 hrs prn

30.Sore Throat:Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn

ADDITIONAL ORDERS:

______

______

DISCHARGE:  May discharge in ______hrs when discharge criteria met:

FORM 3-18112 REV. 08/2015 WHITE: Medical Record CANARY: Pharmacy Page 1 of 2

PLACE LABEL HERE

SHOULDER SURGERY

POST-OP ORDERS

a.Tolerating po fluidsd. No nausea and vomiting

b.Pain managed by po analgesia e. Voiding quantity sufficient

c.Ambulatory- minimal assistance

FORM 3-18112 REV. 08/2015 WHITE: Medical Record CANARY: Pharmacy Page 1 of 2

SHOULDER SURGERY

POST-OP ORDERS PLACE LABEL HERE

 In AM

Instruct:

 Start pendulum swings tomorrow x 3 day. Otherwise, stay in sling at all times/no other shoulder motion

 Start elbow flexion and extension exercises tomorrow

Follow up in office in ______days/week(s)

______

DateTimePhysician SignaturePID Number

FORM 3-18112 REV. 10/2008 WHITE: Medical Record CANARY: Pharmacy Page 1 of 3