PLACE LABEL HERE

UTERINE FIBROID EMBOLIZATION (UFE)

POST-PROCEDURE ORDERS

The following orders will be implemented. Orders with a “” 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?

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_____

  1. Telemetry: If patient Medical/Surgical, must complete form # 36084
  2. Isolation: Contact Droplet Airborne For: ______
  1. Check vital signs, distal pulses and entrance site for evidence of bleeding:

Every 15 min x 4 times, then q 30 min x 4 times, then q 1 hr x 4 times

6. If entrance site bleeds or develops a hematoma:

Hold pressure for 15 min

Reassess site and distal pulses.

If bleeding or hematoma swelling continues, hold pressure again.

Notify Radiologist or Hospitalist for assistance to stabilize bleeding/hematomas.

7.Notify Radiologist if distal pulses change to non-palpable

8.Diet: Advance as tolerated

9.Foley Catheter to bedside bag. D/C in a.m.

10.Activity: bedrest with ______leg straight for ______hrs, then:

Up with assistance for the first time and then up as tolerated or ______

SCHEDULED MEDICATIONS:

11.IV: D5½ NS at 150 ml/hr for 6 hrs after procedure, then convert to INT.

12.Hold medications containing Metformin 48 hrs post procedure.

13.Pain: See PCA orders (form # 2119), D/C PCA in a.m.

Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs (15 mg if CrCl 31-50, > 65 y/o old or < 50 kg) x 5 days (maximum). DC if CrCl < 30.

14.Antibiotic(choose one):

Cipro (ciprofloxacin) 400 mg IV x 1 dose, to be given at ______

Cleocin (clindamycin) 600 mg IV q 6 hrs x 2 doses, start at______

*3-20448*FORM 3-20448 REV. 05/2015 WHITE: Medical Record CANARY: Pharmacy Page 1 of 2

PLACE LABEL HERE

UTERINE FIBROID EMBOLIZATION (UFE)

POST-PROCEDURE ORDERS

The following orders will be implemented. Orders with a “” 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.

  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 can not take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po q 4 hrs prn intead 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.

  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 5-10 mg (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

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

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

ADDITIONAL ORDERS:

______

Call ______with any problems at______(after hours, page interventional radiologist on call)

______

DateTimePhysician SignaturePID Number

FORM 3-20448 REV. 05/2015 WHITE: Medical Record CANARY: Pharmacy Page 2 of 2