PLACE LABEL HERE

ORTHOPEDIC ADMISSION

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. 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: ______

5.Consult: ______, Reason______ Notified

Consult: ______, Reason______ Notified

6.Labs: On Admission: ______

 In AM: ______

7.Xrays: On Admission: ______

8. Neurovascular assessment to ______extremity:  q 2 hrsx4  q 4 hrsx4  q 8 hrs

9. Vital signs per routine

10. I & O q 8 hrs

11. Foley catheter to bedside bag

12. Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)

13.Activity: ______Weight bearing status:______

14. Traction:Buck’s: Weight______Skeletal: Weight_____Other: Weight_____ Comments:______

15. Elevate affected extremity and apply ice or  Cold therapy pad  Other: ______

16.Diet: Clear liquids; advance as tolerated to:  Regular Cardiac  Diabetic ___ calorie  Renalor  npo

17. Oral Nutritional Supplement Standing Orders (form #31417), initiate if patient meets criteria

18.Wound Care: ______

19. Initiate Sleep Apnea Orders (form # 21266), if OSA screen is positive for suspected or reported sleep apnea

20.Incentive Spirometry q1 hr and prn

SCHEDULED MEDICATIONS:

21. IVF:  D5 ½ NS  D5 NS  ½ NS  D5 LR  LR at ______ml/hr IV 

 Discontinue IVF when tolerating oral fluids

22. VTE Prophylaxis: (Do not begin anticoagulant therapy until epidural catheter out for 4 hrs):

Foot compression device, Reason: Knee Replacement

Apply/maintain antiembolic stockings

Surgery end time______

 Coumadin (warfarin) ____ mg po q day at 1700, start today.

 Aspirin, enteric coated, 325 mg po bid, First dose in AM POD # 1

 Lovenox (enoxaparin)

 30 mg SQ q 12 hrs x 2 doses, First dose 12 hrs post-op, then 40 mg SQ q 24 hrs

 40 mg SQ q 24 hrs, First dose in AM POD 1, If CrCl < 30, 30 mg SQ daily

 Arixtra (fondaparinux), if CrCl < 30 or weight < 50 kg, Arixtra will be therapeutically interchanged to Lovenox

 2.5 mg SQ q 24 hrs, start 8 hrs post-op

 2.5 mg SQ q 24 hrs, First dose in AM POD # 1

 Xarelto (rivaroxaban), if CrCl < 30, Xarelto will be therapeutically interchanged to Lovenox

 10 mg po q 24 hrs, First dose 8 hrs post-op

 10 mg po q 24 hrs, First dose in AM POD # 1

 Eliquis (apixaban) 2.5 mg po q 12 hrs,First dose 12 hours post op, if CrCl < 30, Eliquis will be therapeutically interchanged to Lovenox

 No Pharmacological Prophylaxis (Documented Reason Required):

 Bleeding Risk Patient Refusal Thrombocytopenia

 Active Bleeding (GI Bleed, Cerebral Hemorrhage, Hemorrhage, Retroperitoneal Bleed)

 Other: ______

Copy to pharmacyOrder writer’s initials ______

*3-31669*FORM 3-31669 REV. 03/2016 Page 1 of 2

PLACE LABEL HERE

ORTHOPEDIC ADMISSION

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).

23. Bowel Management:Colace (docusate) 100 mg po two times daily

Senokot (sennosides) give 2 x 8.6 mg tabs po daily at bedtime

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

25. If not on PCA:  OxyCONTIN (oxyCODONE, Extended Release)  10 mg  20 mg po q 12 hrs x 4 doses .

26. CeleBREX (celecoxib) 100 mg or 200 mg or 400 mg po q day or bid

27. Ultram (tramadol) 50 mg or 100 mg po q 6hr or q 8 hrs or q 12 hrs (CrCl < 30)

28. Antibiotics:

Pre-Op: Ancef (cefazolin) 2 gm (or 3 gm if > 120 kg) IV pre-op to be administered by anesthesia

OR beta lactam (penicillin and cephalosporin) allergy only,

Cleocin (clindamycin) 600 mg IV pre-op to be administered by anesthesia

ORVancomycin IV to be administered 1-2 hrs preoperatively

 If patient weight < 90 kg, 1 gm IV x 1 dose (infuse over 1 hr)

 If patient weight ≥ 90 kg, 1.5 gm IV x 1 dose (infuse over 1.5 hrs)

REQUIRED: Rationale for using Vancomycin as an antimicrobial prophylaxis

History of MRSA/positive screen

Allergy to penicillin and cephalosporins

HOLD PREOP ANTIBIOTIC UNTIL INTRA OP CULTURES OBTAINED

 Scheduled:  Ancef (cefazolin) 2 gm IV q 8 hrs

 Rocephin (ceftriaxone) 1 gm IV q 24 hrs

 Cleocin (clindamycin) 600 mg IV q 8 hrs

 Vancomycin, pharmacy to dose

PRN MEDICATIONS (If > one drug is ordered for the same indication, clinical assessment will be used per policy 520-06)

  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

or Motrin (ibuprofen) 400 mg po q 6 hrs prn

  1. 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: Melatonin 5 mg po q HS prn

or Ambien (zolpidem)5 mg (female or males ≥ 65 y/o) or 5-10mg (male < 65 y/o) po at HS prn

  1. Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn

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

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

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-31669 REV. 03/2016 Page 1 of 2