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Rehabilitation hospital

Orders with an open box must be checked if desired Indicates routine order, Strike through if not desired ADMISSION
Admit as Observation Dr. ________________________, MD/DO Monitored Bed (Telemetry) preferably on Ortho Unit DIAGNOSIS
NKDA Other ____________________________________________________________________ Ice chips, advance to regular diet as tolerated _________ kCal ADA diet Other Boost TID with meals Protein shakes with meals VITAL SIGNS
Vital signs and neurovascular assessments: per policy. Call MD if: HR> _______or < _________; RR > ______ or < _______; Temp > _______ F SBP > _______ or < _________, SaO2 < _____% WOUND CARE
Wet to dry saline dressing changes every____hours to____ UE; ____LE WoundVac to 125mmHg continuous suction, change every 72 hrs Pin care every ___ hours with hydrogen peroxide/normal saline 1:1 solution, per Nursing Standard of Dry dressing change every day and as needed ACTIVITY
Weight bearing as tolerated _______________UE; _______________LE Non weight-bearing _______________ UE; ______________ LE Toe touch weight-bearing _______________ UE; _______________ LE Physical Therapy to evaluate and treat daily Occupational Therapy to evaluate and treat daily Out of bed to chair daily starting _______________________________________ Bedrest Overhead trapeze to bed Fall precautions CONSULTS
General Internal Medicine for :_______________________________________ Infectious Disease: ________________________________________________ Physical Medicine and Rehab: ___________________________________________________ Trauma: Patient with multiple fractures/injuries DVT PROPHYLAXIS
Pharmacologic VTE Prophylaxis must be started within 24 hours of surgery for hip replacements
(Refer to DVT/PE
unless epidural is in use or reason documented (reason:____________________________________ )
Assessment Order
[NU285] for
EPC cuffs OR
PlexiPulse on at all times while in bed recommendations if
Arixtra 2.5 mg subcutaneously ever 24 hours (CrCl must be > 30 ml/min, Weight must be > 50 kg) Lovenox 40 mg subcutaneously daily
Lovenox 30 mg subcutaneously daily (for CrCl < 30 ml/min)
Lovenox 30 mg subcutaneously twice daily (knee surgery)
Lovenox 40 mg subcutaneously twice daily (morbid obesity)
Coumadin __________ mg oral evening of surgery, then per sliding scale daily at 5 PM.
If INR is: Give Coumadin
> 2 None INR target _______________________________
1.5 – 2 2.5 mg
1 – 1.4 5 mg Total duration of anticoagulation ______________
<1 7.5 mg
Pharmacy to Dose Coumadin
If epidural in use, hold Arixtra, Lovenox and Coumadin until after epidural discontinued
02 @ 2-3 liters per nasal cannula to keep Sa02> 92% Foley to gravity, discontinue post-operative day #1 CBC with diff every morning Basic Metabolic Panel every morning PT/INR every morning BLOOD & BLOOD
Please complete Blood/Blood Products Doctor’s Orders

Study_______________________________________ Reason _____________________________ Study_______________________________________ Reason ____________________________ Study_______________________________________ Reason_____________________________ IV FLUIDS
Other__________________________ Rate__________ Change IV to saline lock when I & O are adequate ANTIBIOTICS
Please complete POST-Operative Antibiotic Surgical/Procedure Prophylaxis Doctor’s Order Form
(PH033) or Anti-Infective Doctor’s Orders (PH019)

May give oral and IV medications simultaneously for pain level of 8 or above, respiratory rate of at least Changes in this the
10, and level of consciousness (arousable, able to follow simple command). same as the TKA 5/23
OxyContin _______ mg oral every 12 hours
Tylenol 650 mg oral every 4 hrs PRN mild pain rated 1 to 3 out of 10
Percocet 5/325 mg 1-2 oral every 4 hrs PRN moderate pain 4-7 out of 10 Choose either Percocet
Vicodin 5/500 mg 1-2 oral every 4 hrs PRN moderate pain 4-7 out of 10 or Vicodin, Not Both
Oxycodone IR 5 mg oral every 2 hrs PRN pain rating 8 – 10 out of 10 severe pain
Morphine Sulfate 2 mg IV every 2 hrs PRN moderate pain 4-7 out of 10 or not able to take oral meds
Morphine Sulfate 4 mg IV every 2 hrs PRN severe pain 8-10 out of 10 or not able to take oral meds
Caution: Consider reduced morphine doses in patients with impaired renal function
PCA – See completed PCA Protocol (PH011)
Pain Management Team Consult
Benadryl 25 mg oral at bedtime PRN insomnia Choose only one
Ambien 10 mg oral at bedtime PRN insomnia
Sonata 5 mg oral every HS PRN insomnia (Preferred sleep aid for geriatric patients)
Lunesta 1 mg oral every HS PRN insomnia (Second choice sleep aid for geriatric patients)
Miralax 17 gm oral daily starting post-operative day, may increase to TID FOR CONSTIPATION
Dulcolax 10 mg PR daily PRN if no BM for 3 days Fleet enema PR every day PRN if no BM for 3 days Concentrated MOM 10 ml oral every 6 hrs PRN if no BM for 3 days FOR NAUSEA
Zofran 4 mg IV every 4-6 hrs PRN nausea, use first and if no relief in 2 hours use Phenergan Phenergan 25 mg IM or oral every 6 hrs PRN nausea, use if Zofran not relieving after 2 hours DIABETES
Finger stick blood glucose before meals and at bedtime MANAGEMENT
Scale to house
Blood sugar less than 60: give 25 mL IV Dextrose 50% and call MD standard
Blood sugar 75 – 150; none Blood sugar 151 – 200: 2 units SC x 1 Blood sugar 201 – 250: 4 units SC x 1 Blood sugar 251 – 300: 6 units SC x 1 Blood sugar 301 – 350: 8 units SC x 1 Blood sugar 351 – 400; 10 units SC x 1 Blood sugar greater than 401+; 12 units SC x 1 and call MD ADDITIONAL
Oscal 500 + D 1 oral TID
Multivitamin 1 oral daily
Benadryl 25 mg oral every 4-6 hrs PRN itching
Valium 5 mg IV or oral TID PRN muscle spasms
Ativan 0.5mg IV/oral PRN muscle spasms or anxiety (Geriatric Patients)
Albuterol 2.5 mg nebulizer every 6 hrs PRN wheezing or shortness of breath

For urinary output less than 30ml/hr (240ml in 8 hrs) IMMEDIATELY
For inadequate analgesia For oversedation Other: If HemoVac in place, empty drains every shift and record output Discontinue Foley when ordered (Monitor daily and contact MD if no order written to discontinue) Straight Cath Q 6 hrs PRN no void after Foley discontinued (if applicable) Turn and reposition Q 2 hrs Ice pack as needed for edema Incentive spirometry Q 1 hr while awake I & O every shift and record ADDITIONAL ORDERS


Form Description
Current Form Number OC027
Letter Fold
Unit Size

Special Instructions:


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