High Dose Radiation Postoperative [ ] General. Page 1 of 11 High Dose Radiation Postoperative. Height Weight Allergies
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1 Height Weight Allergies General Admission/Level of Care [127413] [ ] Admit to Inpatient [ADT1] Diagnosis: Estimated length of stay: Certification: I reasonably expect the patient will require inpatient services that span a period of time over two-midnights. (See Rationale Section in the order for options) Additional documentation will be found in progress notes and admission history and physical. Must be completed by Physician for Inpatient Admissions: Rationale for Inpatient Admission: Plans for post hospital care: See Discharge Summary/ Progress Note Level of Care: [ ] Refer to Observation [ADT12] Diagnosis: Monitor for: Notify provider when: Level of Care: SAH, SCH, SFH, SJMC & Highline Code Status (Single Response) [123416] ( ) Full code [COD2] ( ) Full treatment WITH intubation but WITHOUT ACLS [COD3], - Initiate Code Blue for management of airway in the presence of a primary respiratory event ( ) Full treatment WITHOUT intubation and WITHOUT ACLS [COD4], - Do NOT initiate Code Blue. Page 1 of 11
2 ( ) Comfort Care [COD1], 1) Provider must complete comfort care orders #668 2) RN or designee to place a purple wristband on Patient 3) Do NOT initiate Code Blue 4) Do NOT transfer to higher level of care SAH, SCH, SFH, SJMC & Highline Code Status (Single Response) [132250] ( ) Full code [COD2] ( ) Full treatment WITH intubation but WITHOUT ACLS [COD3], - Initiate Code Blue for management of airway in the presence of a primary respiratory event ( ) Full treatment WITHOUT intubation and WITHOUT ACLS [COD4], - Do NOT initiate Code Blue. ( ) Comfort Care [COD1], 1) Provider must complete comfort care orders #668 2) RN or designee to place a purple wristband on Patient 3) Do NOT initiate Code Blue 4) Do NOT transfer to higher level of care Page 2 of 11
3 Harrison Code Status (Single Response) [171271] ( ) Full code [COD2] ( ) Full treatment WITH intubation but WITHOUT ACLS [COD3], - Initiate Code Blue for management of airway in the presence of a primary respiratory event ( ) Full treatment WITHOUT intubation but WITH ACLS [COD9], -Initiate Code Blue for management of cardiac arrhythmias in the presence of a primary cardiac event ( ) Full treatment WITHOUT intubation and WITHOUT ACLS [COD4], - Do NOT initiate Code Blue. ( ) Comfort Care [COD1], 1) Provider must complete comfort care orders #668 2) RN or designee to place a purple wristband on Patient 3) Do NOT initiate Code Blue 4) Do NOT transfer to higher level of care Page 3 of 11
4 Harrison Code Status (Single Response) [171272] ( ) Full code [COD2] ( ) Full treatment WITH intubation but WITHOUT ACLS [COD3], - Initiate Code Blue for management of airway in the presence of a primary respiratory event ( ) Full treatment WITHOUT intubation but WITH ACLS [COD9], -Initiate Code Blue for management of cardiac arrhythmias in the presence of a primary cardiac event ( ) Full treatment WITHOUT intubation and WITHOUT ACLS [COD4], - Do NOT initiate Code Blue. ( ) Comfort Care [COD1], 1) Provider must complete comfort care orders #668 2) RN or designee to place a purple wristband on Patient 3) Do NOT initiate Code Blue 4) Do NOT transfer to higher level of care Vital Signs [128907] [ ] Frequent vital signs [NUR2069] Indication: Q15 minutes x (# of occurrences): Q30 minutes x (# of occurrences): Q1 hour x (# of occurrences): 4 Q2 hours x (# of occurrences): Q4 hours x (# of occurrences): 6 Then: Per unit routine, Until discontinued, Starting S Page 4 of 11
5 Cardiac Monitoring [149575] [ ] Cardiac monitoring [NUR436] Routine, Until discontinued, Starting S, PACU only (Anesthesia) Activity [127888] [ ] Up ad lib [NUR129] Routine, Until discontinued, Starting S, [ ] Up as tolerated [NUR129] Routine, Until discontinued, Starting S, [ ] Up with assistance [NUR131] Routine, As needed, [ ] Strict bed rest [NUR162] Routine, Until discontinued, Starting S, [ ] Bed rest with bedside commode [NUR40] Routine, Until discontinued, Starting S, [ ] Bed rest with bathroom privileges [NUR25] Routine, Until discontinued, Starting S, [ ] Patient may shower [NUR550] Routine, Until discontinued, Starting S, Diet/Nutrition () [100969] [ ] Advance diet as tolerated [DNS10] Once Target Diet: [ ] Diet General [DIET24] Diet effective now, Starting S Select/Nonselect: Additional Modifiers: Viscosity/Liquids: Texture: Fluid Restriction / day: Supplement: Diet Comments: [ ] Diet NPO [DIET41] Diet effective now, Starting S NPO Except: Diet Comments: [ ] Diet Liquid [DIET42] Diet effective now, Starting S Diet: Diet: Additional Modifiers: Viscosity/Liquids: Diet Comments: Page 5 of 11
6 SCIP Urinary Catheter Orders (Single Response) [205085] REQUIRED ( ) Discontinue existing retention catheter [NUR2055] Routine, Once For 1 Occurrences Post Op Day: POD #1 ( ) Continue Catheter [NUR697] Routine, Until discontinued, Starting S, Initiate Medical Staff Approved Urinary Catheter Protocol ( ) Catheter was not placed Intra-Operatively [NUR172585] Routine, Until discontinued, Starting S Nursing Interventions [127893] [ ] Nursing communication [NUR185] Routine, Until discontinued, Starting S Provider Name: Transfer to Tacoma Valley Radiation Oncology Center when patient is awake, oriented (to baseline) and blood pressure/pulse are within 20% of baseline under the medical care. Specify provider., [ ] Nursing communication [NUR185] Routine, Until discontinued, Starting S Provider Name: Transfer to Peninsula Radiation Oncology Center when patient is awake, oriented (to baseline) and blood pressure/pulse are within 20% of baseline under the medical care. Specify provider., [ ] Keep head of bed flat [NUR71] Routine, Until discontinued, Starting S, [ ] Nursing communication [NUR185] Routine, Until discontinued, Starting S, Keep rectal tube in place., IV Fluids IV Fluids [ ] [ ] Saline Flush and Lock Panel [ ] [X] sodium chloride 0.9 % syringe [7319] [X] Saline lock IV [IVT11] [X] lidocaine injection [420118] 2 ml, IntraCatheter, Every 8 hours, Routine, Continuous, 0.3 ml, IntraDermal, As needed, IV start, [ ] sodium chloride 0.9 % flush [7319] 10 ml, IntraCatheter, Every 8 hours, [ ] sodium chloride 0.9% (NS) infusion [27838] 100 ml/hr, IntraVENous, Continuous, Page 6 of 11
7 [ ] dextrose 5 % and sodium chloride 0.45 % infusion [9814] 100 ml/hr, IntraVENous, Continuous, [ ] lactated ringers infusion [4318] 125 ml/hr, IntraVENous, Continuous, Medications Medications: Pain [197434] [ ] Analgesics: FIRST CHOICE (Single Response) [195052] ( ) HYDROMORPHONE IV ORDERABLE [420079] IntraVENous, For 7 Days, NOT numbered, nurse to ( ) MORPHINE SULFATE IV ORDERABLE [420065] 2 mg, IntraVENous, Every 4 hours PRN, severe pain, NOT numbered, nurse to ( ) ketorolac (TORADOL) injection [22473] 15 mg, IntraVENous, For 5 Days, NOT numbered, nurse to ( ) oxycodone-acetaminophen (PERCOCET) mg per tablet [5940] ( ) oxycodone (ROXICODONE) immediate release tablet [10814] 1 tablet, Oral, Every 4 hours PRN, moderate pain, NOT numbered, nurse to 5 mg, Oral, NOT numbered, nurse to ( ) HYDROmorphone (DILAUDID) tablet [3760] 2 mg, Oral, Every 4 hours PRN, severe pain, For 7 Days, NOT numbered, nurse to Page 7 of 11
8 ( ) HYDROcodone-acetaminophen (NORCO) mg per tablet [34544] ( ) HYDROcodone-acetaminophen (NORCO) mg per tablet [34505] pain, NOT numbered, nurse to pain, NOT numbered, nurse to ( ) ibuprofen (ADVIL,MOTRIN) tablet [3843] 400 mg, Oral, Every 6 hours PRN, mild pain, Start 6 hours after last ketorolac [TORADOL] dose, if given. NOT numbered, nurse to ( ) acetaminophen (TYLENOL) tablet [101] Oral, NOT numbered, nurse to [ ] Analgesics: SECOND CHOICE (Single Response) [195053] ( ) HYDROMORPHONE IV ORDERABLE [420079] IntraVENous, For 7 Days, ( ) MORPHINE SULFATE IV ORDERABLE [420065] 2 mg, IntraVENous, Every 4 hours PRN, severe pain, ( ) ketorolac (TORADOL) injection [22473] 15 mg, IntraVENous, For 5 Days, Page 8 of 11
9 ( ) oxycodone-acetaminophen (PERCOCET) mg per tablet [5940] ( ) oxycodone (ROXICODONE) immediate release tablet [10814] 1 tablet, Oral, Every 4 hours PRN, moderate pain, 5 mg, Oral, ( ) HYDROmorphone (DILAUDID) tablet [3760] 2 mg, Oral, Every 4 hours PRN, severe pain, For 7 Days, ( ) HYDROcodone-acetaminophen (NORCO) mg per tablet [34544] ( ) HYDROcodone-acetaminophen (NORCO) mg per tablet [34505] pain, pain, ( ) ibuprofen (ADVIL,MOTRIN) tablet [3843] 400 mg, Oral, Every 6 hours PRN, mild pain, Start 6 hours after last ketorolac [TORADOL] dose, if given. ( ) acetaminophen (TYLENOL) tablet [101] Oral, Page 9 of 11
10 [ ] Analgesics: THIRD CHOICE (Single Response) [195054] ( ) HYDROMORPHONE IV ORDERABLE [420079] IntraVENous, For 7 Days, ( ) MORPHINE SULFATE IV ORDERABLE [420065] 2 mg, IntraVENous, Every 4 hours PRN, severe pain, ( ) ketorolac (TORADOL) injection [22473] 15 mg, IntraVENous, For 5 Days, ( ) oxycodone-acetaminophen (PERCOCET) mg per tablet [5940] ( ) oxycodone (ROXICODONE) immediate release tablet [10814] 1 tablet, Oral, Every 4 hours PRN, moderate pain, 5 mg, Oral, ( ) HYDROmorphone (DILAUDID) tablet [3760] 2 mg, Oral, Every 4 hours PRN, severe pain, For 7 Days, Page 10 of 11
11 ( ) HYDROcodone-acetaminophen (NORCO) mg per tablet [34544] ( ) HYDROcodone-acetaminophen (NORCO) mg per tablet [34505] pain, pain, ( ) ibuprofen (ADVIL,MOTRIN) tablet [3843] 400 mg, Oral, Every 6 hours PRN, mild pain, Start 6 hours after last ketorolac [TORADOL] dose, if given. ( ) acetaminophen (TYLENOL) tablet [101] Oral, DATE TIME ORDERING PROVIDER PRINT NAME PROVIDER SIGNATURE DATE TIME RN ACKNOWLEDGED Page 11 of 11
[ ] Cardiac monitoring Routine, Until discontinued, Starting today, PACU (only)
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