Interventional Radiology Post Procedure Orders

Transcription

1 Interventional Radiology Post Procedure Orders ALLERGIES & SENSITIVITIES: NKA Unapproved Abbreviations: QD, Q.D., qd, q.d., QOD, Q.O.D., qod, q.o.d., MgSO₄, MSO₄, MS, IU, U or u, ug, Trailing Zero (X.0mg), Leading Zero (Xmg) Weight Height Diagnosis Date Time Description LEVEL OF CARE check appropriate box Place in Day Surgery Extended Recovery (OP only) Place in Observation Admit to Inpatient BED TYPE: SDS Med/Surg Telemetry ICU Notify Dr. of room number. Condition Patient Condition Satisfactory Patient Condition Fair Patient Condition Serious Patient Condition Critical Code Status Full Code Do Not Recuscitate (DNR) Limited Code Medications only Chest compressions only Do not intubate Vital Signs Vital signs per unit routine Vital signs every 8 hours Vital signs every 12 hours Vital signs (Specify) Vital signs q15 min x 4, q30 min x2, q 1 hr x1, then per unit routine Vital signs q15 min x 4, q30 min x2, q 1hr x2, then per unit routine Vital signs q15 min x 4, q 30 min x2, q1 h x3, then per unit routine Neuro checks with vital signs Precautions Aspiration precautions Seizure precautions Isolation precautions: Contact Airborne Page 1 of 9

2 Droplet Laboratory Post Thrombolysis Laboratory Orders Fibrinogen level stat Fibrinogen level every 4hrs CBC q 6h. PTT q 6h Post Denver Shunt Laboratory Orders Stat fibrinogen level Stat PT/INR Stat CBC Timed fibrinogen level at Timed PT/INR at Timed CBC at Post Renal Biopsy Laboratory Orders Hg/HCt every 2hrs post renal biopsy Hg/HCt every 4hrs post renal biopsy CBC in am Renal panel in am Radiology Xray chest, PA/LAT view at diagnosis Respiratory Respiratory Therapy Protocol Titrate oxygen, Maintain SPO2 greater than or equal to 92% BIDRT Pulse Oximetry Continuous Spot check Diet Oral Diets Regular/House Renal Cardiac Consistent Carbohydrate (Diabetic) Full Liquid Clear Liquid NPO Supplement Activity Bedrest x 2 hours, flat for first hour then ad lib Bedrest x 3 hours, flat for first 2 hours, then ad lib Bedrest x 3 hours, right side down, then ad lib Bedrest x 3 hours, right side down for the first hour, then supine HOB </= to degrees for 2 hours, then ad lib Strict bedrest with right leg straight until then ad lib left leg straight until then ad lib May logroll for comfort Page 2 of 9

3 Bedrest with bathroom privileges with assistance NURSING Convert any IV fluids to saline lock after procedure completed for all CHF or ESRD patient Advance diet to patient s usual diet as tolerated NPO until then advance diet to patient s usual diet as tolerated Remove saline lock at Discontinue PCA at Cardiac monitoring including off unit tests Cardiac monitoring except off unit tests Notify MD for: Temp greater than or equal to 101 degrees F Systolic BP greater than 140 mm Hg Diastolic BP greater than 90 mm Hg Pulse greater than 100 or less than 60 Respiratory rate greater than 24 or less than 10 per minute Abnormal CK/CKMB/Troponin results Notify physician for INR greater than 1.5 Notify physician for HGB less than 8 Notify physician for Platelett count less than 50 Orthostatic vital signs every 2 hours x2: Lower head of bed to flat for 10 minutes, check blood pressure and heart rate Raise head of bed to 45 degrees and recheck blood pressure and heart rate Have patient stand then recheck blood pressure and heart rate Call IR MD if SBP drops by 20 points or pulse increases by 20 points with sitting or Standing Post Thrombolysis Nursing Orders Monitor for and report blood in urine No new IM or IV sticks while patient is receiveing tpa. Place sign on door. May use sheath sideport for lab draws after wasting 10ml of blood from sheath Notify IR MD if bleeding, hematoma, change in neuro exam, loss of pulses, decrease in HCT by more than 3 grams Post Denver Shunt Nursing Orders Elevate head of bed at least 45 degrees until 8 am tomorrow Pump Denver Shunt chamber 20 times in the morning and 20 times in the evening Check baseline blood pressure and heart rate Orthostatic vital signs every 2 hours x2: Lower head of bed to flat for 10 minutes, check blood pressure and heart rate Raise head of bed to 45 degrees and recheck blood pressure and heart rate Have patient stand then recheck blood pressure and heart rate Call IR MD if SBP drops by 20 points or pulse increases by 20 points with sitting or standing Call IR MD if INR>2. Drop in fibrinogen of 30% or greater from baseline or fibrinogen less than 100 Remove foley catheter at Nursing Communication: Nursing Communication: Page 3 of 9

4 Venous Sheath Management Remove venous sheath following arterial sheath removal and hemostasis Remove venous sheath now and hold manual pressure Cover site with dressing after hemostasis achieved Ambulate with assistance first time after hours then resume usual activity level Tubes and Drains Record drain output every shift, minus flush Flush drain q shift with 10 cc NS Tubes and Drains GI Insert nasogastric tube to low wall suction intermittent Insert nasogastric tube to low wall suction continuous Tubes and Drains GU Insert urinary catheter (indwelling) Insert urinary catheter (straight cath) Irrigate urinary catheter Irrigate bladder: continuous Irrigate bladder: manual PRN to maintain urinary catheter function Chest tubes Place chest tube to continuous suction Place chest tube to water seal Arterial Sheath Management Sheath Management w/closure Device Communications: Nursing hemostasis patch PRN for oozing or suboptimal hemostasis. Apply to groin for 24 hours. Cover site with Bio-Occlusive dressing after hemostasis is obtained Position Patient: Maintain Head of Bed not greater than 30 degrees continuous starting today for 6 hours Ambulate with assistance first time after bedrest complete then resume usual activity level Communications: Nursing resume activity, after bedrest with BRP for 12 hours Ambulate hours AFTER PROCEDURE Communications: Nursing remove dressing after 24 hours Sheath Management Without Closure, No Anticoagulation Remove Sheath: Arterial Now Remove Sheath: Arterial at Connect A-Line to pressure bag and invasive monitor until sheath removed Immobilize leg while sheath in place Bedrest, strict, with head of bed no higher than 30 degres and affected leg straight for hours after sheath removed Ambulate with assistance first time after bedrest complete then resume usual activity level Apply manual pressure to obtain hemostasis Vasovagal Protocol Apply pressure dressing with hemostasis patch PRN for capillary bleeding Femostop Protocol PRN bleeding Notify physician for major arterial bleeding, SBP less than 90mmHg Communications: Nursing remove dressing after 24 hours Page 4 of 9

5 Sheath Management Without Closure, Heparin Remove Sheath: Arterial Now Remove Sheath: Arterial when Activated Clotting Time (ACT) is less than 150 seconds Remove Sheath: Arterial at Connect A-Line to pressure bag and invasive monitor until sheath removed Communications: Nursing Bedside ACT (I-STAT) PRN starting today Immobilize leg while sheath in place Bedrest, strict, with head of bed no higher than 30 degrees and affected leg straight for hours after sheath removed Ambulate with assistance first time after bedrest complete then resume usual activity level Apply manual pressure to obtain hemostasis Vasovagal Protocol Apply pressure dressing with hemostasis patch PRN for capillary bleeding Femostop Protocol PRN bleeding Notify physician for major arterial bleeding, SBP less than 90mmHg Communications: Nursing remove dressing after 24 hours Sheath Management Radial Access Leave arterial sheath in place, and connect to pressure line until further orders Bedrest for hours after procedure Ambulate wi th assitance first time after bedrest complete then resume usual activity level TR Band Management After 2 hrs, withdraw 2ml slowly and observe site for oozing or bleeding If no oozing/bleeding noted continuing aspirating 2 ml of air every 2 minutes until device bladder is empty If bleeding occurs at any time during air removal, reinflate with 2ml and wait 30 minutes before attempting removal If bleeding is again noted, re-inflate with 2ml of air for an additional 20 minutes and then deflate 2ml every 15 minutes Immobilize wrist, no lifting or pushing with access arm for hours IV Fluids Lactated Ringers IV at ml/hr Sodium Chloride 0.9% IV at ml/hr Sodium Chloride 0.9% with Potassium Chloride 20 meq/l IV at ml/hr Sodium Chloride 0.9% with Potassium Chloride 40 meq/l IV at ml/hr Sodium Chloride 0.45% IV at ml/hr Sodium Chloride 0.45% with Potassium Chloride 20 meq/l IV at ml/hr Sodium Chloride 0.45% with Potassium Chloride 40 meq/l IV at ml/hr Dextrose 5% in Lactated Ringers IV at ml/hr Dextrose 5% in Lactated Ringers with Potassium Chloride 20meq/L IV at ml/hr Dextrose 5% in Lactated Ringers with Potassium Chloride 40meq/L IV at ml/hr Dextrose 5% in Sodium Chloride 0.45% IV at ml/hr Dextrose 5% in Sodium Chloride 0.45% with Potassium Chloride with 20meq/L IV at ml/hr Dextrose 5% in Sodium Chloride 0.45% with Potassium Chloride 40meq/L IV at ml/hr Page 5 of 9

6 Medications Vasoopressin 20 units in 100ml Sodium Chloride 0.9% via arterial catheter at 0.1 unit/minute via arterial catheter 0.2 unit/minute via arterial catheter 0.3 unit/minute via arterial catheter 0.4 unit/minute via arterial catheter Thrombolysis Medication Orders (drip catheter) tpa (Alteplase) 10mg/250ml NS infused through angiocatheter at ml/hr tpa Sliding Scale: If fibrinogen >200, no changes to tpa rate If fibrinogen >100 and <200, reduce tpa to half current rate If fibrinogen <100, stop tpa and call IR MD Sodium Chloride 0.45% at 30ml/hr if fibrinogen <100 Heparin 2000 units/1000ml NS infused through sideport of sheath at 15 ml/hr Antiemetics Metoclopramide (Reglan) 10 mg IV Q6H PRN nausea/vomiting Ondansetron (Zofran) 4 mg IV Q6H PRN nausea/vomiting Ondansetron (Zofran) 4 mg PO Q6H PRN nausea/vomiting Prochlorperazine (Compazine) 10 mg IV Q6H PRN nausea/vomiting Prochlorperazine (Compazine) 25 mg suppository per rectum Q12H PRN nausea/vomiting Promethazine (Phenergan) 12.5 mg IV Q6H PRN nausea/vomiting Promethazine (Phenergan) 25 mg IM Q6H PRN nausea/vomiting Constipation Docusate (Colace) 100mg PO BID PRN constipation Anti-anxiety Lorazepam (Ativan) 1 mg PO Q4H PRN anxiety/agitation Insomnia Zolpidem (Ambien) 5 mg PO HS PRN insomnia. May repeat X 1 after 60 minutes if ineffecive Fever Acetaminophen (Tylenol) 650 mg PO Q4H PRN greater than 100F Acetaminophen (Tylenol) 650 mg suppository fever greater than 100F and patient unable to tolerate PO Ibuprofen (Motrin) 400 mg PO Q4H PRN mild pain or fever greater than 100F Mild Pain Acetaminophen (Tylenol) 650mg PO every 6 hours PRN mild pain Acetaminophen (Tylenol) 650mg/20.3 ml PO every 6 hours PRN mild pain Ibuprofen (Motrin) 600mg PO TID PRN mild pain Hydrocodone-Acetaminophen (Norco) 5/325mg PO every 6 hours PRN mild pain Morphine 2mg IV every 4 hours PRN mild pain Page 6 of 9

7 Moderate Pain Hydrocodone-Acetaminophen (Norco) 7.5/325mg PO every 6 hours PRN moderate pain Morphine 4mg IV every 4 hours PRN pain moderate pain Severe Pain Oxycodone/Acetaminophen 5/325 (Percocet) PO every 6 hours PRN severe pain Hydromorphone (Dilaudid) 2mg IV every 6 hoursprn severe pain PCA Management (Select Drug/Dose) Please Reference Hospital-Recommended Dosing Parameters {insert link in electronic version} Morphine 30mg/30ml (Final concentration: 1mg/ml) NO BASAL RATE Loading dose: mg PCA dose mg every minutes Not to exceed mg every 4 hours Morphine 30mg/30ml (Final concentration: 1mg/ml) BASAL RATE Basal rate: mg/hour Loading dose: mg PCA dose mg every minutes Not to exceed mg every 4 hours Hydromorphone (Dilaudid) 6mg/30ml (Final concentration: 0.2mg/ml)NO BASAL RATE Loading dose: mg PCA dose mg every minutes Not to exceed mg every 4 hours Hydromorphone (Dilaudid) 6mg/30ml (Final concentration: 0.2mg/ml) BASAL RATE Basal rate: mg/hour Loading dose: mg PCA dose mg every minutes Not to exceed mg every 4 hours Sodium Chloride 0.9% at 20ml/hr while on PCA if no other maintenance IV fluids are ordered. Naloxone 0.4mg IV PUSH STAT Q2MIN PRN decreased mentation, unarousable, arousal score 5/5, respiratory rate less than 10 breaths/minute Antiemetic Ondansetron (Zofran) 4mg IV PUSH Q6H PRN nausea/vomiting Promethazine (Phenergan) 25mg suppository per rectum Q4H PRN nausea/vomiting Pruritus: Diphenhydramine (Benadryl) 25mg IV PUSH Q4H PRN itching Hydroxyzine (Atarax) 25mg IM Q4H PRN itching Page 7 of 9

8 Nursing: PCA: Initiate PCA in PACU if patient is post-operative PCA: Discontinue all previously ordered opioid medication before PCA implementation PCA: Discontinue all previously ordered anti-emetic medications before PCA implementation PCA: Discontinue all previously ordered anti-puritic medication before PCA implementation PCA: Educate family and patient PCA by proxy is NOT allowed PCA: Educate patient on proper administration and use of PCA management PCA: ETCO2 monitoring until PCA is discontinued PCA: Assess vital signs, pain, and sedation Q4H for Med-Surg PCA: Assess vital signs, pain, and sedation Q2H for ICU/Critical Care PCA: Assess vital signs before initiation or any dose/rate change. Reassess vital signs every 15 minutes x2 then every 30 minutes x1 after any dose/rate change. Report significant deviations from baseline to ordering physician. PCA: Excessive Sedation Activate RRT PCA: Excessive Sedation Stop PCA PCA: Excessive Sedation Apply Oxygen PCA: Excessive Sedation Notify MD Stat Discharge Discharge to home when pt is tolerating diet and pain is managed on PO meds Discharge to home after hours AND when tolerating diet and pain is managed on PO meds Call Interventional Radiologist before discharge Communicate discharge instructions and medication istructions Provide written copy of discharge instructions and medication list Physician s Signature: Date: Time: Page 8 of 9

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