See also: Common inpatient medication orders at St. Clare's
date and time
admit to gen surg/ortho/medicine under dr x
diagnosis
diet (npo, cf, ff, dat, cardiac diet, diabetic diet, renal diet)
activity (aat)
weight-bearing (FWBAT, PWB, TTWB, NWB)
vitals qNh
blood type and screen
blood cross and hold 2/4 units
withdrawl checks per protocol
ins/outs
ivf
accurate ins/outs
foley straight to drain
chest tube -20 mmHg
ng to low continuous suction
replace losses 1:1 with NS+20mEq KCl or LR qShift
pantoloc 40 mg IV OD
incentive spirometry
drugs
analgesia
antiemetics
antihistamine
antibiotics
patients own meds
heparin 5000U sc bid/tid* (TID if high clot risk e.g. cancer)
only hold if patient actively bleeding
investigations
cbc, LBCs, LFTs, INR/PTT
ekg
cxr pa/lat
blood c+s
urine r&m and c&s
service consults
social work, pt, ot, dietician
if Total knee replacement
FWBAT (full weight bearing as tolerated)
AAT
PT/OT referral
Vital signs routine
O2 to keep sats >90%
IV NS at __cc/hr. Heploc WDW (when drinking well)
CBC & LBC POD #1 & 3
Debulk dressing POD 1
Change dressing POD 5, then q2days PRN
Removal of staples (ROS) POD #14
X-ray (L or R) knee in recovery
Foley SD
D/C foley in AM then Foley in/out q6h PRN
if Total hip replacements/hip fracture surgery
Dx: L or R THA
DAT
Weight bearing status
Removal of staples POD 10
X-ray R or L hip in recovery room
foley plan as for knee above
