ADMISSION Orders

Nursing
o Vitals (T-BP-HR-R-Pox: q4- routine, q2- stepdown, q1- ICU)
o Notify MD if T › 101.5, SBP ‹ 90 or › 160, DBP › 100, P ‹ 60 or › 100, R
‹ 12 or › 24, Pox ‹ 93%, UO ‹ 30cc/hr
o Strict I & O’s Notes “SOAP”
o Telemetry (telemetry floor or step-down)
o Catheters (NGT-low cont suction, CT-20 cm suction, foley-
Subjective: Pt complaints. Pain? Tol diet? F/C? N/V? Bowel
urimeter)
function? CP/SOB? OOB/amb?
o Dressing changes / wound care
o Activity (bedrest, c-spine / logroll precautions, up ad lib)
Objective:
 VS: Tmax (if febrile, note time)/ Tcurrent, BP, HR, R, Pox (on ___ L
Nutrition
O2)
o Diet (NPO, NPO x meds p MN, clrs, reg, ADA)
I/O: (including urine, drain outpts- NGT, CT, JP per shift & over
o IVF (NS or LR – resuscitative, D5 ½ NS c 20 KCl – maintenance)
24h)
PE:
Management
Gen:
 Imaging / Studies (CXR, US, CT, IR procedures)
CVS:
 Medications
Lungs:
 Antibiotics
Abd: (include wound, incision, stoma)
 Pain medication
Ext: (vasc if applicable)
 Antihypertensives / cardiac meds
 Insulin sliding scale (if DM)
Assessment/ Plan:
 Home meds
 “___ yo POD#___ s/p __________”
 Prn meds
 GI prophylaxis (pepcid, nexium if NPO)
 Ex:
o Stress ulcer prophylaxis Sucralfate 1gm PFT/NG - Advance diet
q6h Ranitidine 150mg PFT/NG q12h -OR- 50mg - D/c IVF
IV q8h (q24h for renal failure) Protonix 40mg - Cont abx
po/IV qday - Pain control
 - Δ IV → po meds / restart home meds
 DVT prophylaxis (SCD’s, chemoprophylaxis) - F/u labs, cx’s
 Labs (if indicated) in am (CBC, BMP, Mg, coags) - F/u studies (US, CT, ERCP, c-scope)
- For OR today
 - D/C home  Discharge pts
- Will discuss plan w/ team, attending  Call consults
 F/u studies (i.e. radiology)
 Pre op pts
 Post op pts
 Chart check for attending notes containing new plans, notes by
consulting services (cardio, pulm, GI, renal)
ROUNDS  OR if assigned cases
 ER/floor consults as they come
AM Rounds
 Get sign-out: call the night interns (ER and floor) for a sign-out of PM Rounds
new pts on the list and any issues re: the floor patients overnight  If time, get vitals, I/O’s
 Pre-rounds  Update team on problems that arose over the day with pts, labs,
 Gather vitals (Tm/Tc, BP, HR, Pox, I/O’s over 24h and last shift) studies, plans
 Examine pt (heart, lung, abdomen, wound, legs)  Will often chart check and post-op as a team
 ** Take down dressings  Get an updated plan for each patient
 Write notes  Tuck the pts in and sign out

Rounds
 Present succinctly:
 Start with: name/age/co-morbidities/post-op day and procedure
(“Mr. Smith is a 50 yr old with a PMHx sig for HTN, CAD, DM who
is POD #1 s/p lap chole.”)
 Mention: c/o, course O/N, Tm/VSS, pertinent positives on physical,
problems, and plans
 Clarify plan for each pt (advance diet, drop fluids, Δ IV → po meds,
removing tubes, studies, pre- op, D/C)
 Redress wounds

Post-Rounds
 Floor duties:
 Certify notes
 Orders via computer
 Check/replete labs; order labs for tomorrow
 Pt care (i.e. d/c drains, write TPN, arrange SW)
 Team rounds on floor
 PREOP ANTIBIOTICS
ROUTINE PREOP WORKUP Basics
 Should be given immediately before or w/in 1 hr of incision
(varies by attending / institution)  Who needs abx prophylaxis?
 Labs YES
 CBC  Pts with prosthetic valves, rheumatic or valvular dysfunction,
 Chem-7 prosthetic vascular grafts
 PT/PTT  In general, dental/oropharyngeal, respiratory, GI, urologic,
 UA gynecologic procedures
 β-HCG  Clean-contam, contam, and dirty all need abx
 Type and screen or crossmatch if needed NO
 EKG (if › 40 yo)  Clean cases (i.e. breast bx, thyroid sx, IHR)- NO abx unless cardiac,
 CXR (if › 40 yo) vascular, ortho, or neurosurg (sx involving groins, grafts, valves,
hardware)
 Gastroduodenal sx in pts w/ normal gastric acidity and no CA,
PATIENT ASSESSMENT ulcer, bleeding, or obstruction
ORDERS  Urologic sx if urine is sterile

 NPO after MN except meds Wound Classification & Infection Rates
 IVF Category Description (-) (+)
 IV Abx “on call” (better yet, “in holding” or “in OR”) abx abx
 Clarify if anticoagulation needs to be held
 Clarify preop dose of heparin / lovenox, if indicated Clean No infection; resp, GI, GU tract not entered 1-2% 1-2%
(i.e. breast bx, IHR)
 Pts on steroids may require a stress dose before and after surgery
 Ex: Hydrocortisone 50-100 mg prior to sx then q8h for 1-2 days, Clean- Resp, GI, GU tract entered under controlled 6- 3.3%
then taper to baseline based on clinical response Contaminated conditions (i.e. lap chole, elective colon 11%
resection)

Contaminated Open fresh accidental wounds, wounds w/ 13- 6.4%

gross spillage (i.e. penetrating abd trauma, 20%
enterotomy during laparotomy for SBO)
 Dirty Infected wounds, wounds w/ devitalized tissue 27- 7.1% Anaerobes Flagyl
(i.e. perf’d diverticulitis, necrotaizing fasciitis) 40% Clindamycin

Body Parts / Systems & their Pathogens & Abxs

Body Part / Pathogens Abx Recs BOWEL PREP
System

Mechanical bowel prep (MBP)

Skin & Soft Tissue GPC, occas GNR Ancef
 For elective colon resections, MBP does NOT decrease / prevent
overall infectious complications, wound infection, anastomotic
Head & Neck GPC, anaerobe Ancef or Clinda
leak
 Vigorous prep can lead to dehydration, electrolyte abnormalities,
Gastric GPC, GNR Ancef
bacterial translocation
Biliary GNR, Ancef, Cefoxitin, or LVQ
 NO MBP: elective colon resection
enterococci  YES MBP: inadequate localization of lesion, possibility of intra-op
colonoscopy
Colorectal GNR, anaerobes Ancef / Flagyl, Cefox / Flaygl, LVQ /
Flagyl Prophylactic abx: oral + IV regimen is best
 Often a combo of the following:
Traumatic Wound GPC, clostridia Ancef, PCN G, Zosyn
 Clears for 24-48 hrs; NPO after MN the day before surgery
 PO antibiotics
Vascular GPC Ancef
 Neomycin and erythromycin base (1 gm each) po at 1 PM, 3 PM,
Coverage Needed & Abxs and 11 PM the day before surgery; can substitute 1 gm
metronidazole for erythromycin
Coverage Needed Abx Recs
 Flagyl 500 mg po q 6h for 24h
 IV antibiotics
Gm (+) and some Gm (-) Ancef 1-2 gm IV
 On call/ in holding to cover gram negatives and anaerobes (see
above)
* If PCN allergic Vanco 1 gm IV
or MRSA Clindamycin 600 mg IV

Gm (-) aerobes and LVQ 500 mg /Flagyl 500 mg IV

anaerobes Cefoxitin 1-2 gm IV
Cefotetan (N/A these days)
Zosyn 3.375 gm IV

* If PCN allergic LVQ 500 mg /Flagyl 500 mg IV

Clindamycin 600 mg IV
POSTOP ORDERS
Be sure to include:
 Diet (NPO usually, lap choles can have clears)
 IVF
 Pain control (Percocet 1-2 tabs po q 4 hrs prn; Morphine PCA 1mg
q 8 min with no basal infusion)
 Beta-blockade for cardioprotection, if indicated (Metoprolol 5 mg
IV slow push q 6 h with holding parameters i.e. SBP ‹ 110, HR ‹ 65)
 GI prophylaxis (if pt is NPO, give H2-blocker or PPI)
 DVT prophylaxis
 SCD’s
 Chemoprophylaxis (i.e. Heparin 5000 units SQ q8h or Lovenox 40
mg SQ qd) - clarify with attending first
 Incentive Spirometry (nurse to instruct and have pt use 10x/hr
while awake)
 Labs immediately post-op in RR for pts undergoing major surgery
(CBC, BMP, Mg), consider cardiac enzymes, EKG, CXR
immediately postop for high cardiac risk pts
 Labs for am (CBC, BMP, Mg)
 Prn meds (i.e. Zofran 4 mg IV q 6 hr for nausea/vomiting, Tylenol
650 mg po or pr q 4 hr prn for mild pain, HA, temp›101

POSTOP CHECKS
 Check vitals, urine outputs, drain outputs
 See and examine patient, write a SOAP note
 Note chest, belly (or area of body operated on) exam, wound/
dressing appearance
 Vascular exam if pertinent
 Address pt issues/ complaints (pain, N/V, etc)
 F/u labs, EKG, CXR if they were ordered post-op
 Follow UO closely to ensure adequate resuscitation
 Phosphorus
LABS  Usually replete when Phos ‹ 2.0
 IV: comes in KPhos or NaPhos (usually give 15-30 mmol diluted in
Ordering Labs 250 mL D5W over 6 hrs)
 If NPO: CBC, BMP, Mg in am  1 mL KPhos = 4.4 mEQ K & 3 mMol phos
 If TPN: daily CBC, BMP, Mg with weekly CMP, with pre-alb &  1 mL NaPhos = 4 mEQ Na & 3 mMol phos
lipids, FSBG q 6h  PO options:
 If infection/ abscess: CBC to trend WC  K-Phos Neutral (tab) = 8 mmol phos : 1.1 mEQ K : 13 mEQ Na
 If bleeding: serial H/H’s q6h  Neutra-phos (capsule/packet) = 8 mmol phos : 7.1 mEQ Na and K
 If on heparin gtt: PTT q6h each; Neutra-phos K = 8 mmol phos : 14.25 mEQ K: no Na
 If on coumadin: PT/INR in am  Phospho-soda (liquid) = 4.15 mmol phos : 4.82 mEQ Na : no K per
 Can usually stop labs if pt on clrs/ reg diet ml
 Skim milk = 8 mmol phos : 5 mEQ K : 3 mEQ Na per cup
Potassium (nl 3.5-5.0)
 Replete when K ‹ 4.0 unless pt is on HD Calcium (nl 8.5-10; ionized 4.4-5.5)
 If NPO → give IV  Not usually repleted unless really low and corrected for albumin
 10 mEQ KCl IV will increase K by 0.1 mMol/L  Ionized Ca more accurate
 Peripheral line: 10 mEQ over 1 hr x ___ times  IV: calcium gluconate 1-2 g IV over 30 min
 Central line: 20 mEQ over 1 hr x ___ times  PO: calcium carbonate 1000-1500 mg po
 If on diet give po
 Can give po (powder, liquid, or sustained release tabs)
 1 mEQ K per inch banana
 Consider KPhos if phos is also low
 Be careful about repleting K on renal patients!

Magnesium (nl 2.0-2.7)

 Replete when Mg ‹ 2.0
 1 gm will increase Mg by 0.1 mg/dL
 Usually give IV Mag Sulfate 1-2 gm over 1 hr
 Mag oxide 400 mg po ~ 2.5 gm IV (can cause diarrhea)
 Remember K will not respond to K replacement if Mg is low

FLUIDS & ELECTROLYTES

 PO Diets
Fluids Ordering
 For resuscitation use isotonic fluids (LR or NS) @ 100-150 cc/hr Common kinds
 Maintenance is D5 ½ NS w/ 20 KCl @ 75-100 cc/hr  NPO: nothing by mouth
 Estimate by weight: 4 cc/kg/hr for 1st 10 kg + 2 cc/kg/hr for 2nd 10  Clears: 500-800 kcal/d (ex: ginger ale, broth, jello)
kg + 1 cc/kg/hr for each kg thereafter (100:50:20 cc/kg/day)  Fulls: 900-1200 kcal/d, high in fat, lactose (ex: milk, creamy soups,
 D5NS is isotonic pudding)
 ½ NS, D5 ½ NS, D5W, D10W are hypotonic  Regular: 1800-2200 kcal/d
 Banana bag = D5 NS w/ 100 mg thiamine, 1 mg folate, 1 amp
multivitamins, give as first bag of IV QD Special diets and indications
 Albumin can also be given to ↑ intravascular volume; use if want  Mechanical soft: dysphagia
to restrict fluid administration (CAD, CHF, renal pts)- check w/ Sr.  Pureed: pts w/o teeth
first  Diabetic/ADA: diabetes
 Salt restricted: HTN, renal disease, CHF
Management  Renal (low Na, K, less protein) +/- fluid restriction
 In general, pt s/p abdominal surgery are initially given resuscitative  Low Residue (low fiber, no foods w/ skins and seeds): active
fluids (NS, LR) while NPO diverticulitis, s/p bowel resection
 After 48 hrs, fluids are changed to D5 ½ NS w/ 20 K  Post-gastrectomy (6-8 small meals): s/p gastrectomy,
 Half / drop rate when starting clrs esophagojejunostomy
 D/C IVF when tolerating reg diet  Post-gastric bypass clears (30 cc’s po q 15min): sugar free jello,
 Do not give LR to renal pts (LR has K in it) or pts w/ liver failure broth, water
(2˚to lactate)  Consider supplements (Ensure, Resource, Carnation breakfast) to
 D10W can be used as a temporary substitute for TPN, but must boost nutritional intake
monitor glucose levels
Progression
Electrolytes  In general, diet is advanced with return of bowel fxn (+ Flatus ±
 See on previous page BM)
 If + F/BM → advance to clears
 If tol clears → (± fulls) → reg
 Once on clears, can ↓ IVF (i.e. to 75 cc/hr) and Δ meds from IV →
po
 Fall back a step if pt does not tolerate advancement
 Varies per attending preference
Tube Feeds
NUTRITION  If the gut works, use it!
  Non-fuctioning GI tract (prolonged bowel obstruction / ileus, IBD,
Indications: for pts with functional GI tract but insufficient oral EC fistula, GI ischemia, severe pancreatitis)
intake
Contraindications: How to calculate
 Bowel obstruction  Protein= 1.0 g/ kg weight/day (if pt stressed, 1.5-2 g/kg)
 Prolonged ileus  Calc non-protein kcals needed: 25 kcal/kg/day (if stressed, 30-35)
 GI bleeding  1/3 of total kcals in form of lipids
 Severe inflammation or enteritis  2/3 of total kcals in carbs
 Severe diarrhea  To calc gms needed of both, divide lipid kcals by 9 and carb kcals
 GI ischemia by 3.4
 Rate: usually in 2 L bag ~ 83 cc/hr x 24 hrs
Administered via: OGT, NGT, Dobhoff, PEG-tube, G-tube, J-tube
Management
Kinds:  Need central access (i.e. triple lumen, PICC) and virgin port
 Standard (1-1.2 kcal/ml; isotonic) = Jevity 1.2, Ensure  Can replete lytes via TPN
 Volume restricted / nutrient dense (1.5-2.0 kcal/ml) = Jevity 1.5,  Check blood glucose q 6 h; cover with ISS or add insulin to the bag
Resource 2.0  Include Pepcid 40 mg in each bag (renal pts only 20 mg)
 Disease specific = Glucerna (diabetes), Nepro (renal failure)  F/u nutrition recs in chart
 Elemental (rapid absorption of nutrients for pts w/ GI impairment)
= Peptamen, Vital

Initiating TFs:
 Start TFs (1/2 or full-strength) @ low rate (20-40 ml/h) and
increase concentration and rate incrementally to goal as tolerated
 If gastric residual high (› 200 cc) → hold TFs and reassess in 1-2 hrs
 Other options: can cycle TFs overnight or bolus TID or QID

TPN
CATHETERS
See Tubes & Lines for details on insertion & maintenance
Indications
NG Tubes
 Pre-op for severely malnourished pts
 Trend character and volume of output q shift
 Make sure it is functioning properly (see “Tubes & Drains")
 D/C when bowel function returns (+ flatus)
Foley Catheters
 Use urimeter for accurate UO measurements
 D/C when pt is OOB/ambulating
 Pts s/p LAR: foley may be left in longer to prevent bladder
distension and protect the low anastomosis
 Pts w/ spinal anesthesia: D/C foley 6 hrs after epidural is pulled
 Void check 8 hrs after discontinuing foley; if pt does not void,
straight cath → if UO › 250 cc, leave foley in
Chest Tubes
 Trend character and amount drainage (serosang, serous, milky)
 Check for the presence or absence of an air leak (kink tubing that
leads to wall suction and have pt cough hard: + AL if bubbles in the
middle chamber)
 If no AL → place CT to water seal
 If still no AL and ↓ drainage (‹ 100 ml/d) → can D/C CT; get f/u CXR
to r/o PTX
Drains
 Record character and output
 D/C when output low +/- diet
o < 30 cc/24 hrs for 2 consecutive days
 JP drain s/p cholecystectomy: check for bilious output— could
represent bile leak or biliary obstruction
 Leave pancreatic drains in place until after pt is eating
WOUNDS & DRESSINGS
** To maximize efficiency, take down dressings/ expose the wound
during prerounds. After the team evaluates the pt, have supplies ready
to redress the wound. The MS/intern not presenting on the next pt
should stay behind and quickly pack/dress the wound.
On Rounds
 Have in pockets basic wound care supplies: 4x4’s, tape, scissors
 Pts requiring more complex wound care should have relevant
materials stocked at bedside (i.e. 4x4’s, drain sponges, Kerlex,
ABD pads, suture removal kits, NS)
Basic Management
 Original dressings usually taken down on POD #2, then open to air
 If pt has fever and severe pain at wound site POD #0-2, take drsg
down immediately to inspect wound and notify Sr (r/o necrotizing
infection i.e. grey, foul-smelling drainage)
 Superficial wound infections: d/c a few staples, open the wound,
drain any pus, and pack ± abx
 Open wounds: pack damp→ dry BID w/ saline-soaked Kerlex
 Complex wounds/ VACs- consult wound care nurse to coordinate
care; change VACS 2-3x/week
 Necrotic tissue/ ulcers may require sharp debridement; chemical
debridement (i.e. accuzyme) also available
 Superficial abrasions: Bacitracin
 Burns: Silvadene w/ non-adherent gauze (i.e. Adaptic) and Kerlex
wrap for most (sulfamyalon for better eschar penetration)
 Set up VNA if pt requires wound care after discharge
PAIN Assessment
Review History
 Location, quality, severity, timing, provoking / alleviating factors,
associated symptoms
 ___ POD, procedure, diet (? NPO), current pain med regimen (type
of medication, dosing, route, frequency)
 Pain med / narcotic use in the past? What has worked for pt? On
Methadone? (Will need more on top of this post-op)
 Allergies, pain med intolerance
 Comorbidities (e.g. renal failure → avoid NSAIDs)
not exceed
3200 mg)
Physical Exam
 Vitals (tachycardic 2° pain? Other abnormalities signaling possible Tylenol #3 Codeine 30 mg + 1-2 tabs po q4- Narcotics:
complication or missed diagnosis?) acetaminophen 300 mg 6h prn - Nausea /
vomiting
 Focused history including operative site - Drowsiness
Vicodin Hydrocodone 5 mg + 1-2 tabs po q4- - Itching
acetaminophen 500 mg 6h prn - Constipation
(also ES 7.5/750, HP - Respiratory
10/660)
MEDICATION OPTIONS depression
- Tolerance,
Lortab Hydrocodone 5 mg + 1-2 tabs po q4- dependence,
Tylenol acetaminophen 500 mg 6h prn addiction

 Alone: 650 mg po q4h prn (also 2.5/500, 7.5/500,

10/500)
 In combination with narcotic (see below)
Percocet Oxycodone 5 mg + 1-2 tabs po q4-
NSAIDs acetaminophen 325 mg 6h prn
 PO (also 2.5/325, 7.5/325,
7.5/500, 10/325, 10/650)
o Ibuprofen (Advil, Motrin)
o Celebrex (selective COX-2 inhibitor)
Oxycontin Oxycodone (10, 20, 40, 10-40 mg po
 IV: Toradol (i.e. ketorolac): 30 mg iv q 6 hrs x 3 days only (extended release) 80, 160 mg) q12h
o give only if nl renal fxn and ↓ bleeding risk; x 3 days only
MS Contin Morphine (15, 30, 60, 15-60 mg po
100, 200 mg) q8-12h

Common PO Pain Medications (~ weakest to strongest) Dilaudid Hydromorphone (2, 4, 8 2-4 mg po q3-
mg) 4h prn
Brand Name Generic Name Dose Adverse Effects
IV
Tylenol Acetaminophen 325 mg 325-650 mg Liver failure  IV (bolus or intermittent prn dosing)
(extra strength 500) q4h prn (do not o Morphine
exceed o Hydromorphone (Dilaudid)
4gm/day)
o Fentanyl
Advil, Motrin Ibuprofen 200 mg (400, Mild-mod: 400 NSAIDS: GI
 IV PCA (patient-controlled analgesia)
600, 800) mg q4h prn; ulceration, o Titrate to effect by increasing demand dose or decreasing
Acute pain: bleeding, renal lock-out interval
800 mg TID- failure, CV
QID prn (do thrombotic events o Avoid basal / continuous infusion (esp. in narcotic-naïve or
sleep apnea pts) – risk of overdose / over-sedation
 o Advantages over IV PCA: better pain relief and respiratory
IV Narcotic Meds and Common Dosing function, opioid-sparing, less sedating
o Disadvantages: insertion risks, catheter-related problems
IV Acute Intermittent PCA (usual starting dose)
Medication (bolus) prn dosing (e.g. dislodgement, infection)
dosing o Side effects
 Hypotension (2° to sympathetic blockade): give
Morphine 4 (2-10) mg 2-4 mg IV q4h 1 mg q 8 min (titration example: volume (IVF)
IV prn ↑ to 1.2-1.5 mg and ↓ interval to
q 6 min)  Spinal headache: supportive care, if persistent,
may need a blood patch
Dilaudid 1-2 mg IV 0.2-0.6 mg IV 0.1-0.2 mg q 8 min  Leg weakness: often b/c infusion rate too high,
q2-3h prn but need to r/o epidural hematoma or abscess if
persistent (notify anesthesia / pain team)
Fentanyl 50-100 mcg 25-50 mcg IV 10 mcg q 8 min  If pt w/ hx dependency, ψ issues, pain not relieved by conventional
IV q1-2h prn
doses, consider a PAIN CONSULT by anesthesia

Other routes
 Transdermal patch (extended release)
o Fentanyl (Duragesic): start at 25 mcg/hr q 72 hr (supplied
in 25, 50, 75, 100 mcg/hr patches)
 Buccal / oro-mucosal (for breakthrough cancer pain in pts taking
equivalent of 60 mg morphine/day)
o Fentanyl (Actiq) lollipop: start at 200 mcg x 1, redose in 15
min if necessary
 Epidural PCA
o Usually a combination of local anesthetic and opioid