Session 5 - Post-Op Orders *wink wink nudge nudge* Flashcards
post-operative orders
Relate to the patient’s treatment after his/her surgical procedure. Written by the surgeon.
What does a post-op order usually contain?
- Medications
- Diet
- Intake and Output
- Intravenous Fluids
- Vital Signs
- Urinary Catheter
- Activity
- Positioning
- Wounds and Skin Treatment
- Suction
- Abdominal Drains
- Referrals to Multidisciplinary teams
- Discharge and follow up
Examples of post-op medication
Demerol 50-75 mg IM q3-4h prn
Gravol 25-50 mg PO/IV q4-6h prn
Morphine 5-10 mg IV q4h prn
Ancef 2 gm IV q8h
Dalteparin 5000U SC daily
Ativan 1 mg sl qhs prn
Examples of post-op diet orders
- NPO
- Ice chips only
- CF - DAT
- Full Fluids
- Soft Diet
- Regular Diet
- DAT
- Sips - DAT
Examples of post-op positioning orders
- Keep head of bed up 30 degrees
- Elevate HOB
- Patient to remain on left side x 24hrs
Examples of intake and output post-op orders
- Monitor I & O q4h
- Monitor and record I & O q shift
- Output q6h
Examples of IV post-op orders
- IV 2/3 1/2 @ 150 cc/hr
- IV TKVO
- IV NS @ 100 cc/hr
- D/C IV WDW
Examples of wound and skin care treatment post-op orders
- Change dressing OD, clean with NS
- Remove staples and apply steri-strips
- Wet to dry saline soaks to drain site
- Change dressing POD #1
- ROS POD #12
Examples of activity post-op orders
- Bedrest
- Bedrest with BRP
- Dangle on side of bed
- Walk with assistance
- Up with aid
- Up in chair
- Up as tolerated
- AAT
- WBAT
Examples of catheter post-op orders
- Foley to straight drainage
- Catheterize if unable to void
- D/C foley
- In and out catheter
- Foley prn
- CBI (Continuous Bladder Irrigation) with NS
- Scan bladder PVR
Examples of vital signs post-op orders
- VS TID
- Vitals q shift
- Vitals q4h
- BP QID and prn
- VS Q1H - Q4H when stable
- VS q1h x4
What is the normal temperature and how is it taken?
37 degrees Celsius
May be taken orally, rectally, axillary, or by ostoscope
What is the normal pulse or heart rate and how is it taken?
Adult: 70-80 / min
May be taken at the radial (wrist), carotid (neck), femoral (groin), pedal (foot), or by apex (over the heart with a stethoscope)
What is the normal respiration rate and how is it determined?
Adult: 15-20 / min
The respiration rate is taken by watching the patient’s chest rise and fall
What is the normal blood pressure rate?
Adult: 120/80
What is systolic and diastolic?
Systolic is the top number of the blood pressure. It records the heart at work, or contracting.
Diastolic is the bottom number of the blood pressure number. It records the heart at rest.
Examples of suction post-op orders
- NG to low suction
- Insert NG is nausea and vomiting
- NG to intermittent suction
Examples of incisional post-op orders
- Drain hemovac q shift
- D/C hemovac 24hrs
- D/C davol in am
Examples of abdominal drain post-op orders
- JP drain
- Remove JP drain in am
Examples of referral post-op orders
- PT to assess and mobilize
- OT to assess for walker
- Dietician to assess for tube feeds
- Wound Care Nurse to see for Ostomy teaching
- SW to arrange for home care supports
Examples of discharge and follow up post-op orders
- Discharge today
- Follow up in office in 2 weeks
- Discharge later today is patient has voided
- Discharge when okay with Physio
- Follow up with GP next week
Correct post-op order in the chart
- Surgical Consent Form
- Preoperative Checklist
- Anesthetic Record
- Surgical Count Sheet
- Perioperative Nursing Record
- Physicians Operative Record *
- PARR Record *
* Physicians Operative Report and PARR Record can be in either order
