Admission/Pre-op Admission/Pre-op H & P CC: (Chief complaint) HPI: (History of Present Illness) PSHx: (Past surgical history) PMHx: (Past medical history) - esp. clotting disorders Medications: types and dosage Allergies: FH: (Family history) Family members w/clotting disorders or anesthesia reactions SH: (Social history) tobacco, EtOH, street drug, caregivers, home, occupation ROS: esp fevers, chills, night sweats, weight loss, URI, GI, dysuria, bruising/bleeding Physical exam: Vitals, Wt: General: HEENT: Ears, sclera, conjunctiva, mouth, throat, lymph nodes, thyroid CV: Regular rate and r hythm? S1S2, murmurs Lungs: Auscultation, +/- percussion Abdomen: Bowel sounds, soft vs vol/involuntary guarding , distention, tenderness GU: hernias, rashes, lesions Rectal: tone, masses, hemoccult Extremities: edema, rashes, lesions Neuro: Mental status, CN II-XII, gross motor, gross sensory, DTRs Labs: Most likely Ua, CBC, Chem 7, +/- coags (PT, PTT), +/- Type & cross CXR: Depends on age and risk factors. EKG: Depends on age and risk factors Assessment: Be brief, i.e. 67 year-old di abetic male with right inguinal hernia. Plan: Be brief, include additional labs, FEN (fluids, electrolytes, electrolytes, nutrition), status of operation (date and time if known), antibiotics if indicated, consent. Admission Orders (Post-op) Admit to: Ward #, team, attending, Resident, Intern, Med Student. Include pager numbers. Diagnosis: S/P (status post ) procedure __________ Condition: stable, fair, critical Vitals: Vitals Vital s q 1/2/4/6 h. Also include neuro checks, O2 sats, etc. if needed. Activity: OOB(out of bed) ad lib/with assistance, BR with BRP (Bed rest with bathroom privileges), Strict BR, ambulate with assistance TID, etc. Allergies: Specific or NKDA (no known drug allergies) Nursing: -Daily wts, I & Os (ins and outs) -DVT prophylaxis: prophylaxis: Teds/ pneumoboots pneumoboots -incentive spirometer 10 puffs q 1h while awake -wound care -Drains/tubes (Deleted drain i nformation) -Accucheck q__h if diabetic
Diet: IVF: Meds:
Labs: Extra:
NPO, clears, full liquids, advance as tolerated, diabetic, cardiac, etc. rd LR , NS, or D5 ½ NS @ ____cc/h (use LR and NS for fluid loss and 3 spacing typically for 24h post-op. Use D5 ½ NS +/-KCl for maintenance fluid) -Preop medications (order all that pt should use in hospital) -Pain: MSO4 (morphine), Percocet, Tylenol 3, PCA (patient controlled analgesia) -Stool softener, particularly if giving narcotics (i.e. docusate sodium) -Antibiotic (if preop/intraop antibiotics need continuing) -Ulcer prophylaxis: ranitidine, cimetidine, lansoprazole, omeprazole -DVT prophylaxis: Enoxaparin or SQ heparin if creatinine >1.5 -Other AM labs (CBC, Chem 7, etc.) -Call HO (house officer) T>38.5, P>100or <50, SBP>160 or <110, DBP> 100 or<50, RR > 30, Urine output <60cc in 2h. -Telemetry, CXR, EKG, etc.
Operative Note The med student can wri te t hi s in t he OR or PACU immedia t ely af te r t he operat ion i s fini shed. You can before surgery.
st ar t t he
not e
Preop Diagnosis: (i.e. Right inguinal hernia) Postop Diagnosis: (i.e. Right inguinal hernia) Procedure: (i.e. Right inguinal herniorrhaphy) Surgeon: (list attending, residents, and med students) Anesthesia: (i.e. general, local, epidural, spinal) IVF: List amount and type of fluids administered during operation. Check with anesthesia for this. EBL: (estimated blood loss - check with anesthesia) Blood products: list amount and type administered. Urine output: check with anesthesia Drains: indicate placement Specimens: what was sent to pathology? Complications: Clear with attending before writing a complication . Findings: Pathology encountered, structural abnormalities Disposition: To PACU in stable condition, To ICU/SICU in critical condition. Postop Note The post op not e i s wri tt en in t he char t wi th in sev eral hour s af te r t he pat ient arri ve s on t he floor. It should be in t he SOAP not e format and should incl ude t he following: Heading: Postop Note - Service (i.e. Blue surgery) - your rank (i.e.MS3) Subjective: Comment on the patients activity and symptoms: Pain control, ambulation, flatus, bowel movement, urination, diet, breathing. Objective: Vitals: current temp (Tc), BP range, HR, RR, +/- O 2 sats I/Os (ins and outs): Record total input and total output since surgery y y
Physical exam: Be brief. All patients need Resp, cardiac, abdominal, extremities (i.e. edema, rash), neuro (global mental status, i.e. awake, alert, and cooperative), condition of wound (i.e. dressed and dry, erythematous, drainage, tenderness), and other info pertinent to this surg ery. Labs: Postop Hgb A/P: Post-op check S/P _____ Briefly comment on how the patient is doing. The plan should be brief and should be reflective of postop orders. y
y
Pre-Rounds, Rounds, and the Progress Note One of the main tasks of the medical student is to pre-round on ones assigned patients and chart the daily progress note. Check with your resident regarding what time you should arrive, usually between 5:30-6:30am, however it may be earlier. It is best to have this note completed before your senior resident arrives to round. Progress Note - Service (i.e. blue surgery) - your title (i.e. MS3) Heading: Hospital day # __, Post op day # ___, S/P _____ (procedure)
Subjective: Comment on the patients activity and symptoms: Pain control, ambulation, flatus, bowel movement, appetite, diet, breathing. Objective: Vitals: Maximum temp (Tmax), current temp (Tc), BP range, HR, RR, O2 sats, weight. I/Os (ins and outs): Record total input and total output for 24h and for last shift. Include po, IV fluids rate and type, urine output, stool output, emesis, drains, and NG output. Meds: List all meds. Include dosage for pain meds, antibiotics, and those meds which pertain to this surgery. Physical exam: Be brief. All patients need Resp, cardiac, abdominal, extremities (i.e. edema, rash), neuro (global mental status, i.e. awake, alert, and cooperative), condition of wound (i.e. dressed and dry, erythematous, drainage, tenderness), and other info pertinent to this surgery. Labs: results, labs pending Assessment/Plan: Be brief. Begin your assessment with patients age, post op day # ___, S/P ____ (procedure). State general condition, any significant improvements or concerns since last note. The plan can be bullet points. You may want to include pain control, activity, FEN, wound care, foley/drains, prophylaxis (DVT, ulcer) and disposition. Surgery plans are very straight forward, just ask yourself, why is the pt still in the hospital? ie IV medications, pain control, bowel has not returned to function, surgical complication, placement after d/c ectand address this in your plan. y y
y
y
y
y
y y y y
Postop Fever Etiology The 5 Ws Wind: Atelectasis POD #1-2 (Although this is in the textbooks, recent studies show no association between atelectasis and fever), pneumonia Water: UTI (POD #3-5) Wound: Infection (POD #4-7) Walking: DVT, Pulmonary embolus (POD #5-10) Wonder drugs: drug reaction
y
Fluids and Electrolytes rd
rd
Blood loss and 3 spacing: 3 spacing is fluid accumulation in tissue interstitium and in the bowel lumen, typically occurring for 24-48 h following surgery. Replace with isotonic solution (NS or LR). Typically resolves on day 3 when this fluid shifts back into the intravascular space, at which time overhydration can be a problem (particularly in heart failure pts). Diuresis typically occurs with this fluid shift on post-op day 3. Maintenance fluid and electrolytes: Daily fluid losses: Urine=12001500 ml sweat=200400ml resp=500ml
Daily Electrolytes: + K = 1-2 meq/kg + Na = 2-3 meq/kg Cl = 1-2 meq/kg
LR 4
Solutions (meq/L) NS ½ NS 0
0
130 154 77 110 154 77
feces=100ml
Daily fluid/electrolyte Hourly fluid replacement: replacement: st 1 10 kg: 100cc/kg/day 4cc/kg/hr nd 2 10 kg: 50cc/kg/day 2cc/kg/hr Each kg>20 20cc/kg/day 1cc/kg/hr e.g. 70 kg man 2500cc/day* 110cc/hr* * Given as D5W ½ NS + 20meqKCl/L = 193 meq Na and 50 meq K. + Never add K to a patient whos renal function is questionable.
General Surgery Admission / Post-Op Orders Admit: Admit to Observation Services Admit to Inpatient Discontinue all preoperative orders including medications Location: ICU Med/Surg Med/Surg w /Tel OB Other____________________ Return to room per PACU protocol Diagnosis /Procedure Preformed: _____________________________________________________ Attending Physician: _____________________ Consulting Physician:_________________________ Vital Signs : Every 4 hours PACU routine, then every 4 hours Strict Intake and Output every 4 hours for 24 hours, then every shift Other: ___________________________________________________________________________ Call Physician if: Temperature 100.4 degrees F or greater times 2 taken 4 hours apart or 101.5 degrees F or greater one time; sustained pulse of greater than 110 or le ss than 50 for more than 10 minutes; respiration greater than 25 or less than 8; sustained blood pressure gre ater than 160 SBP or 90 DBP on 2 occasions taken 30 minutes apart; or SBP less than 90 or DBP less than 50 Allergies: No Known Drug Allergies Latex _______________________________________________ Activity: Out of bed in the AM out of bed ad lib / as tolerated Other_________________________ At least out of bed to halls 3 times a day and to chair 2 times a day Diet: Strict NPO Strict NPO after midnight NPO except ice chips Clear liquid Full liquids Regular diet (1800 calorie AHA 1800 calorie ADA 1800 Calorie Renal) Soft mechanical ADAT to Regular 1800 calorie AHA 1800 calorie ADA 1800 calorie Renal diet Other: ___________________________________________________________________________ Physicians Initials: ______ Date:_________________ Page 2 of 5
IV Fluids: NS NS D5NS D5 NS D5LR LR Saline lock ADD 10 mEq KCL/ liter IVF 20 mEq KCL/ liter IVF Other_________________ IVF rate @ ___________________________ml/HR HLIV when tolerating good oral intake Nursing: Foley Catheter: To gravity drainage Notify physician if urine output is less than 120 ml in 4 hours, less than 250 ml in 8 hours, or less than 30 ml per hour times 2 hours Discontinue Foley in AM, replace Foley if unable to void within 6 hours In/out catheterization every 4 hours PRN if patient is unable to void NG tube low intermittent wall suction Incentive spirometry: every 30 minutes while awake with RT to demonstrate. Encourage cough and deep breathing Oxygen O2 @ 2 liters per nasal canula Other________________ Wean O2 per protocol Dressing/Wound Care: ________________________________________________________________ ________________________________________________________________ Drains: _____________________________________________________________________________ Medications: See Medication Reconciliation Form for all meds Antibiotics: No Post-Op Antibiotics required Post- Op Antibiotics: Physician to choose any one for patients without Beta-lactam allergy not allergic to Penicillin or Cephalosporins Ancef (Cefazolin) 1 gm (2 gm if patient weight is 80 kg or greater) IV every 8 hours for 24 hours. Give first post-op dose in the PACU , second and third doses to be scheduled every 8 hours from the first post-op start time; AND Flagyl (Metronidazole) 500 mg IV every 8 hours for 24 hours. Post Op doses to be scheduled from the pre-op dose start time Mefoxin (Cefoxitin) 1 gm (2 gm if patient weight is 80 kg or greater) IV every 8 hours for 24 hours. Give the first dose in the PACU, second and third doses to be scheduled every 8 hours form the first post-op dose Zosyn (Piperacillin/tazobactam) 3.375 gm IV every 6 hours for 24 hours. Post-Op doses scheduled from pre - op start time Vancomycin 1 gm IV every 12 hours for 24 hours. Post-Op doses scheduled from pre-op start time
Post-Op Antibiotics: Physician to choose any one fo r patients
ith Beta-lactam allergy
w
allergic to Penicillin or Cepholosporins Cleocin (Clindamycin) 600 mg (900 mg if patient weight is 80 kg or greater) IV every 8 hours for 24 hours. Post-op doses to be scheduled from the pre-op dose start time; AND
Gentamicin 80 mg (120 mg if patient weight is 80 kg or greater) IV every 12 hours for 24 hours. Post-Op doses to be scheduled from pre-op dose start time Cleocin (Clindamycin) 600 mg ( 900 mg if patient weight is 80 kg or greater ) IV every 8 hours for 24 hours. Post Op doses to be scheduled from the pre-op dose start time; AND Levaquin (Levofloxacin) 500 mg IV times 1 dose to be scheduled 24 hours from the pre-op start time Flagyl (Metronidazole) 500 mg IV every 8 hours for 24 hours. Post-Op doses to be scheduled from the pre-op dose start time; AND Levaquin (Levofloxacin) 500 mg IV times 1 dose to be scheduled 24 hours from the pre-op dose start time Other : _______________________________________________________________ Continuous Antibiotics: Zosyn (Piperacillin/tazobactam) 3.375 gm IV every 6 hours Levaquin (Levoflaxacin) 500 mg IV every day Cipro (Ciprofloxacin) 400 mg IV every 12 hours Flagyl (Metronidazole) 500 mg IV every 8 hours Primaxin (Imipenem/cilastatin) 500 mg IV every 6 hours Invanz (Ertapenem) 1 mg IV every day Vancomycin 1 gm IV every 12 hours Other ________________________________________________________________ DVT Prophylaxis: Pneumatic Compression Devices and TED hose on patient until ambulating independently. These should be placed immediately upon arrival to unit if not already in place Pharmacological prophylaxis for DVT not recommended due to excessive intra-operative bleeding or high risk of bleeding be st ar te d If pharmacological prophylaxi s not cont raindicat ed choose one of t he following( to in 24 hour s of surgery t ime if st ar te d post-operat i ve ly): wi th Lovenox (Enoxaparin) 40 mg SubQ daily (If creatinine clearance less than 30ml/min, give enoxaparin 30 mg SubQ daily) Arixtra (Fondaparinux) 2.5 mg SubQ Daily Heparin 5000 Units SubQ every 8 hours Stress Ulcer Prophylaxis: Not indicated Prilosec (Omeprazole) 40 mg PO daily OR Nexium (Esomeprazole) 40 mg IV daily Protonix (Pantoprazole) 40 mg PO OR IV daily Famotidine (Pepcid) 20 mg twice daily PO OR IV (If creatinine clearance less than 50ml/min, give famotidine daily) Physicians Initials: ______ Date:_________________ Page 4 of 5
Comfort Medications: Nausea: Reglan (Metoclopramide) 10 mg IV every 4 hours PRN nausea Zofran (Ondansetron) 4 mg IV every 6 hours PRN for breakthrough nausea or vomiting Phenergan (Promethazine) 6.25 mg IV every 6 hours PRN severe nausea or vomiting Pain: Toradol (Ketorolac) 30 mg IV initial dose, then 30 mg IV every 6 hours PRN pain times 48 hours or as anti-inflammatory or as adjunct to pain medication (no other nonsteroidal anti-inflammatories while Toradol order in effect) Morphine: _____________________________________________________________ Dilaudid: ______________________________________________________________ Norco (Hydrocodone/acetaminophen 325 mg) 5mg 7.5 mg 10 mg 1-2 tabs PO every 4 hours PRN pain Ibuprofen: _____________________________________________________________ Tylenol (Acetaminophen):_________________________________________________ Other: ________________________________________________________________ Other: Tylenol (Acetaminophen) 650 mg PO every 4 hours PRN headache or temp > 101.1 F Maalox Plus (Aluminum/ Magnesium/Simethicone) 30 ml PO every 4 hours PRN indigestion/gas Aluminum Hydroxide 30 ml PO every 4 hours PRN indigestion ( for Renal patients) MOM (Milk of Magnesia) 30 ml PO every 6 hours PRN for constipation Surfak (Docusate Calcium) 240 ml PO daily PRN constipation as stool softener Dulcolax (Bisacodyl) 10 mg PO BID PRN constipation. If unable to take PO, give suppository PR Metamucil (Psyllium) 1 package PO BID PRN constipation, as fiber supplement
mg OR 10 mg PO at bedtime PRN insomnia Restoril (Temazepam) 15 mg PO at bedtime PRN insomnia If 65 or over use 7.5 mg PO at bedtime and repeat 1 time if needed Benadryl (Diphenhydramine) 25 mg PO every 6 hours PRN itching/rash. If unable to take PO, may give IV Ambien (Zolpidem) 5
Robitussin DM (Guaifensin/Dextromethorphan) 10 ml PO every 4 hours PRN cough/congestion Nicotine patch: Apply daily to skin PRN nicotine withdrawal. Dose: 21 mg 14 mg 7 mg Colace (Docusate sodium) 100 mg PO BID Other
: _______________________________________________________________ Other Medications : Cardiac Meds: __________________________________________________________________ ________________________________________________________________________ Diabetic Meds: __________________________________________________________________ ________________________________________________________________________
Lab/Diagnostic : None In AM (Date:______) Post-op (PACU Upon arrival to floor) Admission (ASAP) BMP CMP CBC Renal Panel Amylase/Lipase PTT/TNR Chest X-Ray pKUB Acute abdominal series CT Scan : _____________ Other: ____________________________________________________________________________ Evaluate and Treat: N/A Physical Therapy Occupational Therapy Speech Therapy Wound Care Nurse Nutrition Case Manager / SW to start discharge planning Social Services SNF Evaluation
