Also, remember to help write post op notes after a procedure, when a patient goes to the floor, check on them before afternoon rounds if possible and write a short post op check, which is similar to a SOAP note.
Remember to write down the foley output and drain output, how is pain control, nausea, etc. Neurovascular status is numero uno.
Admit to blank s/p blank procedure pod#0
Diagnosis
Condidtion:stable-guarded-ICU if critical
Vitals q routine
Activity: Non weight bearing LLE
Allergies: Penicillin (rash or hives)
Nursing: Elevate LLE from two pillows; (Abduction brace for THA, CPM for TKR,) Drains to suction or gravity, TED/SCD, call H.O. for Temp, BP, etc.
Diet: NPO--sips--clears--
IV: D51/2 normal at 100cc/hr
Meds: PCA see form o continuous, 2mg IV q 10 min 12 mg maximum 10 minute lockout (depends whats needed as most of these orders)
Tylenol 650 mg po prn if temp greater than 100.5
benadryl 25 mg po prn itching, insomnia
droperidol .625 mg iv q6 n/v
see antibiotic order form
Labs: PT/Ptt.inr q am, CBC, chem 10
Postoperatively, if the patient has had a major procedure, they will preferably be placed on a PCA for pain control. They will also have a foley catheter in. When you are an intern, you have to remember to write the order to have the foley taken out on post operative day 1, so, for example, when you have a total joint, the patient wont seed his artificial joint with bacteria from urosepsis. The PCA will come off on day number 2 sually and the dressing will be changed, a good thing to do is to have 2 inch paper tape and make a long, clean dressing and hang it from the trapeze in the patients room so it is ready on rounds. Four by fours can go directly on skin but not ABDs. Have plenty of four bys and abds with you. If a patient is having problems with pain, remember you can just switch the PCA from morphine to dilaudid and this will sometimes help the patient. .2 dilaudid=1mg of morphine.
As far as anticoagulation, you will never make written orders until told. Most attendings have a protocol.Some attendings like sub q heparin after a procedure or lovenox. Lovenox can really make a wound ooze, so make sure you inspect the dressing but do not remove it on day 1 unless told. If you are using coumadin, you will usually start with 0 on postop day 0 and then 10 on post op day 1, you need to watch the INR and if you always know how much the patient has had ad what the INR is you will be helping out. Physical therapy is routinely consulted , but you need to know what the weight bearing status is of the patient. NWB, nonweight bearing, TDWB, touch down, Parital ,and full weight bearing anre terms often used. Stipulate this in your PT order or they will call you to ask. Find out from the attending , he or she wil let their wishes be known after surgery. There is a device called a CPM which passively ranges a TKR patient after surgery to maintain mobility and reduce stiffnes of the joint. This machine does not always stay on , and you need to watch that. Otherwise, there is also a drain to deal with. If you have 2 Davol drains that are attached to two postoperative knees, and one has put out 55 cc over 24 hours, you will likely pull that drain on day 1, never pull a drainuntil your resident has ok'd it. If you are on call at night, and drain2 was putting out 200 cc, you will likely take the drain off suction, and speak with yor resident about it. once the drains and foley are gone, and the patient can tolerate food, they will no longer need IV antibiotics or fluid. Remember to heplock once the patient is taking good PO intake.
Other postop stuff has to do with nausea and vomiting, what kind of meds to put the patient on when you turn off the PCA (Percocet, vicodin, etc.) Having social work consulted if the patient will need home health care, and setting that stuff up can help a lot. Always have tape, scissors, and some blandk note and order forms folded in your pocket. Also, remember that you need to make sure that the patient has the appropriate TEDs and SCDs depending on the operative side, etc. Carefully ask about breathing trouble and auscultate, there will be patients who get PE's and when this happens, they are going to need a heparin drip IV. If a patient is in shock, they will not be perfusing their extremities and lovenox will do no good you need to keep the patient Type and screened and type and cross for a s many units the chief thinks you wil need. Know the signs of an M.I. and know the postoperative day that M.I. and P.E. usually happen. Remember third spacing, how to work up temps greater than 100.5, have q tips to probe wounds and betadine to paint them if needed. Etc...
