PHYSICIAN PRE AND POST PROCEDURE ORDERS

Date: _______________                                                                                                                                  Time:________________________

Pre-Op Orders:                       ___ 1.  Consent for procedure: _____________________________________________________

                                                      ___ 2.  NPO for six (6) hours prior to procedure

                                                      ___3.  Start IV 1000cc of N.S., KVO rate.

Intra-Procedure Medications: Give IV Push per Order:

                                                      Versed____________________mg IVP

                                                      Robinul___________________mg IVP

                                                      Ketamine _________________mg IVP

                                                      Phenergan ________________mg IVP

                                                      Other:____________________mg IVP

Post-Op Orders:                      ___ 1.  BP-P-R-O2 q15 min x 4

                                                      ___ 2.  O2 at 2L/minute via nasal nannula for sat less than 90%

                                                      ___ 3.  May give Romazicon .2mg IV for repirations less than 12 per minute and/or

                                                       Sat less than 90% on 2L of O2 if patient has received Versed.  Notify physician

                                                       of patient condition.

                                                      ___ 4.  Diet: as tolerated

                                                      ___ 5.  Discharge with instructions and designated driver when following discharge

                                                                  Criteria met:

                                                                              Alert and oriented or return to pre-op baseline

                                                                              V.S. returned to pre-op baseline or within 20% of pre-op

                                                                              Tolerating p.o. fluids

                                                                              Skin warm and dry/or return to pre-op baseline

                                                                              No active bleeding

                                                                              No complaint of acute pain

                                                                              Gait steady/or return to pre-op baseline

                                                                              Patients that have L.S.B. on SGB, report any new numbness or

                                                                              Weaknesses to M.D. prior to discharge

Additional Orders: ________________________________________________________________________________________

_________________________________________________________________________________________________________

_______________________________________                                                                ______________________

Physician Signature                                                                                                                                                               Date