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Embed code for: PNB orders 2016
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PHYSICIAN NOTE: Place an "X" in any box for orders you wish to be initiated. Unchecked boxes will not be initiated. All bulleted orders will be initiated unless a line is clearly drawn through that order.
1. ALLERGIES: ___________________________
2. MEDICATIONS: Weight ___________ lbs ______________ kg
3. ANESTHESIA TEAMS: ☐ GSAA: 361-360-1960 ☐ EMCARE: 361-224-0761
□ Lumbar Plexus
□ TAP block
□ Adductor Canal
□ Other: _______
□ Sciatic / Popliteal
□ Fascia Iliaca
Patient has a ☐ Bilateral ☐ Left ☐ Right
□ Single control
____ ml / hr
□ Dual control
____ ml / hr
ON-Q PUMP Pain Ball with Select-A-Flow:
□ 0.1 %Ropivacaine (Naropin)
□ 400 mL filled to 550 mL
□ 600 mL filled to 750 mL
□ 0.15 % Ropivacaine (Naropin)
□ 0.2 % Ropivacaine (Naropin)
Available premixed solutions:
See physician's orders for additional pain medications. For EMCARE Anesthesia group, call on-call provider for any additional pain medications.
4. Special Precautions:
a. Patients with peripheral nerve blocks of the lower extremity will experience significant leg weakness.
DO NOT ALLOW PATIENT TO STAND WITHOUT ASSISTANCE.
b. For patients with a paravertebral block, notify on-call teams for any arm or leg weakness, breathing difficulty or change in level of consciousness.
c. No MRI procedures while catheter is in place.
Observe patient for signs/symptoms of local anesthetic toxicity:
metal taste in mouth
ringing in ears
If above toxicity signs/symptoms turn off infusion immediately and call the on-call teams above.
For questions or problems with blocks, please call anesthesia teams above.
If no response, call Operating Room (361-881-3651) or House Supervisor for on-call Anesthesiologist.
Date: ________________ Time: ____________ Prescriber Signature: _________________________________
Date: ________________ Time: ____________ Noted by: __________________________________________
Barcode CHRISTUS SPOHN HEALTH SYSTEM
Perioperative: Peripheral Nerve Block Orders
OROS028 (2786621) Place patient label here