PERCUTANEOUS CECOSTOMY INSERTION
- Pre-Procedure Doctors Orders -
                    
HOSPITAL NO.
___________________		 NURSING UNIT
___________________		 REGISTRATION NO.
___________________
                  
PATIENT NAME (LAST)
___________________		 (FIRST)
___________________		 SEX
___________________
             
BIRTH DATE
[ yyyy | mm | dd ]		 ADMIT DATE
[ yyyy | mm | dd ]		 REFERRING DOCTOR
___________________
              
ALLERGIES
___________________
___________________
___________________
___________________
___________________		 SYMPTOMS OF ALLERGIES
___________________
___________________
___________________
___________________
___________________		        
Date of wt. ___________________

Patients wt. _________________kg

Signature ___________________
ALL MEDICATION ORDERS ARE PROCESSED IN ACCORDANCE WITH APPROVED HOSPITAL POLICIES-SEE FORMULARY FOR DETAILS
PRE-PROCEDURAL ORDERS FOR PERCUTANEOUS CECOSTOMY
  1. Ensure patient has received only clear fluids for 2 days prior to procedure
    (no solids after admssion)
          
  2. Night before procedure:
    Administer oral Fleet® Phospho® Soda solution ______________ ml.
              
  3. Day of procedure:
    Start maintenance IV and infuse 2/3-1/3 (3.3% Dextrose + 0.3% NACL)
    with 20mmol KCl/L at  _____________  mL/hr.
            <10kg:                    4mL/kg/hr
            10kg to 20kg:         40mL/hr plus 2mL/kg/hr
            >20kg:                   60mL/hr plus 1mL/kg/hr
              
  4. Obtain flat plate of abdomen on admission to assess bowel status and show the Interventional Radiologist.
           
  5. Repeat oral Fleet® Phospho® Soda solution if necessary.
            
  6. NPO @ ___________________ (3 hours prior to procedure).
              
  7. EMLA® cream to right lower quadrant of abdomen 2 hours prior to procedure.
              
  8. Acetaminophen (per rectum) ______________ mg (15mg/kg) 1 hour prior to procedure.
                
  9. On call to Interventional Radiology (just prior to procedure):
    Administer Gentamicin IV ______________ mg (2.5mg/kg) as a single dose.
    Metronidazole IV ______________ mg (10mg/kg) as a single dose.
    Ampicillin IV ______________ mg (20mg/kg) as a single dose.
________________  
Date		 ________________
Time		 ______________________MD
Signature
______________________
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