Adult Pre-Operative Eye Surgery
Orders preceded by a checked box (☑) are in effect unless crossed out. Orders preceded by a box (☐), require a check (✓) to initiate.
Orders with blanks indicate additional information is needed.
Date:
Time:
Allergies:
Admitting Diagnosis:
ADMIT BED TYPE:
Inpatient
Observation
Outpatient
Patient Name:
Date of Birth:
Nursing Orders
Oval eye patches #10, and 1 inch micropore tape at bedside
Medications
flurbiprofen 0.03% (aka OCUFEN) ophthalmic solution 1 drop
Right
Left
eye every 15 minutes times
moxifloxacin 0.5% (aka VIGAMOX) ophthalmic solution 1 drop
Right
Left
eye 1 hour pre-op
tobramycin-dexamethasone (aka TOBRADEX) ophthalmic solution 1 drop
Right
Left
eye 1 hour pre-op
scopolamine 0.25% (aka ISOPTO HYOSCINE) ophthalmic solution 1 drop
Right
Left
eye every 5 minutes times
cyclopentolate 1% (aka CYCLOGYL) ophthalmic solution 1 drop
Right
Left
eye every 5 minutes times
phenylephrine 2.5% (aka NEO-SYNEPHRINE) ophthalmic solution 1 drop
Right
Left
eye every 5 minutes times
tetracaine 0.5% (aka OPTICAINE) ophthalmic solution 1 drop
Right
Left
eye every
minutes times
atropine 1.0% ophthalmic solution 1 drop
Right
Left
eye every
minutes times
tobramycin 0.3% (aka TOBREX) ophthalmic solution 1 drop
Right
Left
eye every
minutes times
Other:
Right
Left
eye every
minutes times
Notes
Please Initial:
Noted
Order entry
First RN
Date / Time
Date / Time
Date / Time
Second RN
Date / Time
PATIENT LABEL
(VALID ONLY WHEN SIGNED BY PHYSICIAN)
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