IF YOU RECEIVED THIS FACSIMILE IN ERROR, PLEASE CALL 604-244-5114 IMMEDIATELY

Ensure that this PPO is completed and

signed by the Most Responsible
GASTROSTOMY or GASTROJEJUNOSTOMY Physician (MRP) after a gastrostomy
PCIS LABEL
INTERVENTIONAL RADIOLOGY
tube is inserted. If not, contact the
POST-PROCEDURE ORDERS (Regional)
MRP as soon as possible.
(items with check boxes must be selected to be ordered)
Nurses
Initials

CATHETER INSERTED AND SIZE:

INTRA-PROCEDURE ORDERS GIVEN UNDER PHYSICIAN DIRECTION:

lorazepam 1 mg sublingual x 1 dose PRN
midazolam 0.5 to 2 mg IV PRN

(refer to Procedural Sedation and Analgesia (PSA) General (CPD-400))

fentanyl 25 to 50 mcg IV PRN

(refer to Procedural Sedation and Analgesia (PSA) General (CPD-400))

dimenhyDRINATE 25 to 50 mg IV PRN nausea (maximum 50 mg)

Other: _________________________________________________________________________________________
POST PROCEDURE ORDERS
DIET:

ACTIVITY:

NPO except for sips of water with medications on the day of procedure (PO
throughor
NG/Corpak)
If a or
Corpak
NG tube is in
place, it is not to be used
Do not use NG/ Corpak tube (if present) for feeding
after a gastrostomy tube has
Resume previous PO diet order at 0800 hours day after procedure
been inserted.
Bed rest with bathroom privileges x ___6___ hours, then activity as tolerated

CONSULTS:

Dietitian to see patient and assess for tube feeding recommendations

MONITORING: Vital signs Q30 MIN x 2 hours then Q1H

x 4 time for the skin to heal around the tube. To
It takes
promote
wound healing and proper closure, to prevent any
TREATMENTS:
leakage, and to keep the stomach flush to the abdomen, the
Remove NG/ Corpak tube at ______________________________________________________________________
suture(s) need(s) to be cut as close to the skin as possible.
May start using G/GJ feeding tube at __________ hours
_____________(date)
(if nothe
peritoneal
signs (e.g.
Ensure
that this order and
date range
are including,
written on the
but not limited to:abdominal pain, tenderness, guarding)
kardex by the unit clerk or most responsible nurse
Irrigation orders:
None
Flush tube with _____ mL warm water every ____ hours and before and after medications
Flush tube with 30 mL warm water every 4 hours and before and after medications
Assess need for restraints (as per restraint CPD and ensure consistent monitoring and
documentation) PRN x 7 days to prevent catheter dislodgement
IV hydration: ___________________________________________________________________
WOUND CARE: Change outer gauze dressing after 24 hours, then change daily and PRN
Cut suture as close as possible to the skin entry site between day 10 to14 post procedure
OTHER: ______________________________________________________________________________________
DISCHARGE:

Arrange routine tube change at _________ months after the procedure

If from another facility, the patient may be transferred to ________ at ________ hours today

CONTACT PERSON / NUMBER FOR PROBLEMS/QUESTIONS: _________________________________________

________________ _______________________________ ____________________________ _______ __________
Date
Printed Name
Signature
College ID
VCH.RD.RH.0350 | DEC.2014

CHART COPY

Page 1 of 2

IF YOU RECEIVED THIS FACSIMILE IN ERROR, PLEASE CALL 604-244-5114 IMMEDIATELY

Ensure that this PPO is completed and

signed by the Most Responsible
GASTROSTOMY or GASTROJEJUNOSTOMY Physician (MRP) after a gastrostomy
PCIS LABEL
INTERVENTIONAL RADIOLOGY
tube is inserted. If not, contact the
POST-PROCEDURE ORDERS (Regional)
MRP as soon as possible.
(items with check boxes must be selected to be ordered)

VCH.RD.RH.0350 | DEC.2014

CHART COPY

Page 2 of 2