A UMC Health System Performance Improvement Initiative for use in all units where cardiac/surgical patients are admitted.

Transcription

1 A UMC Health System Performance Improvement Initiative for use in all units where cardiac/surgical patients are admitted Denotes guideline requirement Attending Physician: Resident/Fellow: Allergies_ Diagnosis: Co-Morbidities: Code Status: Full Code DNR Comfort Care Other Consult: Height: Weight: _ Pre-Operative Orders: 1. Schedule and obtain consent for: 2. Old Chart to floor 3. NPO Past midnight, except for medications with a sip of water After a clear liquid breakfast 3. Patient teaching to include instructional video 4. Clip from chin to navel. (If a change-out prep groin for possible temporary pacemaker insertion) 5. Hibiclens scrub prepped area including neck, navel, and axillas 6. IV Fluids: Dextrose 5% / 0.45% Sodium Chloride at 50 ml/hour to 20 gauge in left arm. Start at_ 7. Labs: CBC, CMP, and PT (Check to see if labs are available from office for outpatients) Pregnancy test if premenopausal woman 8. EKG on floor 9. On Call to Cath Lab: a. Have patient void b. Nasal Bactroban swab to bilateral nares c. Antibiotics: Ancef 1 gram IVPB on call to Cath Lab d. Vancomycin 1 gram IVPB on call to Cath Lab if allergic to other antibiotics (Penicillin or Cephalosporin) 10. Additional Orders Page 1 of 5- Implantable Device Plan

2 Peri-Operative Orders: 1. Place cap on patient s head to cover hair 2. Prep and drape patient per policy and procedure 3. Ancef 1 gram to back table 4. Additional Orders Post-Operative Orders: Admit to: Inpatient CICU Outpatient 1. Vital Signs every 15 minutes x 4, then every 30 minutes x 4, then QID 2. Portable CXR 4 hours Immediate, post procedure on floor upon arrival to room Reason: Post PPM insertion to rule out pneumothorax. Notify MD if pneumothorax present. 3. PA and Lateral CXR in the AM. Reason: rule out delayed pneumothorax and lead positioning Lead EKG in AM 5. Bedrest for hours or until AM, then activity as tolerated 6. Sling to arm. Do Not Bind 7. Instruct patient not to raise elbow on implant side above shoulder level for 4 weeks 8. Diet: Clear Liquids Advance as Tolerated Full Liquids Mechanical Soft Regular Renal AHA ADA Other 9. Convert IV to INT once diet is tolerated 10. Medications: (See Admission Medication Reconciliation Form & Discomfort orders) a. Antibiotic: Ancef gram IVPB hours from initial does. Give at b. Vancomycin IVPB in AM 11. Keep site dry. Do not shower, Sponge bath only 12. Keep dressing in place for 2 days (DO NOT REMOVE STERI-Strips). Do not touch incision NOTIFY PHYSICIAN FOR HEMATOMA DEVELOPMENT OR FOR NEEDED DRESSING CHANGE 13. Provide printed post implant instructions to the patient. Review these instructions with the patient and document 14. HUC, call physician s office to make appointment for wound care in days. Phone #:_ 15. NO LOVENOX OR HEPARIN UNTIL FURTHER ORDERED Page 2 of 5- Implantable Device Plan

3 GENERATOR CHANGE OUTS 1. No 12 Lead EKG.s are needed 2. No CXR s are needed 3. No need to bind arm or use sling 4. Vital Signs every 15 minutes x 4, then every 30 minutes x 2, then x 2 before discharge 5. Bedrest x 2 hours post sedation 6. Diet: : Clear Liquids Advance as Tolerated Full Liquids Mechanical Soft Regular AHA Renal ADA Other 7. Provide printed post implant instructions to the patient. Review these instructions with the patient and document 8. HUC, call physician s office to make appointment for wound care in days. Phone #:_ Additional Orders Page 3 of 5- Implantable Device Plan

4 PATIENT DISCOMFORT MEDICATION PLAN Indicate desired medications by checking appropriate box. If more than one box is checked for an indication, then use the ordered medications in the descending order. PAIN MANAGEMENT: (TARGET MAXIMUM OF 3000 MG OF ACETAMINOPHEN PER 24 HOURS FROM ALL SOURCES) (DO NOT EXCEED 4000MG OF ACETAMINOPHEN PER 24 HOURS) MILD PAIN (Pain Scale 1-3): Acetaminophen (Tylenol) mg PO every 4 hours PRN mild pain (Do not exceed 4,000 mg in 24 hours), if NPO use: Acetaminophen (Tylenol) 650 mg suppository PR every 4 hours PRN mild pain (Do not exceed 4,000 mg in 24 hours), if acetaminophen is ineffective/contraindicated use: Ibuprofen (Motrin) 400 mg PO every 6 hours PRN mild pain (Do not exceed 3,200 mg in 24 hours) MODERATE PAIN (Pain Scale 4-7): Hydrocodone/acetaminophen (Lortab) 5/500 mg 1 2 tabs PO every 4 hours PRN moderate pain (Do not exceed 4 grams of acetaminophen in 24 hours), if ineffective/contraindicated or NPO use: Ketorolac (Toradol) mg IV every 6 hours PRN moderate pain x 48 hours (May give IM if no IV access) Other SEVERE PAIN (Pain Scale 8-10): Morphine 2 4 mg slow IV push every 4 hours PRN severe pain, if ineffective/contraindicated use: Hydromorphone (Dilaudid) 1 mg slow IV push every 4 hours PRN severe pain NAUSEA/VOMITING: Promethazine (Phenergan) 25 mg PO every 4 hours PRN nausea/vomiting, if ineffective/contraindicated or NPO use: Ondansetron (Zofran) 4 mg IV every 8 hours PRN nausea/vomiting BOWEL MANAGEMENT: Docusate (Colace) 100 mg PO at bedtime PRN for constipation, if contraindicated or ineffective after 12 hours use: Bisacodyl (Dulcolax) 10 mg suppository PR daily PRN constipation, if contraindicated or ineffective after 6 hours use: Sodium phosphate enema (Fleet enema) PR daily PRN constipation (Do not use in renal patients) INDIGESTION/GAS: DIARRHEA: Aluminum hydroxide/magnesium hydroxide (Maalox) 30 ml PO every 4 hours PRN indigestion Simethicone (Mylicon) mg PO every 4 hours PRN gas/bloating Loperamide (Imodium) 4 mg PO initially then 2 mg PO with each loose stool (Max 16 mg hours) Indicate desired medications by checking appropriate box. If more than one box is checked for an indication, then use the ordered medications in the descending order. Page 4 of 5- Implantable Device Plan

5 ANXIETY: Alprazolam (Xanax) 0.25 mg PO three times a day PRN anxiety, if ineffective/contraindicated or NPO use: Lorazepam (Ativan) mg IV every 6 hours PRN anxiety SLEEPLESSNESS: Zolpidem (Ambien) 5 mg PO at bedtime PRN sleeplessness, may repeat x 1 in one hour if ineffective ALLERGIC REACTIONS: Diphenhydramine (Benadryl) 25 mg PO every 4 hours PRN itching, if ineffective or NPO use: Diphenhydramine (Benadryl) 25 mg IV every 4 hours PRN itching COUGH / SORE THROAT: Phenol-menthol (Cepastat) 1 lozenge PO PRN sore throat (Do not exceed 6 lozenges in 24 hours) Guaifenesin/dextromethorphan (Robitussin DM) 10 ml PO every 4 hours PRN cough TEMPERATURE: Acetaminophen (Tylenol) mg PO every 4 hours PRN fever (Do not exceed 4,000 mg in 24 hours), if ineffective/contraindicated use: Ibuprofen (Motrin) mg PO every 4 hours PRN fever (Do not exceed 3,200 mg in 24 hours) HEMORRHOIDS: MUCOSITIS: Witch hazel/glycerin (Tucks) pads at bedside wipe affected area as PRN, if ineffective use: Mineral oil/petrolatum/phenylephrine (Preparation H) ointment apply to affected area every 6 hours PRN. If ineffective/contraindicated use: Pramoxine/hydrocortisone (Proctofoam HC) at bedside apply to affected area every 8 hours PRN Dexamethasone/diphenhydramine/nystatin/NS (Fred s Brew) 15 ml swish and spit every 2 hours while awake PRN mucositis. If ineffective/contraindicated use: Viscous lidocaine (Xylocaine) 15 ml swish and spit every 4 hours PRN mucositis BLADDER SCAN: Bladder scan as needed for patients complaining of urinary discomfort and/or bladder distention present OR 6 hours post- Foley removal and patient has not voided. If bladder scan volume is >250 ml please notify the physician. OTHER: Page 5 of 5- Implantable Device Plan