ADULT CARDIAC SURGERY TELEMETRY BED TRANSFER ORDERS 1 of 4

Transcription

1 ADULT CARDIAC SURGERY TELEMETRY BED TRANSFER 1 of 4 9 Actual 9 Estimated Attending Surgeon: Medical Record Number Weight kg 9 Actual 9 Estimated Height cm ALLERGIES: REFER TO ALLERGY PROFILE/ POWERCHART Procedure: Advance Directives Status (supporting documentation in chart): (3) Check, circle and/or fill in all orders to be implemented as appropriate. 1. TELEMETRY: 9 Transfer to telemetry bed 9 Telemetry duration: 9 until post-operative day 4 9 other: 9 Telemetry may be discontinued for ordered tests/transport Cardiac Surgery Algorithm/Decision Tree: New Onset Atrial Fibrillation (DTKH ) 2. VITAL SIGNS: 9 Every 4 hours and notify provider if: systolic blood pressure is less than 90 mmhg or greater than 150 mmhg heart rate less than 50 beats per minute or greater than 120 beats per minute 9 Oxygen saturation every 8 hours 9 Initiate emergency epicardial pacing for symptomatic bradycardia (heart rate less than 50 beats per minute). Notify provider immediately. Refer to Emergency Epicardial Pacing for Symptomatic Bradycardia Protocol 3. DIET: 9 House 9 Cardiac 9 Diabetic: American Diabetic Association 4. ACTIVITY: 9 Out of bed to chair, ambulate with assistance, three s a day. 9 May ambulate off suction 9 Document room air saturation with ambulation post-operative day 3 5. OXYGEN SUPPORT: liters 9 nasal cannula 9 mask 9 Wean oxygen to saturation greater than 9 Incentive spirometry every hour while awake 9 Flutter valve 6. INTRAVENOUS (IV) FLUIDS: 9 Peripheral IV: 9 Intermittent infusion device 9 Triple lumen catheter 9 Peripherally inserted central catheter (PICC) Initials Place STAT barcode sticker within this box only on form copy being scanned

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3 ADULT CARDIAC SURGERY TELEMETRY BED TRANSFER 2 of 4 Medical Record Number (3) Check, circle and/or fill in all orders to be implemented as appropriate. 7. INTAKE AND OUTPUT: 9 Chest tube to 20 cm water suction. Measure drainage every 8 hours. 9 Intake and output every 8 hours. Report urine output less than 200 ml in 8 hours. 9 Daily weights on stand scale. 9 Discontinue indwelling urinary catheter 9 Continue indwelling urinary catheter for: 9 accurate intake and output 9 urinary retention 9 other (reason must be documented): 8. INCISION CARE: 9 Change initial sternal dressing post-operative day 2 then daily until discharge 9 Chlorhexidine 2% wipes daily starting post-operative day 2 9 If able to shower, patient to use chlorhexidine 4% wash to cleanse incisions 9 Provena negative pressure wound therapy 9 Other: 9. LABS: 9 Complete Blood Count, Basic Metabolic Panel, and Magnesium level with next morning labs 9 Glucose fingerstick before meals and at bed 9 Daily Prothrombin Time (PT)/International Normalized Ratio (INR) if patient on Warfarin 10. DIAGNOSTICS: 9 Electrocardiogram (EKG) in morning 9 Chest X-ray in morning (indication): 9 Other Study (indication): 11. CONSULTATIONS: 9 Nutrition 9 Smoking Cessation 9 Physical Therapy evaluation and treatment 9 Other: 12. PATIENT EDUCATION: Review: 9 After Heart Surgery - A Patient Education Booklet 9 Nutrition for Heart Health 13. MEDICATIONS: A. DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS (Risk Assessment on Back) REQUIRED to (3) check all that apply: 9 Heparin 5000 units subcutaneous every 8 hours 9 Enoxaparin 40 mg subcutaneous daily 9 Enoxaparin 30 mg (if Glomerular Filtration Rate is less than 30) subcutaneous daily 9 Pneumatic Compression Device (PCD): Knee High Pump 9 Pneumatic Compression Device (PCD): Foot Pump 9 Other Orders: 9 DVT Prophylaxis not indicated (Reason): 9 DVT Prophylaxis contraindicated (Reason): Initials Place STAT barcode sticker within this box only on form copy being scanned

4 ADULT CARDIAC SURGERY TELEMETRY BED TRANSFER 3 of 4 RISK FACTORS Medical Record Number AGE points IMMOBILITY points SURGERY points greater than 60 years 2 Coma 2 Hip/Pelvic/Long Bone Fracture years 1 Patient confined to bed greater than 72 hours Recent uninterrupted travel greater than 4 hours 2 1 Multiple Trauma 5 Laparoscopic/Pelvic Surgery 2 Major Surgery greater than 45 minute duration 2 PRE-EXISTING/CURRENT MEDICAL CONDITIONS points points Ischemic Stroke/Paralysis 5 Current Heart Failure/ Myocardial Infarction 1 Previous DVT or Pulmonary Embolism (PE) 3 Obesity (greater than 20% Ideal Body Weight [IBW]) 1 Hypercoagulation State* 3 Pregnancy/Postpartum less than 1 month 1 Cancer 2 Severe Dehydration 1 Central Venous Catheter greater than 1 week (excludes Renal Nephrotic syndrome 1 2 Access) Varicose Veins/Vein Surgery/Phlebitis 1 Infection (severe/sepsis) 1 Inflammatory Bowel Disease 1 Chronic Obstructive Pulmonary Disease (COPD)/Respiratory Distress/Steroid or Oxygen Dependent 1 Chemotherapy 1 Estrogen Use (oral contraceptives, hormone replacement therapy [HRT]) 1 Family Medical History unexplained DVT 1 * Examples of Hypercoagulation State: Protein C or S deficiency Antithrombin III deficiency Lupus Anticoagulant Homocysteinemia LOW RISK (Score of 1 or less) No prophylaxis Ambulate MODERATE TO HIGH RISK* (Score of 2-4) Heparin 5000 units subcutaneous every 8 hours -OR- Pneumatic Compression Device (PCD) HIGHEST RISK/MULTI MODAL* (Score of 5 or higher) Heparin 5000 units subcutaneous every 8 hours -AND- Pneumatic Compression Device (PCD) *Recommendations apply to general medical and surgical patients. Please see below for additional recommendations for specific patient populations. ALTERNATIVE RECOMMENDATIONS FOR SPECIFIC PATIENT POPULATIONS Neurosurgery Heparin 5000 units subcutaneous every 8 hours -AND- Pneumatic Compression Device (PCD) DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS RISK ASSESSMENT Orthopaedic Surgery See form KH00202 Total Knee/Hip Arthroplasty Post-Operative Orders Trauma/ Spinal Cord Injury Enoxaparin 30 mg subcutaneous every 12 hours -AND- Pneumatic Compression Device (PCD) Consider platelet monitoring for prolonged anticoagulation Coronary Artery Bypass Surgery Enoxaparin 40 mg subcutaneous daily (Enoxaparin 30mg subcutaneous daily if Creatinine Clearance [CrCl] less than 30 ml/minute) Bariatric Surgery Enoxaparin 40 mg subcutaneous every 12 hours High Risk Bleeding History of (any population with moderate Heparin-induced to high venous Thrombocytopenia thromboembolism [VTE] risk) Pneumatic Compression Device (PCD) Fondaparinux 2.5 mg subcutaneous daily (Contraindicated if Creatinine Clearance [CrCl] less than 30 ml/minute) References: Modified From: Motyke, GD, Zebal, LP and Caprini, et al. A Guide to Venous Thromboembolism Risk Factor Assessment. Journal of Thrombosis and Thrombolysis, Geerts W, Bergqvist D, Pineo G et al. Prevention of Venous Thromboembolism. Chest 2008; 133: 381S-453S

5 ADULT CARDIAC SURGERY TELEMETRY Medical Record Number BED TRANSFER 4 of 4 (3) Check, circle and/or fill in all orders to be implemented as appropriate. B. EXISTING MEDICATIONS: 9 Use the Kaleida Transfer Profile (KTP) form for transfer medication orders (available in Powerchart). See attached KTP form. C. ANTIDIABETIC AGENT: 9 Complete Adult Subcutaneous Insulin Orders (KH01169) D. NEW MEDICATIONS Antiplatelet Medication: 9 Aspirin 81 mg by mouth daily 9 Clopidogrel 75 mg by mouth daily Anticoagulation Medication dose route interval Beta-Blocker Medication dose route interval indication Angiotensin Converting Enzyme (ACE) Inhibitor Medication dose route interval Statin (HMG-CoA reductase inhibitor) Medication dose route interval Other Medication dose route interval indication a. b. c. d. E. IMMUNIZATIONS Per New York State Department of Health Mandatory Immunization Program and Kaleida Policy CL.6: All patients 6 to 64 years old with chronic health conditions and all patients age 65 or older admitted to Kaleida will be screened to determine eligibility for the pneumococcal immunization and all eligible patients will be offered the vaccine. All patients admitted to Kaleida age 6 months and older will be screened to determine eligibility for influenza immunization and all eligible patients will be offered the vaccine. The immunization(s) will be held if the patient has a contraindication. Please select the appropriate contraindication(s) and sign the Adult Pneumococcal/Influenza Vaccination Screening & Orders (KH01183) to have the immunization(s) held. 14. ADDITIONAL : NURSING 9 TORB From: Date: Time: Signature: NOTED BY RN Date: Time: Signature: PROVIDER Date: Time: Print Name/Stamp: Signature: TORB = Telephone Orders Read Back Place STAT barcode sticker within this box only on form copy being scanned

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