Standardized Nurse Activated Protocols (SNAPs)
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- Melanie Ryan
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1 SNAPs by presenting complaint/problem help nurses initiate care before the patient is seen by a physician. SNAPs should be approved by ED team consensus If patient unstable in any way, immediately notify the emergency physician. Fever is defined as oral T > 100.3ºF or rectal T > 101.3ºF Standing orders are separated into tests/procedures and medications/fluids. Medication dosing is for adults unless otherwise mentioned Of course, withhold a medication when the patient reports allergy or sensitivity or if you feel it may be contraindicated Abdominal Pain Upper, Right-Sided, Peri-umbilical, or Diffuse CBC, CMP, lipase, UA For age >40, diabetic, or history of CAD: EKG, cardiac enzymes Keep patient NPO Request physician to order CT or US, if necessary Dilaudid 1mg IVP (0.5 mg if > 60 yrs or < 60 kg) Zofran 4 mg IVP PRN for nausea/vomiting Abdominal Pain Lower CBC, BMP, UA, urine culture, prepare for pelvic examination Keep patient NPO Request physician to order CT or US, if necessary Dilaudid 1mg IVP (0.5 mg if > 60 yrs or < 60 kg) Zofran 4 mg IVP PRN for nausea/vomiting Allergic Reaction (severe) Benadryl 50mg IV, Solumedrol 125 mg IV, Pepcid 20 mg IV If hypotension or respiratory distress: Epinephrine.3mg IM
2 Altered Mental Status ECG Rapid glucose CBC, BMP, cardiac enzymes, drug screen, ETOH level, drug levels as applicable UA and urine culture If evidence of sepsis or toxic appearing: lactate, VBG If on Coumadin: PT/INR, type and screen, CT Head Hydrate with 250 ml NS bolus Animal bite Cleanse skin and irrigate wound Obtain radiograph if extremity wound and bony tenderness or possible foreign body Tetanus Protocol For dog/cat bites Augmentin 875/125 mg po if no PCN allergy and weight > 50 kg Asthma or COPD Exacerbation Obtain IV access if severe distress Supplemental oxygen to maintain SpO2 >93% Begin nebulizer with Albuterol 2.5 mg/atrovent 0.5mg Child: Give Orapred 2 mg/kg PO or, if unable, Solumedrol 1 mg/kg IVP Adult: Give prednisone 60 mg PO or, if unable, Solumedrol 125 mg IVP Chest Pain (under age 35) ECG (and obtain prior ECG) Chest Pain (age 35 and older) Obtain IV access (saline lock) and draw blood ECG (and obtain prior ECG) CBC, CMP, cardiac enzymes If on Coumadin, order PT/INR, if on Digoxin, order Digoxin level O2 2L NC if SpO2 < 95% on RA ASA 325 mg po (unless allergic or already taken in last 24 hours)
3 Cough AND fever, hypoxia, tachypnea, or high suspicion for pneumonia Dehydration / Diarrhea / Vomiting CBC, BMP, UA, urine HCG (all females age years old), urinalysis Hydrate with 1 L NS bolus (consider oral re-hydration in children) Child > 25 kg and adults: Zofran 4 mg ODT or IVP PRN for nausea/vomiting Dizzy / Lightheadedness AND age >50, diabetes, or history of CAD Obtain IV access (saline lock) and draw blood ECG CBC, BMP, magnesium, cardiac enzymes, UA Hydrate with 250 ml NS bolus Eye chemical exposure Apply Tetracaine, 2 drops to each affected eye Irrigate affected eyes (manually or with irrigating contact lens) Check visual acuity Fever Antipyretics or Mild-Moderate Pain Adults First choice: Acetaminophen: 650mg q 4h PO or PR o Do not use in those with known with allergy, sensitivities, or liver disease Second choice: Ibuprofen: 400 mg q 6h o Do not use in pregnant patients or those with known allergy/sensitivity, renal disease, peptic ulcer disease, or taking Coumadin Children First choice: Ibuprofen: 10 mg/kg up to max 400 mg PO o Do not use in pregnant patients or those with known allergy/sensitivity, renal disease, peptic ulcer disease, or on Coumadin Second choice: Acetaminophen: 15 mg/kg up to max 650 gram PO or PR o Do not use in those with known with allergy, sensitivities, or liver disease
4 Fever in the Elderly or Chronically Ill ECG CBC, CMP, blood cultures x 2 UA and urine culture If evidence of sepsis or toxic-appearing: lactate, VBG Hydrate with 250 ml NS bolus Tylenol 650 mg PO or PR Flank Pain CBC, BMP, UA, urine culture Request physician to order CT or US, if necessary Dilaudid 1mg IVP (0.5 mg if > 60 yrs or < 60 kg) Zofran 4 mg IVP PRN for nausea/vomiting Fracture (suspected) Xray appropriate area Dilaudid 1mg IVP (0.5 mg if > 60 yrs or < 60 kg) Zofran 4 mg IVP PRN for nausea/vomiting If fracture is open, irrigate wound and cover with sterile dressing, Ancef 1g IV, Tetanus Protocol GI Bleed (>50 years old, severe bleeding, or abnormal vitals) CBC, BMP, PT/INR, PTT, Type and Screen ECG Headache (severe) If on coumadin: PT/INR, type and screen, CT Head Reglan 10mg IV Benadryl 25 mg IV Hydrate with 500 ml NS bolus Hematuria UA, urine culture
5 Hyperglycemia CBC, BMP, serum ketones, UA Request physician to order CT or US, if necessary Hydrate with 500 ml NS bolus Hypoglycemia If normal mental status and well appearing: PO juice or soda then meal tray Otherwise, obtain IV access and draw blood Repeat blood sugar in 45 minutes If abnormal mental status or ill appearing: 1 amp D50W IV Laceration Irrigate wound X-ray appropriate area if high suspicion for foreign body Tetanus Protocol Overdose ECG CBC, CMP, UA, drug screen, ETOH level, Tylenol level, salicylate level, additional drug levels as applicable Palpitations Obtain IV access (saline lock) and draw blood ECG CBC, BMP Pregnancy <14 wks and Bleeding or Pelvic Pain CBC, quantitative HCG, type/rh UA and urine culture Keep patient NPO Prepare for pelvic exam Pelvic ultrasound (preg survey/first trimester) Hydrate with 500 ml NS bolus
6 Seizure (new onset or altered mental status) Rapid glucose CBC, CMP, magnesium CT Head Obtain seizure drug levels if applicable Seizure precautions Ativan 2mg IV/IM if actively seizing Seizure (history of seizures and normal mental status) Rapid glucose Obtain seizure drug levels if applicable (Dilantin, Depakote, Tegretol, Phenobarbital) Seizure precautions Ativan 2mg IV/IM if actively seizing Shortness of Breath (under 50) O2 2L NC if SpO2 < 95% on RA Shortness of Breath (age 50 and older) ECG (and obtain prior ECG) CBC, BMP, cardiac enzymes, BNP level O2 2L NC if SpO2 < 95% on RA Sore Throat (suspicion for strep throat) Rapid Strep Stroke Symptoms Obtain IV access (saline lock) and draw blood Rapid glucose ECG (and obtain prior ECG) CBC, BMP, magnesium, cardiac enzymes CT Head If on Coumadin: PT/INR, type and screen O2 2L NC if SpO2 < 95% on RA
7 Syncope ECG (and obtain prior ECG) CBC, BMP, magnesium, cardiac enzymes, BNP level If on Coumadin: PT/INR, type and screen, CT Head O2 2L NC if SpO2 < 95% on RA Hydrate with 500 ml NS bolus Tetanus Protocol for Adults Indications: eye/skin wound or infection and last immunization > 5 years for dirty wounds or last immunization > 10 years for clean wounds Discuss with physician if patient has not received initial tetanus immunization series dt 0.5 ml IM in deltoid of upper extremity [May use Tdap (Adacel) in adults under 65 years and not known to be pregnant] Urinary Tract Infection (suspected) UA and urine culture Urinary Retention Urinary catheter with leg bag UA and urine culture Lidocaine 2% jelly (Urojet) injected into urethra for males Weakness AND age >50, diabetes, or history of CAD Obtain IV access (saline lock) and draw blood ECG CBC, BMP, magnesium, cardiac enzymes, UA Hydrate with 250 ml NS bolus
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Patient Name: Diagnosis: Allergies with reaction type: Hip Hemiarthroplasty Post Op Version 2 4/20/17 Patient Placement General Diagnosis/Procedure: Preferred Location/Unit Ortho/Neuro PCU ICU General
Monitor patient s ability to self-administer insulin. (To evaluate safe administration of drug.)
Nursing Process Focus: Patients Receiving Regular Insulin (Humulin, Novolin) Assessment Prior to administration: Assess any patient allergies. Older forms of insulin are made from beef and pork and may
Diagnosis: Allergies with reaction type:
Patient Name: Diagnosis: Allergies with reaction type: CHRONIC HOME HEMODIALYIS ORDERS Version 4 1/21/2013 1. TREATMENT ORDERS A. Frequency of treatment 5 6 times per week. B. Weight and blood pressures,
disease or in clients who consume alcohol on a regular basis. bilirubin
NON-OPIOID Acetaminophen(Tylenol) Therapeutic class: Analgesic, antipyretic Aspirin (ASA, Acetylsalicylic Acid) Analgesic, NSAID, antipyretic Non-Opioid Analgesics COMMON USES WHAT I NEED TO KNOW AS A
For the Patient: Methotrexate Other names: MTX
For the Patient: Methotrexate Other names: MTX Methotrexate (meth oh trex ate) is a drug that is used to treat many types of cancers. It is a clear yellow liquid that is injected into a vein. Tell your
POST-OP CARDIAC SURGERY PHYSICIAN S ORDER SHEET USE BALLPOINT PEN ONLY. CARDIAC INTENSIVE CARE UNIT
PHYSICIAN S SHEET Automatically Activate, if not in agreement, cross out and initial Activated by Checking Box ALLERGIES: None known YES Patient s Height: Patient s Weight: ALL MEDICATION and INTRAVENOUS
Routine, Every 2 hours, Starting today, If temperature greater than 38.5 C initiate Evaluation for Possible Sepsis Physician Order #829
Height Weight Allergies General Vital Signs [X] Frequent vital signs Indication: Q15 minutes x (# of occurrences): 4 Q30 minutes x (# of occurrences): 4 Q1 hour x (# of occurrences): Q2 hours x (# of occurrences):
Acute Stroke with Alteplase Administration Order Set
Review Due Date: 2017 October PATIENT CARE DERS Weight: Adverse Reactions or Intolerances Drug No Yes (list) Food No Yes (list) _ Latex No Yes Admission Admit to Neurology service: Dr. Critical Care Diagnosis:
COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 510
COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 510 Effective Date: August 31, 2006 SUBJECT: CARE OF THE INDIVIDUAL RECEIVING CLOZAPINE 1. GENERAL: Clozapine
A UMC Health System Performance Improvement Initiative for use in all units where patients with are admitted for Surgical Care Improvement Project.
ENDOLUMINAL AAA POST-OP PLAN A UMC Health System Performance Improvement Initiative for use in all units where patients with are admitted for Surgical Care Improvement Project. *Denotes guideline requirement
Assessment. Consults & Referrals
University of Virginia Health System Clinical Pathway: Whipple Enhanced Recovery After () LOS: 4-5 days Date of Origin/Revision: June 29, 2016/September 6, 2017/January 31, 2018 : SAS : : : D1 D2 D 3/
For the Patient: GIAVPG Other Names: First-line palliative chemotherapy for advanced gallbladder and bile duct cancer using Gemcitabine and Cisplatin
For the Patient: GIAVPG Other Names: First-line palliative chemotherapy for advanced gallbladder and bile duct cancer using Gemcitabine and Cisplatin GI = GastroIntestinal AV = Advanced PG = Cisplatin,
Enquiry Severity Immediate or other. Joint or muscle pain - any part of the body. Abdominal pain Acute Non-acute. Acne Anxiety Acute Non-acute
We operate a hybrid triage system offering a mixture of telephone consultations, on the day emergency consultations with a doctor or pre bookable (3 days in advance) GP / Nurse Practitioner appointments
Nilotinib (nil ot' i nib) is a drug that is used to treat some types of cancer. It is a capsule that you take by mouth.
For the Patient: Other names: TASIGNA (nil ot' i nib) is a drug that is used to treat some types of cancer. It is a capsule that you take by mouth. Blood tests may be taken regularly during treatment.
Physician Orders ADULT: Medical Response Team Standing Orders Protocol Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase When to Initiate: Other-See Special Instructions, If MRT is notified per MD, Condition H or any associate, review and Initiate
ST. DOMINIC-JACKSON MEMORIAL HOSPITAL JACKSON, MISSISSIPPI
Date & Time TAVR Pre-Op Admission Clinical Pathway Page 1 of 3 1. Admit as INPATIENT to Dr.. For Surgery Today or Tomorrow 3. Diagnosis: 4. Allergies: Pharmacy Mnemonic: PRETAVR 5. Vital signs on arrival.
OB/GYN POSTPARTUM VAGINAL DELIVERY PLAN
OB/GYN POSTPARTUM VAGINAL DELIVERY PLAN PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Patient Activity Up Ad Lib/Activity as Tolerated Bedrest STRICT Bedrest Up to
Supplementary Appendix
Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: Jain S, Kamimoto L, Bramley AM, et al. Hospitalized patients
JOHN MICHAEL ROACH, MD
GASTROENTEROLOGY JOHN MICHAEL ROACH, MD 520 N. 4 TH AVE. PASCO, WA 99301 Phone: (509) 546-8383 Name: Date of Birth: First Middle (full) Last m/d/yr Primary care provider: Referring physician: Local Pharmacy: