Dx Weight PHYSICIAN S Allergies DETAILS Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Code Status Code Status: Full Code Code Status: DNR - Do Not Resuscitate Code Status: DNI - Do Not Intubate Code Status: DNR/DNI - Do Not Resuscitate or Intubate Code Status: Partial Resuscitative Effort Patient Care Vital Signs Per Unit Standards Daily Weight Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest Bedrest Bathroom Privileges Bedrest Up to Bedside Commode Only Ambulate Patient Ambulate in Room Ambulate in Hallway Strict Intake and Output (Strict I & O) Per Unit Standards Insert Urinary Catheter Foley, To: Dependent Drainage Bag Urinary Catheter Care (Foley Catheter Care) POC Blood Sugar Check q6h 72 hr q1h 24 hr q1h, Until 2 hrs after Insulin Drip is DC d Continuous Telemetry (Intermediate Care) Intermittent Telemetry Dietary Oral Diet Regular Diet AHA Diet Clear Liquid Diet Full Liquid Diet Order Taken by Signature: Page: 1 of 13 Chest Pain Plan Version: 6 Effective on: 08/12/15
PHYSICIAN S DETAILS ADA Diet 1800 Calories, AHA 1600 Calories, AHA 1800 Calories 1600 Calories NPO Diet NPO NPO After Midnight, Except Meds NPO After Midnight, Except Meds, Except Ice Chips IV Solutions 1/2 NS IV, 75 ml/hr IV, 125 ml/hr IV, 150 ml/hr IV, 200 ml/hr D5 1/2 NS IV, 75 ml/hr IV, 125 ml/hr IV, 150 ml/hr IV, 200 ml/hr D5NS IV, 75 ml/hr IV, 125 ml/hr IV, 175 ml/hr IV, 200 ml/hr NS (Normal Saline) IV, 75 ml/hr IV, 125 ml/hr IV, 150 ml/hr IV, 200 ml/hr nitroglycerin 50 mg/250 ml D5W (CP) Start at rate: mcg/min IV NPO After Midnight NPO After Midnight, Except Ice Chips Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. famotidine 20 mg, PO, tab, BID 20 mg, IVPush, inj, BID morphine 2 mg, IVPush, inj, q10min, PRN chest pain Administer until pain level is less than 4/10. LORazepam 1 mg, IVPush, inj, q6h, PRN agitation nitroglycerin (nitroglycerin sublingual) 0.4 mg, SL, tab, q5minx3, PRN chest pain, x 3 dose, for pain level 0 to 4 Ace Inhibitors If Ejection less than 40% Give Ace Inhibitor or ARB per Core Measures. If Ace Inhibitor or ARB not given, choose the Contraindications Order below and Complete Order Taken by Signature: Page: 2 of 13 Chest Pain Plan Version: 6 Effective on: 08/12/15
PHYSICIAN S DETAILS Contraindications ACEI or ARB Allergy to Both Allergy to One-Must Try the Other Angioedema Caused by an ACE or ARB Hyperkalemia Hypotension Moderate or Severe Aortic Stenosis Renal Artery Stenosis Worsening Renal Function Other (specify below in other reason) captopril 6.25 mg, PO, tab, TID Administer 1 hour before meals 12.5 mg, PO, tab, TID Administer 1 hour before meals 25 mg, PO, tab, TID Administer 1 hour before meals lisinopril 2.5 mg, PO, tab, Daily 5 mg, PO, tab, Daily 10 mg, PO, tab, Daily 20 mg, PO, tab, Daily ramipril 2.5 mg, PO, cap, Daily 5 mg, PO, cap, Daily 10 mg, PO, cap, Daily Angiotensin Receptor Blockers If Ejection less than 40% Give Ace Inhibitor or ARB per Core Measures. If Ace Inhibitor or ARB not given, choose the Contraindications Order below and Complete Order Taken by Signature: Page: 3 of 13 Chest Pain Plan Version: 6 Effective on: 08/12/15
PHYSICIAN S DETAILS Contraindications ACEI or ARB Allergy to Both Allergy to One-Must Try the Other Angioedema Caused by an ACE or ARB Hyperkalemia Hypotension Moderate or Severe Aortic Stenosis Renal Artery Stenosis Worsening Renal Function Other (specify below in other reason) candesartan 4 mg, PO, tab, Daily 8 mg, PO, tab, Daily 16 mg, PO, tab, Daily 32 mg, PO, tab, Daily Anti Platelets Must be given within 24 hours of arrival per Core Measures. If not given, choose the Contraindications Order below and Complete Contraindications Aspirin Allergy Coumadin or Pradaxa Already Prescribed History of GI Bleed Positive Occult Blood in Stool Other (specify below in other reason) aspirin USE FOR AMI, 325 mg, PO, tab, Daily This medication must be given immediately for AMI or STROKE if not given in ER. USE FOR AMI, 325 mg, PO, tab, ONE TIME This medication must be given immediately for AMI or STROKE. USE FOR AMI, 81 mg, chewed, tab chew, Daily This medication must be given immediately for AMI or STROKE. clopidogrel 300 mg, PO, tab, ONE TIME 600 mg, PO, tab, ONE TIME clopidogrel 75 mg, PO, tab, Daily, Daily Maintenance Dose Beta Blockers Must be given per Core Measures. If not given, choose the Contraindications Order below and Complete Contraindications Beta Blocker Allergy or Sensitivity Bradycardia or Heart Block Chronic Lung Disease -- Asthma Severe Hypotension Other (specify below in other reason) Order Taken by Signature: Page: 4 of 13 Chest Pain Plan Version: 6 Effective on: 08/12/15
PHYSICIAN S DETAILS atenolol 12.5 mg, PO, tab, Daily 12.5 mg, PO, tab, BID 25 mg, PO, tab, Daily 25 mg, PO, tab, BID 50 mg, PO, tab, Daily 50 mg, PO, tab, BID 100 mg, PO, tab, Daily 100 mg, PO, tab, BID metoprolol 25 mg, PO, tab, BID 50 mg, PO, tab, BID 100 mg, PO, tab, BID carvedilol 6.25 mg, PO, tab, BID Administer with breakfast and dinner. 12.5 mg, PO, tab, BID Administer with breakfast and dinner. 25 mg, PO, tab, BID Administer with breakfast and dinner. Glycoprotein IIb/IIIa Inhibitors ***Patient must be on telemetry while receiving eptifibatide (Integrelin)*** eptifibatide 180 mcg/kg, IVPush, inj, ONE TIME, Maximum dose 22.6 mg ***Patient must be on telemetry while receiving eptifibatide (Integrelin)*** eptifibatide 75 mg/100 ml IV, x 18 hr Final concentration = 0.75 mg/ml (750 mcg/ml). Maximum rate 15 mg/hour (20 ml/hr). Notify physician if administered dose (rate) is greater than the usual dose range. ***Patient must be on telemetry while receiving eptifibatide (Integrelin)*** Start at rate: mcg/kg/min abciximab 0.25 mg/kg, IVPush, inj, ONE TIME, Infuse over 5 min abciximab 9 mg/250 ml NS IV, x 12 hr Give 0.25 mg/kg bolus, over five minutes, followed by 0.125 mcg/kg/min for 12 hours. Final concentration = 36 mcg/ml Start at rate: mcg/min 1 ea, Every Bag Heparins Heparin Infusion Guidelines Order Taken by Signature: Page: 5 of 13 Chest Pain Plan Version: 6 Effective on: 08/12/15
PHYSICIAN S DETAILS heparin 5,000 units, IVPush, inj, ONE TIME, STEMI IV Bolus 4,000 units, IVPush, inj, ONE TIME, STEMI IV Bolus 60 units/kg, IVPush, inj, ONE TIME, STEMI IV Bolus 60 units/kg, IVPush, inj, ONE TIME IV Bolus 70 units/kg, IVPush, inj, ONE TIME IV Bolus heparin 25,000 units/250 ml D5W IV Start at rate: units/hr Heparin ACT Protocol Keep ACT between 130 and 150, See Reference Text for Protocol POC ACT enoxaparin 1 mg/kg, subcut, syringe, q12h 1 mg/kg, subcut, syringe, q24h 0.3 mg/kg, IVPush, syringe, ONE TIME 30 mg, IVPush, syringe, ONE TIME 0.75 mg/kg, subcut, syringe, q12h rivaroxaban 10 mg, PO, tab, In PM Statins atorvastatin 10 mg, PO, tab, Nightly 20 mg, PO, tab, Nightly 40 mg, PO, tab, Nightly 80 mg, PO, tab, Nightly rosuvastatin 5 mg, PO, tab, Nightly 10 mg, PO, tab, Nightly 20 mg, PO, tab, Nightly 40 mg, PO, tab, Nightly simvastatin 5 mg, PO, tab, Nightly 10 mg, PO, tab, Nightly 20 mg, PO, tab, Nightly 40 mg, PO, tab, Nightly 80 mg, PO, tab, Nightly Laboratory CBC with Differential Prothrombin Time with INR PTT Anti Xa Level Basic Metabolic Panel Order Taken by Signature: Page: 6 of 13 Chest Pain Plan Version: 6 Effective on: 08/12/15
PHYSICIAN S DETAILS Comprehensive Metabolic Panel Lipid with Calculated LDL CK Routine, q8h for 3 times CKMB Routine, q8h for 3 times Troponin T Routine, q8h for 3 times Urinalysis Diagnostic Tests DX Chest Portable EKG-12 Lead Every AM for 2 days, Perform EKG PRN for Chest Pain. Chest MUST be marked appropriately Echo Transthoracic (TTE) with contrast i (Echo Transthoracic (TTE) with contrast if needed) Respiratory Respiratory Care Plan Guidelines Oxygen Therapy Via: Nasal cannula, Keep sats greater than: 92% Continuous Pulse Oximetry For 12 hr, DC when sats consistently greater than 92% IS Instruct Consults/Referrals Consult Cardiac Rehab Cardiac Rehab for Inpatient Phase I evaluation and treatment. Arrange Outpatient Cardiac Rehab Phase II evaluation and treatment. Consult Case Management...Additional Orders Order Taken by Signature: Page: 7 of 13 Chest Pain Plan Version: 6 Effective on: 08/12/15
DISCOMFORT MED PLAN PHYSICIAN S DETAILS Patient Care Perform Bladder Scan Scan PRN, If more than 250, Then: Call MD, Perform as needed for patients complaining of urinary discomfort and/or bladder distention present OR 6 hrs post Foley removal and patient has not voided. Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. phenol-menthol topical (phenol-menthol 2.9%-0.12% (Cepastat) lozenge) 1 lozenge, PO, lozenge, q4h, PRN sore throat Do not exceed 6 lozenges in 24 hours dextromethorphan-guaifenesin (dextromethorphan-guaifenesin 20 mg-200 mg/10 ml oral liquid) 10 ml, PO, liq, q4h, PRN cough dexamethasone-diphenhydramin-nystatin-ns (Fred s Brew) 15 ml, swish & spit, liq, q2h, PRN mucositis While awake lidocaine topical (Lidocaine Viscous 2% mucous membrane solution) 15 ml, swish & spit, liq, q4h, PRN mucositis Analgesics acetaminophen 500 mg, PO, tab, q6h, PRN pain-mild (scale 1-3) *****IF acetaminophen ineffective/contraindicated, USE ibuprofen if ordered:***** 1,000 mg, PO, tab, q4h, PRN pain-mild (scale 1-3) *****IF acetaminophen ineffective/contraindicated, USE ibuprofen if ordered:***** acetaminophen 650 mg, rectally, supp, q4h, PRN pain-mild (scale 1-3) *****If acetaminophen ineffective/contraindicated, USE ibuprofen if ordered:***** ibuprofen 400 mg, PO, tab, q6h, PRN pain-mild (scale 1-3) ***Do not exceed 3,200 mg of ibuprofen from all sources in 24 hours*** Give with food. Use if acetaminophen ineffective or contraindicated. HYDROcodone-acetaminophen (HYDROcodone-acetaminophen 5 mg-325 mg oral tablet) 1 tab, PO, tab, q4h, PRN pain-moderate (scale 4-7) *****IF HYDROcodone-acetaminophen ineffective/contraindicated or NPO, USE ketorolac if ordered***** 2 tab, PO, tab, q4h, PRN pain-moderate (scale 4-7) *****IF HYDROcodone-acetaminophen ineffective/contraindicated or NPO, USE ketorolac if ordered***** Order Taken by Signature: Page: 8 of 13 Chest Pain Plan Version: 6 Effective on: 08/12/15
DISCOMFORT MED PLAN PHYSICIAN S DETAILS acetaminophen-codeine (acetaminophen-codeine #3) 1 tab, PO, q4h, PRN pain-moderate (scale 4-7) *****IF acetaminophen-codeine #3 ineffective/contraindicated or NPO, USE ketorolac if ordered***** 2 tab, PO, q4h, PRN pain-moderate (scale 4-7) *****IF acetaminophen-codeine #3 ineffective/contraindicated or NPO, USE ketorolac if ordered***** ketorolac 15 mg, IVPush, inj, q6h, PRN pain-moderate (scale 4-7), x 48 hr ***May give IM if no IV access*** Use if HYDROcodone-acetaminophen ineffective or contraindicated. 30 mg, IVPush, inj, q6h, PRN pain-moderate (scale 4-7), x 48 hr ***May give IM if no IV access*** Use if HYDROcodone-acetaminophen ineffective or contraindicated. morphine 2 mg, IVPush, inj, q4h, PRN pain-severe (scale 8-10) ***Slow IV Push*** *****IF morphine is ineffective/contraindicated, USE HYDROmorphone if ordered***** 4 mg, IVPush, inj, q4h, PRN pain-severe (scale 8-10) ***Slow IV Push*** *****IF morphine is ineffective/contraindicated, USE HYDROmorphone if ordered***** HYDROmorphone 1 mg, IVPush, inj, q4h, PRN pain-severe (scale 8-10) ***Slow IV Push*** Use if morphine ineffective or contraindicated. Antiemetics promethazine 25 mg, PO, tab, q4h, PRN nausea/vomiting *****IF promethazine is ineffective/contraindicated or patient is NPO, USE ondansetron if ordered***** ondansetron 4 mg, IVPush, soln, q8h, PRN nausea/vomiting Use if promethazine ineffective or contraindicated. Gastrointestinal Agents docusate 100 mg, PO, cap, Nightly, PRN constipation *****IF docusate is contraindicated or ineffective after 12 hours, USE bisacodyl if ordered***** bisacodyl 10 mg, rectally, supp, Daily, PRN constipation *****IF bisacodyl is contraindicated or ineffective after 6 hours, USE Fleet Enema if ordered***** Order Taken by Signature: Page: 9 of 13 Chest Pain Plan Version: 6 Effective on: 08/12/15
DISCOMFORT MED PLAN PHYSICIAN S DETAILS sodium biphosphate-sodium phosphate (Fleet Enema) 132 ml, rectally, enema, Daily, PRN constipation loperamide 4 mg, PO, cap, ONE TIME, PRN diarrhea Initial dose after first loose stool 4 mg, PO, liq, ONE TIME, PRN diarrhea Initial dose after first loose stool loperamide 2 mg, PO, cap, as needed, PRN diarrhea 2 mg after each loose stool, up to 16 mg per day 2 mg, PO, liq, as needed, PRN diarrhea 2 mg after each loose stool, up to 16 mg per day Antacids Al hydroxide-mg hydroxide-simethicone (aluminum hydroxide-magnesium hydroxide-simethicone 200 mg-200 mg-20 mg/5 ml oral suspension) 30 ml, PO, susp, q4h, PRN indigestion Administer 1 hour before meals and nightly. simethicone 80 mg, PO, tab chew, q4h, PRN gas 160 mg, PO, tab chew, q4h, PRN gas Sedatives ALPRAZolam 0.25 mg, PO, tab, TID, PRN anxiety *****IF ALPRAZolam is ineffective/contraindicated or patient is NPO, USE LORazepam if ordered***** LORazepam 1 mg, IVPush, inj, q6h, PRN anxiety 0.5 mg, IVPush, inj, q6h, PRN anxiety zolpidem 5 mg, PO, tab, Nightly, PRN insomnia may repeat x1 in one hour if ineffective Antihistamines diphenhydramine 25 mg, PO, cap, q4h, PRN itching *****IF diphenhydramine PO is ineffective or patient is NPO, USE diphenhydramine inj if ordered***** diphenhydramine 25 mg, IVPush, inj, q4h, PRN itching Use if oral dose is ineffective or patient is NPO Anti-pyretics Order Taken by Signature: Page: 10 of 13 Chest Pain Plan Version: 6 Effective on: 08/12/15
DISCOMFORT MED PLAN PHYSICIAN S DETAILS acetaminophen 500 mg, PO, tab, q4h, PRN fever *****IF acetaminophen is ineffective/contraindicated, USE ibuprofen if ordered***** 1,000 mg, PO, tab, q4h, PRN fever *****IF acetaminophen is ineffective/contraindicated, USE ibuprofen if ordered***** ibuprofen 200 mg, PO, tab, q4h, PRN fever Do not exceed 3,200 mg in 24 hours. Give with food. Use if acetaminophen is ineffective or contraindicated. 400 mg, PO, tab, q4h, PRN fever Do not exceed 3,200 mg in 24 hours. Give with food. Use if acetaminophen is ineffective or contraindicated. Anorectal Preparations witch hazel-glycerin topical (witch hazel-glycerin 50% topical pad) 1 app, topical, pad, as needed, PRN hemorrhoid care Wipe affected area *****IF witch hazel-glycerin or phenylephrine ointment ineffective/contraindicated, USE hydrocortisone-pramoxine foam if ordered***** phenylephrine topical (phenylephrine 0.25%-3% rectal ointment) 1 app, rectally, oint, q6h, PRN hemorrhoid care Apply to affected area *****IF witch hazel-glycerin or phenylephrine ointment ineffective/contraindicated, USE hydrocortisone-pramoxine foam if ordered***** hydrocortisone-pramoxine topical (hydrocortisone-pramoxine 1%-1% rectal foam) 1 app, rectally, foam, q8h, PRN hemorrhoid care apply to affected area Order Taken by Signature: Page: 11 of 13 Chest Pain Plan Version: 6 Effective on: 08/12/15
VTE PROPHYLAXIS PLAN PHYSICIAN S DETAILS Patient Care VTE Guidelines See Reference Text for Guidelines ***If VTE Pharmacologic Prophylaxis not given, choose the Contraindications for VTE below and complete reason contraindi cated*** Contraindications VTE Patient low risk for VTE Patient is ambulatory Patient Refusal Family/Caregiver Refusal Cont IV heparin day of/after admission Anticoag therapy not warfarin for Afib Warfarin prior to admit; on hold r/t INR Risk of Bleeding Thrombocytopenia Active Bleeding Alteplase Administered w/in 24 hrs IV Heparin w/in 24 hrs of Surgery Apply Elastic Stockings Apply to: Bilateral Lower Extremities, Length: Knee High Apply to: Left Lower Extremity (LLE), Length: Knee High Apply to: Right Lower Extremity (RLE), Length: Knee High Apply to: Bilateral Lower Extremities, Length: Thigh High Apply to: Left Lower Extremity (LLE), Length: Thigh High Apply to: Right Lower Extremity (RLE), Length: Thigh High Apply Sequential Compression Device Apply to Bilateral Lower Extremities Apply to Left Lower Extremity (LLE) Apply to Right Lower Extremity (RLE) Apply Pedal Pump Apply to Bilateral Feet Apply to Left Foot Apply to Right Foot Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. ***Recommended Trauma Dose = 30 mg, subcut, q12h*** ***Recommended Dose for Morbidly Obese Patients = 40 mg, subcut, q12h*** enoxaparin 40 mg, subcut, syringe, q24h 30 mg, subcut, syringe, q12h 30 mg, subcut, syringe, q24h, For CrCl less than 30 ml/hr 40 mg, subcut, syringe, q12h, For BMI greater than 39 heparin 5,000 units, subcut, inj, q12h 5,000 units, subcut, inj, q8h fondaparinux 2.5 mg, subcut, syringe, q24h ***If you order RIVAROXABAN for your patient, please indicate the reason below*** Order Taken by Signature: Page: 12 of 13 Chest Pain Plan Version: 6 Effective on: 08/12/15
VTE PROPHYLAXIS PLAN PHYSICIAN S DETAILS Reason for Oral Factor Xa Inhibitor Reason: Atrial fibrillation Reason: Persistent atrial fibrillation Reason: Paroxysmal atrial fibrillation Reason: Atrial flutter Reason: Hx Afib/flutter - NA w/in 8wks post CABG Reason: Partial hip arthroplasty Reason: Total hip arthroplasty Reason: Total hip replacement Reason: Total knee arthroplasty Reason: Total knee replacement rivaroxaban 10 mg, PO, tab, In PM 20 mg, PO, tab, In PM, for A-fib/Secondary Prevention for DVT warfarin 5 mg, PO, tab, QPM aspirin 81 mg, PO, tab chew, Daily 325 mg, PO, tab, Daily Order Taken by Signature: Page: 13 of 13 Chest Pain Plan Version: 6 Effective on: 08/12/15