of nurse 1. Admit under ward Attending Physician: Dr. Admit date (YYYY/MM/DD): Cardiologist On-Call: Diagnosis: Lab Tests 2. On admission (if not already performed in Emergency Department or in Coronary Care Unit): CBC, Electrolytes, Urea, Creatinine, Glucose, INR, PTT, Urinalysis 3. Daily INR for duration of warfarin therapy. Complete the Anticoagulation Record Daily 4. Fasting Total Cholesterol/LDL/HDL/Triglycerides within 24 hours of presentation 5. Other: Cardiac Markers (For patients recently admitted to Emergency Department with chest pain) 6. CK on admission then 8 hr, 16 hr and 24 hr later 7. Troponin-T on admission and 8 hr later Patient Monitoring 8. Telemetry 9. ECG with chest pain 10. Patient weight within 24 hours of admission: kg 11. Daily weights 12. Vital signs: bid at 1000h and 2200h or 13. Glucose monitoring frequency: 14. Other: Activity Level 15. Level A: bedrest, commode chair 16. Level B: chair progress from 15-30 min; wash at bedside; commode chair 17. Level C: walk in room and bathroom; wash at bedside or washroom 18. Level D: walk outside room and slowly increase as tolerated; rest for periods in morning and evening; shower after consulting Physician Doctor s : PRINT NAME: Pager: PR 69026 Page 1 of 4
Diet 19. Heart Healthy (Low cholesterol, Low Fat, No Added Salt) 20. 1800 kcal diabetic diet or kcal diabetic diet 21. 87 mmol sodium, 1500 ml fluid restriction or ml fluid restriction (appropriate for patients with congestive heart failure) 22. Other: Oxygen Therapy 23. Maintain oximetry reading greater than or equal to 93%; apply oxygen by nasal cannula from 1 to 6 L/min prn 24. For chronic obstructive pulmonary disease (COPD) patients: Maintain oximetry reading between 88% and 92%; apply oxygen by nasal cannula from 1 to 6 L/min prn IV Therapy 25. Saline lock 26. Other: Medications 27. EC ASA 81 mg po daily 28. clopidogrel 75 mg po daily 29. ANTICOAGULATION FOR NSTACS (NON-ST-ELEVATION ACUTE CORONARY SYNDROMES) (If you choose anticoagulation for NSTACS, select ONLY ONE of the two anticoagulant options below) A. Fondaparinux 2.5 mg sc daily (Note: Do not use fondaparinux if Creatinine Clearance less than 30 ml/min) RN to indicate the exact administration time of the first fondaparinux sc dose in the Emergency Department/Coronary Care Unit: (h) Dosing schedule for subsequent fondaparinux sc doses to be determined according to the following table: Administration time of FIRST fondaparinux sc dose from 0200h to 1000h from 1000h to 1800h from 1800h to 0200h Daily schedule for SUBSEQUENT fondaparinux sc dose 0600h the following day 1400h the following day 2200h the following day B. Acute Coronary Syndrome Heparin Nomogram Do NOT use General Heparin Nomogram I have selected and signed the Acute Coronary Syndrome Heparin Nomogram : PRINT NAME: Doctor s : PRINT NAME: Pager: PR 69026 Page 2 of 4
30. Beta-blocker: 31. ACE Inhibitor: 32. Lipid-lowering therapy: 33. docusate sodium 200 mg po at bedtime 34. ANTICOAGULATION FOR OTHER INDICATIONS (i.e., other than Acute Coronary Syndrome): Patient must NOT be receiving any CONCURRENT anticoagulant Clinical indication: GENERAL Heparin Nomogram. Do NOT use Acute Coronary Syndrome Heparin Nomogram I have selected and signed the General Heparin Nomogram. : PRINT NAME: Venous Thromboembolism (VTE) Prophylaxis (see guidelines on back) 35. Patient must NOT be receiving any CONCURRENT therapeutic anticoagulant. Choose ONE of the following: enoxaparin 40 mg sc daily at bedtime enoxaparin 30 mg sc daily at bedtime for patients weighing less than 40 kg OR with CrCl less than 30 ml/min if enoxaparin not ordered - REASON: Reassess daily for conversion to enoxaparin prn Medications 36. dimenhydrinate (Gravol ) 25-50 mg IV/po/pr q4h prn for nausea or vomiting 37. lorazepam 0.5-1 mg po/sl at bedtime prn for anxiety or sedation. 38. acetaminophen 500-1000 mg po q4h prn for pain (Not to exceed 4 g/day) 39. nitroglycerin 1 spray (0.4 mg) SL prn for angina. May repeat q5min for a maximum of 3 sprays. 40. morphine sulfate 2-5 mg IV push q15min prn for chest pain. Maximum 10 mg/h. 41. Milk of Magnesia 30 ml po once daily prn for constipation. Doctor s : PRINT NAME: Pager: PR 69026 Page 3 of 4
PREVENTION OF VENOUS THROMBOEMBOLISM (VTE) SHOULD BE CONSIDERED FOR ALL PATIENTS ADMITTED TO ACUTE CARE Risk Factors for VTE: Major surgery Stroke Pregnancy Trauma or leg injury Heart failure Birth control pill, hormone replacement therapy Active cancer Previous history of VTE Severe obesity Cancer treatments Family history of VTE Increasing age Immobilization, bedrest Central venous catheter Acute medical illness STEP 1: Is thromboprophylaxis NOT INDICATED? Reasons Patient fully mobile Brief length of stay Actions No routine prophylaxis Reassess daily STEP 2: Is anticoagulant thromboprophylaxis CONTRAINDICATED? Reasons Active bleeding High risk of bleeding Actions TED stockings Reassess daily STEP 3: PROVIDE THROMBOPROPHYLAXIS For almost all patients, the recommended thromboprophylaxis is enoxaparin 40 mg sc daily at bedtime Reduce the dose to 30 mg sc daily at bedtime for patients with CrCl less than 30 ml/min or weight less than 40 kg Increase the dose to 40 mg sc BID for patients weighing more than 100 kg. PR 69026
Other Medications Discharge Planning: Refer to Cardiac Rehab Social Worker to see Refer to Smoking Cessation Counsellor if patient has used tobacco in last 6 months Doctor s : PRINT NAME: Pager: PR 69026 Page 4 of 4