Download Trans-Esophageal Echocardiogram TEE Orders

PLACE LABEL HERE
TRANS-ESOPHAGEAL ECHOCARDIOGRAM (TEE)
ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
1. Diagnosis: ______________________________________________________________________________________
2. PRE-TEE PROCEDURE:
Date of Procedure: _________________________________
Trans-Esophageal Echocardiogram (TEE) Reason: __________________ Group to Read: _______________
Venous Access: INT to right arm, if possible and no current IV access
Normal Saline IV at KVO rate, start immediately prior to procedure
NPO status:

 NPO now and confirm patient has been NPO after midnight (patient coming from home)

 NPO after midnight except medications for TEE tomorrow (patient in hospital)

 NPO now for TEE today (patient in hospital)
Cetacaine (benzocaine/tetracaine/butaben) spray to pharynx x 1 sec immediately prior to procedure x 1 dose
or  DC Cetacaine. Lidocaine 5% ointment, apply to tongue prn q 3 min up to three doses
 Urine hCG for any menstruating female ≥ 12 years of age
 Blood glucose finger stick prior to procedure (diabetic patient)
For ICU patients, nurse to implement moderate sedation flowsheet (form # 20000)
O2 per protocol (# 34431)
3. INTRA-TEE PROCEDURAL MEDICATIONS
 Versed (midazolam) 0.25 -1 mg IV q 2 min prn sedation during TEE procedure
 Fentanyl 25 - 50 mcg IV q 2 min prn sedation during TEE procedure
 Other: ___________________________________________________________
4.  OUTPATIENT POST-TEE PROCEDURE ORDERS
NPO until 30 min after last dose of topical anesthetic
May go home when discharge criteria met:
 Able to tolerate PO fluids
 PAR score ≥ 9 or at pre-procedure level; If PAR ≤ 8 discharge by physician orders
 Able to ambulate with minimal assistance
5.  INPATIENT POST- TEE PROCEDURE ORDERS
NPO until 30 min after last dose of topical anesthetic
Return to floor when PAR score ≥ 9 or at pre-procedure level. If PAR ≤ 8, discharge by physician orders.
Vital signs upon returning to unit and per unit routine
Up with assist first time out of bed, then PRN, or resume previous activity level

______________
Date
______________
Time
_________________________________
Physician Signature
___________
PID Number
Copy to pharmacy
*1-1819*
FORM 1-1819 REV. 07/2014
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