Download Atrial Fibrillation Observation Orders

PLACE LABEL HERE
ATRIAL FIBRILLATION
OBSERVATION 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).
Status:  Place in Observation for: _____________________________
Level of Care: Acute Care Location/Specialty Unit Preference 5 South
Telemetry: If patient Medical/Surgical, must complete form # 36084
 Isolation:  Contact  Droplet  Airborne For: _________________
Consults: ______________________________________________  Notified by physician
______________________________________________  Notified by physician
6. Diagnostics:  Chem 7  Magnesium
 Digoxin level  PT/PTT
 TSH
 Other: _________________________________________
7.  CXR,  Portable  PA and Lateral, Reason: _________________________________
8.  EKG: Reason: Atrial Fibrillation Read by: ____________________________
9. Vital signs per unit routine or q ____ hrs
10. Notify physician for:
Potassium < 4 prior to Corvert (ibutilide) administration
Magnesium < 2 prior to Corvert (ibutilide) administration
QTc interval > 500 millimeters

QTc interval widening of > 25% from baseline occurs during or after Corvert (ibutilide) administration
Failure to convert to NSR one hr after Corvert (ibutilide) administration
Chest Pain, Systolic BP < 90 mm HG, Heart rate > 130 or < 55 BPM
11. Diet:
 Regular
 Cardiac
 Diabetic ______ calorie  Renal
 Other: _______
12. Activity:  Bed rest
 Bedside Commode
 Bathroom privileges
 Up ad lib  Up with assistance
SCHEDULED MEDICATIONS:
13. IVF:  NS
 LR
 D5NS
 D5 ½ NS with 20 KCl
at ___________ml/hr
14. Rate Control:  Digoxin ______________________ mg IV x 1 dose, then _____________________
 CardiZEM (diltiazem) _____________ mg IV x 1 dose, then ___________________
 Lopressor (metoprolol) 5 mg IV X 1 dose, then _____________________________
 Other: _____________________________________________________________
1.
2.
3.
4.
5.
15.
Cardioversion:  Weight ≥ 60 kg: Corvert (ibutilide) 1 mg IV over 10 min
Repeat dose 10 min after initial infusion if not coverted to Normal Sinus Rhythm (NSR)
 Weight < 60 kg: Corvert (ibutilide) 0.01 mg/kg for IV over 10 min
Repeat 10 min after initial infusion if not converted to Normal Sinus Rhythm (NSR)
 KCL 20 mEq IVPB over 2 hr x 1 dose while on continuous monitoring
16.
Potassium replacement:
17.
18.
Magnesium replacement:  Magnesium Sulfate 1 gm IVPB over 1 hr x 1 dose
VTE prophylaxis, Initiate Venous Thromboembolism (VTE) Prophylaxis Orders (form # 33058)
 Low risk: No pharmacologic or mechanical prophylaxis, ambulate 3 times daily
 Heparin 5,000 units SQ q 8 hrs (q 12 hrs if wt < 50 kg or age > 75)
or
 Lovenox (enoxaparin) 40 mg SQ daily at 1700 (30 mg if CrCl < 30 ml/min)
and/or  Mechanical devices: SCDs
Order writer’s initials _________
Copy to pharmacy
*3-37191*
FORM 3-37191 REV. 12/2014
Page 1 of 2
PLACE LABEL HERE
ATRIAL FIBRILLATION
OBSERVATION 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).
PRN MEDICATIONS See policy 520-06 for range orders and pain intensity guidelines.
19.  Electrolyte Replacement Protocol (form # 21340)
20. Mild Pain, Temp >100.5F, HA:  Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
21. Moderate Pain:
 Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered.
or  If patient can not take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po
q 4 hrs prn intead of Norco. DC if Percocet ordered.
or  Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Norco ordered.
and/or  Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (15 mg if CrCl 31-50, > 65 y/o old or < 50
kg) or 10 mg po q 6 hrs prn (max combined duration of IV and po ketorolac is 5 days). DC if CrCl < 30.
22. Severe Pain (Begin when Epidural or PCA has been discontinued)
 Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered.
or  Dilaudid (HYDROmorphone) 0.25-0.5 mg IV q 3 hrs prn. If CrCl < 30, dose at 0.25 mg. Hold for
excessive sedation. DC if Morphine ordered.
23. Nausea/Vomiting:  Zofran (ondansetron) 4 mg IV or po q 6 hrs prn
 If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)
24. Sleep:
 Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn
25. Indigestion:
 Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
26. Stool Softener:
 Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
27. Constipation:
 Milk of Magnesia (MOM) 30 ml po daily prn
If no BM after 48 hrs  Dulcolax (biscodyl) 10 mg per rectum daily prn
and/or
 Senokot-S (docusate/senna) 2 tablets po at bedtime nightly
28. Cough:
 Robitussin (guaifenesin) 15 ml po q 4 hrs prn
29. Sore Throat:
 Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn
ADDITIONAL ORDERS:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________
Date
___________________
Time
_________________________________
Physician Signature
__________
PID Number
Copy to pharmacy
FORM 3-37191
REV. 12/2014
Page 2 of 2