Download Order Set: ED Non-STEMI Unstable Angina Orders

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Physician Orders ADULT
Order Set: ED Non-STEMI Unstable Angina Orders
[R] = will be ordered
T= Today; N = Now (date and time ordered)
Height: ___________cm Weight: __________kg
[ ] No known allergies
Allergies:
[ ]Medication allergy(s):_____________________________________________________________________
[ ] Latex allergy
[ ]Other:__________________________________________________________________
Admission/Transfer/Discharge
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Patient Status Initial Inpatient
Bed Type: [ ] Med Surg [ ]Critical Care [ ] Stepdown [ ] Obstetrics [ ] Other
Patient Status Initial Outpatient
Outpatient Status/Service: [ ] OP-Ambulatory [ ] OP-Diagnostic Procedure [ ] OP-Observation Services
NOTE to MD:
Initial status – inpatient --- For a condition/dx with severity of illness or co-morbid conditions indicating a hospital
stay greater than 24 hours is required.
Initial Status Outpatient – Ambulatory surgery – Outpatient surgery/procedure with discharge anticipated after a
routine or, in some cases, extended recovery.
• Routine recovery after outpatient surgery is estimated at 6-8 hours.
• “Extended” routine recovery may be required for a patient to stay longer (could be overnight) to recover from
anticipated sequela of surgery including effects of anesthesia, nausea, pain.
• For unanticipated sequela of surgery or a complicated post operative course, the patient may require a status
change to inpatient. Please consult with a case manager before making this choice of “status change”.
• Examples: Initial status outpatient is generally selected for patients undergoing PCI, diagnostic caths, EP studies,
ablations, pacemaker implantations, other routine surgeries.
Initial status Outpatient -Observation Services – Short term treatment, assessment and reassessment - estimate
g within 24 hours
discharge
• In some cases (for Medicare patients), this can be extended to 48 hours.
• Observation Services can also be utilized when it is unclear (without additional assessment) whether the patient will
require an inpatient stay.
T;N, of room number on arrival to unit
[ ] Notify physician once
Primary Diagnosis:
Secondary Diagnosis: __________________________________________________
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Vital Signs
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Bedrest w/BRP
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NPO
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Old Chart to Floor
Intermittent Needle Therapy
Insert/Site (INT Insert/Site Care)
Intermittent Needle Therapy
Insert/Site (INT Insert/Site Care)
O2 Sat Spot Check-NSG
O2 Sat Monitoring NSG
Telemetry (Cardiac Monitoring)
Whole Blood Glucose Nsg (Bedside
Glucose Nsg)
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ED Non-STEMI Unstable Angina-20530-QM-0808013112 (Fayette 0412)
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Vital Signs
T;N, q2h(std), based on patient condition
Activity
T;N
Food/Nutrition
Start at: T;N
Patient Care
T;N
T;N,q4day
T;N,Stat,q4day,secondary site
T;N
T;N
T;N, Stat
T;N
*111*
attach patient label here
Physician Orders ADULT
Order Set: ED Non-STEMI Unstable Angina Orders
[R] = will be ordered
T= Today; N = Now (date and time ordered)
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Nasal Cannula (O2-BNC)
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ISTAT Blood Gases (RT Collect)
(ABG- RT Collect)
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Respiratory Care
T;N Routine, 2 L/min, Special Instructions: Titrate O2 to keep O2 sat greater
than or equal to 92%
T;N Stat once
Continuous Infusions
500 mL, IV, STAT, ( 1 dose ), 1,000 mL/hr
1,000 mL,IV,STAT,T;N,75 mL/hr
Medications
Radiocontrast Nephropathy Prophylaxis (RCN) Protocol (see order set below)
VTE Prophylaxis (MEDICAL) Orders attached
NOTE: If aspirin not ordered/given, must document reason not given and/or contraindications.
T;N
Contraindication-Aspirin
[ ] Aspirin allergy
[ ] Intracranial bleed
[ ] GI bleed
[ ] Preadmission oral anticoagulation therapy
[ ] Aspirin sensitivity
[ ] Blood disorder
[ ] Gastritis
[ ] Peptic Ulcer Disease
[ ] Risk of bleeding
aspirin
324 mg,Chew tab,PO,once,STAT,T;N
aspirin
300 mg,Supp,PR,once,PRN Other, specify in Comment,STAT,T;N
NOTE: Select below to document Beta Blocker contraindication
Contraindication-Beta Blocker
T;N
Beta Blocker contraindicated
Beta-Blocker
[ ] Symptomatic bradycardia [ ] Symptomatic hypotension [ ] Moderate/severe LV dysfunction
[ ] Shock/impaired perfusion [ ] PR interval greater than 0.24 seconds on EKG [ ] Second or third degree heart
block without pacemaker
[ ] Active asthma/reactive airway disease
[ ] Other:_______________________________
Sodium Chloride 0.9%
Sodium Chloride 0.45%
metoprolol
5 mg, Injection, IV Push, q5min, STAT, ( 3 dose )
metoprolol
25 mg,Tab,PO,once,STAT,T;N
simvastatin
40 mg,Tab,PO,once,STAT,T;N
atorvastatin
80 mg, Tab, PO, once, STAT
NOTE: Hold Nitroglycerin if SBP less than 100mmHg.
nitroglycerin
0.4 mg, Tab, SL, q5min, PRN Chest Pain, STAT
nitroglycerin (nitroglycerin 50
50 mg / 250 mL, IV, STAT, Titrate
mg/D5W infusion)
morPHINE
2 mg,Injection,IV Push,q5min,PRN Chest Pain,STAT,T;N,( 3 dose )
Heparin Non-VTE Protocol Orders
ondansetron
4 mg,Injection,IV Push,once,STAT,T;N
ondansetron
4 mg, Injection, IV Push, q6h, PRN Nausea/Vomiting, STAT
clopidogrel
600 mg,Tab,PO,once,STAT,T;N
clopidogrel
75 mg,Tab,PO,once,STAT,T;N
ED Non-STEMI Unstable Angina-20530-QM-0808013112 (Fayette 0412)
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attach patient label here
Physician Orders ADULT
Order Set: ED Non-STEMI Unstable Angina Orders
[R] = will be ordered
T= Today; N = Now (date and time ordered)
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Medications continued
Glycoprotein IIb/IIIa Dosing Protocol (see order set below)
acetaminophen
650 mg, Tab, PO, q4h, PRN Headache, STAT
NOTE: If magnesium level is less than 2.1mEq/mL, order Magnesium Sulfate below:
magnesium sulfate
2 g,Injection,IV Piggyback,Routine,T;N,( infuse over 2 hr )
famotidine
20 mg,Injection,IV Push,once,STAT,T;N
Laboratory
Lipid Profile
T;N, STAT, once, Type: Blood, Nurse Collect
CBC
T;N, STAT, once, Type: Blood, Nurse Collect
Comprehensive Metabolic Panel
T;N, STAT, once, Type: Blood, Nurse Collect
(CMP)
Chem 8 Profile POC
T;N, Stat
Prothrombin Time (PT/INR)
T;N, STAT, once, Type: Blood, Nurse Collect
Partial Thromboplastin Time (PTT) T;N, STAT, once, Type: Blood, Nurse Collect
Magnesium Level
T;N, STAT, once, Type: Blood, Nurse Collect
Brain Natriuretic Peptide (BNP)
BNP by Triage POC
T;N, Stat
D-Dimer Quantitative
Urine Drug Screen Triage
STAT, T;N, once, Type: Urine, Nurse Collect
Drug Screen Stat Urine ED Only
T;N, STAT, once, Type: Urine, Nurse Collect
Drug Screen Stat Urine
T;N, STAT, once, Type: Urine, Nurse Collect
Drug Abuse Screen Urine
STAT, T;N, once, Type: Urine, Nurse Collect
NOTE: If possiblitiy of pregnancy, and not previously done in past 72 hours, order appropriate pregnancy
Pregnancy Screen Serum
T;N, STAT, once, Type: Blood, Nurse Collect
Pregnancy Screen Urine
T;N, STAT, once, Type: Urine, Nurse Collect
Pregnancy Screen Urine Point of
T;N, Stat, once
Care
Diagnostic Tests
Electrocardiogram (EKG)
Start at: T;N, Priority: Stat, Frequency: once
Electrocardiogram (EKG)
Start at: T;N, Priority: Stat
Chest 1VW Frontal
T;N, Reason for Exam: Chest Pain, Stat, Portable
Chest 2VW Frontal & Lat
T;N, Reason for Exam: Chest Pain, Stat, Stretcher
CT Thorax W Cont
T;N, Reason for Exam: Chest Pain, Stat, Stretcher
CT Thorax W Cont
T;N, Reason for Exam: Pulmonary Embolism, Stat, Stretcher
CT Thorax W Cont
T;N, Reason for Exam: Aneurysm, Stat, Stretcher
CT Thorax & Abdomen W/Cont Orders (CT Chest & Abdomen W/Cont Orders)
Consults/Notifications
Physician Consult
T;N, Consult: interventional cardiologist
Physician Consult
T;N, Consult: cardiologist
Physician Consult
T;N, Consult: Primary Care Physician
Notify Physician-Continuing
T;N, Notify: physician, recurrent chest pain;new or sustained arrhythmias;
systolic BP less than 90 mmHg or greater than 180mmHg; excessive
bruising,bleeding, or hematoma; syncope/pre-syncope;headache or mental
status changes; heart rate less than 45bpm or greater than 120bpm.
__________________
__________________
Date
Time
ED Non-STEMI Unstable Angina-20530-QM-0808013112 (Fayette 0412)
Page 3 of 3
_________________________________________________
Physician's Signature
__________________
MD Number
attach patient label here
Physician Orders
Care Set: Radiocontrast Nephropathy Prophylaxis
(RCN) Protocol
[X or R] = will be ordered unless marked out.
T= Today; N = Now (date and time ordered)
[ ]Medication allergy(s):______________________________________________________________________________
[ ] Latex allergy
[ ]Other:_________________________________________________________________________
Primary Diagnosis: _____________________________________________________
Secondary Diagnosis: __________________________________________________
RCN Protocol Standard Orders
NOTE:
Risk factors: Diabetes, Heart Failure, Age greater than 75 years, SCr
greater than 1.5 mg/dL or Estimated GFR less than 60 mL/min
RCN Protocol Standard Pre Procedure Orders
Dextrose
5%
in
Water
1,000
mL
+
[ ]
150mEq/1,000mL, IV, routine, T;N, (1 hr), 3mL/kg/hr, Comment: Infuse at
sodium bicarbonate (additive)
3mL/kg/hr over 1 hour prior to procedure
150 mEq
[ ] Sodium Chloride 0.9%
1,000mL, IV, routine, T;N, (12 hr), 1mL/kg/hr, Comment: Infuse at
1mL/kg/hr prior to procedure
[ ] Sodium Chloride 0.45%
1,000mL, IV, routine, T;N, (12 hr), 1mL/kg/hr, Comment: Infuse at
1mL/kg/hr prior to procedure
RCN Protocol Standard Post Procedure Orders
[ ] Dextrose 5% in Water 1,000 mL +
150mEq/1,000mL, IV, routine, T;N, (6 hr), 1mL/kg/hr; Comment: Infuse at
sodium bicarbonate (additive)
1mL/kg/hr
150 mEq
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Sodium Chloride 0.9%
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Sodium Chloride 0
0.45%
45%
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Date
__________________
Time
23017-QM-ver2-PT-RCN Prophy Protocol-Ver3
011912 Page 1 of 1
1,000mL,IV, routine, T;N, (12 hr), 1mL/kg/hr; Comment: Infuse at
1mL/kg/hr
1 000mL IV routine
1,000mL,IV,
routine, T;N
T;N, (12 hr)
hr), 1mL/kg/hr; Comment: Infuse at
1mL/kg/hr
_________________________________________________
Physician's Signature
__________________
MD Number
*111*
Attached patient label here
Physician Orders- ADULT
Physician Orders-ADULT
VTE Medical Prophylaxis Orders
[R] = will be ordered
T= Today; N = Now (date and time ordered)
Height: ___________cm Weight: __________kg
Allergies:
[ ]Medication allergy(s):_____________________________________________________________________
[ ] Latex allergy
[ ]Other:__________________________________________________________________
NOTE: Medical Risk Factor Assessment, Bleeding Risk Factor Assessment and Mechanical Device (SCD)
Contraindication Assessment criteria is listed below VTE orders.
VTE ORDERS
If Bleeding Risk is Present, place SCD order below:
T;N, Apply To: Lower Extremities, Comment: Bleeding Risks Present
[ ] Sequential Compression Device
Apply
If NO Bleeding Risk Present, place ONE Heparin or Enoxaparin order below and place both CBC orders:
5,000 units,Injection, subcutaneous, q12h, Routine, T;N, Comment:
[ ] heparin
Pharmacist may adjust administration times after first dose.
5,000 units,Injection, subcutaneous, q8h, Routine, T;N, Comment:
[ ] heparin
Pharmacist may adjust administration times after first dose.
OR
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enoxaparin
AND BOTH CBCs:
[ ] CBC w/o Diff Routine
[ ] CBC w/o Diff Time Studyy
Do Not Administer VTE Prophylaxis:
[ ] Contraindication-VTE Prophylaxis
40 mg, Injection, Subcutaneous, Qday, Routine, T;N, If CrCl less than 30
mL/min, pharmacy to adjust dose to 30mg SQ Qday. Pharmacist may adjust
administration times after first dose.
Routine,T;N, once, Type: Blood,
Routine,T+2;0400,
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, QODay,
y, Type:
yp Blood
T;N, Reason: Patient has bleeding risk for anticoagulants, and SCDs are
contraindicated. Consider early ambulation.
MEDICAL RISK FACTOR ASSESSMENT: This is a partial list of medical risk factors. Clinicians are advised to consider
other risk factors or conditions that may predispose patients to DVT/PE. Check all that may apply:
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Prolonged immobilization, paralysis, or bed rest ordered
ICU patient
Sepsis diagnosis or Active Infection
Active inflammatory bowel disease
Cancer and/or presence of malignancy
Heart Failure
Respiratory Disease (COPD or Pneumonia)
Ischemic Stroke (non-hemorrhagic)
Prior history of VTE or Pulmonary Embolism
Age greater than 45
Morbid Obesity (BMI greater than 35)
Central Line or PICC Line
Current treatment with estrogens (Oral contraceptives; Hormone Replacement Therapy)
Hereditary clotting disorder
Pregnancy with diagnosed clotting disorder or Antiphospholipid Syndrom diagnosis
Nephrotic Syndrome
No medical risk factors exist
VTE MEDICAL PROPHYLAXIS-22225-QM1008 Ver 4 032911 Page 1 of 2
*111*
Attached patient label here
Physician Orders- ADULT
Physician Orders-ADULT
VTE Medical Prophylaxis Orders
[R] = will be ordered
T= Today; N = Now (date and time ordered)
BLEEDING RISK FACTOR ASSESSMENT: This is a partial list of bleeding risk factors. Clinicians are advised to consider
other risk factors or conditions that may predispose patients to DVT/PE. Check all that may apply:
[ ] Patient already receiving anticoagulation therapy with warfarin, heparin, fondaparinux, enoxaparin or other
anticoagulation therapy
[ ] Active bleeding
[ ] INR greater than 1.5 and patient NOT on warfarin therapy
[ ] INR greater than 2 and patient ON warfarin therapy
[ ] Transplant patients with platelet count less than 100,000
[ ] Platelet count less than 50,000 (applies to patients with no history of transplant procedures)
[ ] Solid organ transplant during this episode of care OR within 30 days of admission
[ ] Documented bleeding or Coagulopathy disorder
[ ] Hemorrhagic Stroke within 6 weeks of admission
[ ] Severe Uncontrolled Hypertension
[ ] Recent Intraocular or Intracranial surgery
[ ] Vascular Access or Biopsy sites inaccessible to hemostatic control
[ ] Recent Spinal Surgery
[ ] Epidural or Spinal Catheter
[ ] Pregnancy, Possible Pregnancy or Postpartum (to include up to 6 weeks post partum)
[ ] Heparin Induced Thrombocytopenia (HIT)
[ ] Heparin allergy or pork allergy
[ ] No Bleeding Risk Factors exists
MECHANICAL DEVICE (SCD) CONTRAINDICATION ASSESSMENT
K
or suspected
t d deep
d
vein
i thrombosis
th
b i or pulmonary
l
embolism
b li
[ ] Known
[ ] Acute stages of inflammatory phlebitis process
[ ] Disruptions in lower extremity skin integrity ( surgical incision, recent skin graft, dermatitis, etc. )
[ ] Arterial occlusion
[ ] Instances where increased venous or lymphatic return is undesirable
[ ] Massive lower extremity edema
[ ] Unable to place device
__________________
__________________
Date
Time
VTE MEDICAL PROPHYLAXIS-22225-QMVer 4 032911 Page 2 of 2
_________________________________________________
Physician's Signature
__________________
MD Number
attach patient label here
Physician Orders ADULT
Order Set: Glycoprotein Iib/IIIa Dosing Protocol
Orders
[R] = will be ordered
T= Today; N = Now (date and time ordered)
Height: ___________cm Weight: __________kg
[ ] No known allergies
Allergies:
[ ]Medication allergy(s):_____________________________________________________________________
[ ] Latex allergy
[ ]Other:__________________________________________________________________
[ ] Glycoprotein Iib/IIIa Dosing Protocol T;N
Or (Glycoprotein Iib/IIIa Dosing
Protocol Orders Initiate)
NOTE: Select either Reopro OR Integrilin orders from below:
NOTE: If platelet count < 100,000, abciximab (ReoPro) is contraindicated and will not be given
ReoPro Dose Orders
NOTE: If platelet count < 100,000, abciximab (ReoPro) is contraindicated and will not be given
[ ] ReoPro - Glycoprotein IIb/IIIa Orders
0.25 mg/kg, Injection, IV Push, once, Routine, Comment: Administer over 2[ ] abciximab
3 minutes
7.2 mg / 250 mL, IV, Routine, ( 12 hr ), 0.125 mcg/kg/min, Comment:
[ ] abciximab infusion
Maximum rate= 10mcg/min
Integrilin ACS Dose Orders
NOTE: If patient is on dialysis, eptifibatide (Integrillin) is contraindicated and won't be given:
[ ] Integrilin ACS Dose Orders
NOTE: Choose bolus and infusion orders from below:
180 mcg/kg, Injection, IV Push, once, Routine, (1 Dose), Comment:
[ ] eptifibatide (eptifibatide bolus)
Administer over 1 minute.
[ ] eptifibatide (eptifibatide infusion (75 75 mg / 100 mL, IV, Routine, ( 24 hr ), 2 mcg/kg/min
mg/100 mL))
NOTE:If calculated CrCl less than 50 ml/min (based on actual weight), place order below:
[ ] eptifibatide (eptifibatide infusion (75 75 mg / 100 mL, IV, Routine, ( 24 hr ), 1 mcg/kg/min
mg/100 mL))
Integrilin Cath Lab Dose Orders
[ ] Integrilin Cath Lab Dose Orders
180 mcg/kg, Injection, IV Push, q10min, Routine, ( 2 dose )
[ ] eptifibatide (eptifibatide bolus)
[ ] eptifibatide (eptifibatide infusion (75 75 mg / 100 mL, IV, Routine, ( 24 hr ), 2 mcg/kg/min
mg/100 mL))
NOTE: If calculated CrCl less than 50 ml/min (based on actual weight), place order below:
[ ] eptifibatide (eptifibatide infusion (75 75 mg / 100 mL, IV, Routine, ( 24 hr ), 1 mcg/kg/min
mg/100 mL))
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Date
Time
PT Glycoprotein Iib-IIIa Dosing Protocol-23006QM1208 Ver4 110411 Page 1 of 1
_________________________________________________
Physician's Signature
__________________
MD Number
*111*