Download UNSTABLE ANGINA/NON STSEGMENT ELEVATION

 3560
Print All
Physician Order Set UNSTABLE ANGINA/NON ST­SEGMENT ELEVATION MYOCARDIAL INFARCTION ADMISSION ORDERS PATIENT LABEL Link To: Thrombolysis in Myocardial Infarction Risk Score (TIMI) Source General Location c Admit to Medical/Surgical with Telemetry d
e
f
g
c Admit to ICU d
e
f
g
Responsible Service/Physicians:
Diagnosis:
Vital Signs c Routine d
e
f
g
Allergies:
Activity c Patient - may leave floor for testing without monitor d
e
f
g
Nursing Orders Assessments b Cardiac monitor Evidence c
d
e
f
g
b Measure weight - on admission
c
d
e
f
g
b Measure intake and output c
d
e
f
g
c Measure height - on admission
d
e
f
g
Interventions c For recurrent chest pain - bed rest, STAT EKG, give sublingual (SL) Nitroglycerin as ordered and notify physician. d
e
f
g
c For recurrent chest pain - If patient develops Chest Pain / Angina symptoms: Initiate Chest Pain Protocol Call, and Rapid Response Team for
d
e
f
g
New onset, recurrent, or worsening of chest pain symptoms See Urinary Catheter Initiation Orders Link Contingency b Dr. Rapid per Protocol c
d
e
f
g
Respiratory c Oxygen via nasal cannula - Titrate to keep oxygen saturation greater than 90%. Discontinue oxygen if room air saturation is greater than 90% d
e
f
g
Patient/Caregiver Education b Education, smoking cessation - If patient is a smoker c
d
e
f
g
c Print - Congestive Heart Failure patient education and documentation from Physician Work Center and give to patient and family d
e
f
g
c Print "CPR Anytime" from Physician Work Center and give to patient and family d
e
f
g
Diet Kcal c Heart Healthy - American Heart Association (AHA) diet
d
e
f
g
g Diet - 2 gm low sodium c
d
e
f
c Diet, diabetic d
e
f
g
c NPO - after midnight except for medications. No caffeine containing food or beverages d
e
f
g
Physician Name (Type):
kcc rev 10/12 nmt 03/10/11 Page 1 of 5 Pager Number:
Physician Order Set PATIENT LABEL UNSTABLE ANGINA/NON ST­SEGMENT ELEVATION MYOCARDIAL INFARCTION ADMISSION ORDERS IV Fluids c NaCl 0.9% IV at
d
e
f
g
c NaCl 0.45% IV at
d
e
f
g
mL/hr mL/hr Medications Platelet Inhibitors Aspirin Evidence c 324 mg PO NOW, if not given in the emergency department (four) 81 mg chewable tablets d
e
f
g
c 81 mg PO daily d
e
f
g
c 325 mg PO daily d
e
f
g
clopidogrel (PLAVIX) Evidence c 600 mg PO NOW if not given in the emergency department d
e
f
g
c 75 mg PO daily d
e
f
g
Beta-Blockers
Evidence Important - * Risk factors for cardiogenic shock (more risk factors present = higher risk of cardiogenic shock): Age greater than 70
years, SBP less than 120 mmHg, sinus tachycardia greater than 110 bpm or HR less than 60 bpm and increased time since onset of
symptoms of ST segment elevation myocardial infarction (STEMI). If beta-blocker contraindicated, document reason
g HOLD BETA-BLOCKERS & CALL PHYSICIAN If heart rate less than 50 beats per minute or SBP is less than 90 mmHg b
c
d
e
f
b Give first dose NOW if not given in the past 24 hours. c
d
e
f
g
metoprolol tartrate (LOPRESSOR) c 25 mg PO q12h d
e
f
g
c 50 mg PO q12h d
e
f
g
metoprolol succinate ext release (TOPROL-XL) c 25 mg PO q24h d
e
f
g
c 50 mg PO q24h d
e
f
g
c 100 mg PO q24h d
e
f
g
carvedilol (COREG) c 3.125 mg PO q12h d
e
f
g
c 6.25 mg PO q12h d
e
f
g
Antihypertensives - ACE Inhibitors/ARB
Evidence b HOLD ACE-INHIBITOR and ARB - If SBP is less than 100 mmHg, and CALL PHYSICIAN c
d
e
f
g
If ACE-INHIBITOR/ARB contraindicated, document reason
lisinopril (PRINIVIL) c 5 mg PO daily d
e
f
g
c 10 mg PO daily d
e
f
g
captopril (CAPOTEN) c 3.125 mg PO q8h d
e
f
g
c 6.25 mg PO q8h d
e
f
g
valsartan (DIOVAN) c 40 mg PO daily d
e
f
g
c 80 mg PO daily d
e
f
g
Evidence Lipid-Regulating Agents: HMG-CoA Reductase Inhibitors
If STATINS contraindicated, document reason
Physician Name (Type):
kcc rev 10/12 nmt 03/10/11 Page 2 of 5 Pager Number:
Physician Order Set UNSTABLE ANGINA/NON ST­SEGMENT ELEVATION MYOCARDIAL INFARCTION ADMISSION ORDERS PATIENT LABEL simvastatin (ZOCOR) c 20 mg PO qHS d
e
f
g
c 40 mg PO qHS d
e
f
g
atorvastatin (LIPITOR) c 10 mg PO qHS d
e
f
g
c 20 mg PO qHS d
e
f
g
c 40 mg PO qHS d
e
f
g
c 80 mg PO qHS (intensive statin therapy) d
e
f
g
rosuvastatin (CRESTOR) c 5 mg PO qHS d
e
f
g
c 10 mg PO qHS d
e
f
g
c 20 mg PO qHS d
e
f
g
Anticoagulants Adult Intravenous Heparin Therapy Protocol
IV Heparin Protocol for use with Glycoprotein llb/llla Inhibitors
enoxaparin (LOVENOX) Evidence c 1 mg/Kg SQ q12h d
e
f
g
bivalirudin (ANGIOMAX) - If planned invasive strategy and taking plavix Evidence c 0.1 mg/Kg IV once d
e
f
g
c 0.25 mg/Kg per hour IV until patient taken to cath lab d
e
f
g
fondaparinux (ARIXTRA) Evidence c 2.5 mg SQ q24h d
e
f
g
Platelet Inhibitors - GP IIb/IIIa For patients with acute MI/STEMI who are undergoing primary PCI and not receiving thrombolysis, consider the use of a GpIIb-IIIa receptor
inhibitor; however, avoid the routine use of a facilitated approach over standard PCI Evidence DO NOT USE INTEGRILIN: If serum creatinine is >4.0 mg/dL, or creatinine clearance less than 20 mL/min, or patient age greater than 80 years eptifibatide (INTEGRILIN) c 180 mcg/Kg IV as bolus dose (NOTE: Use actual body weight; Max Bolus Dose = 22.6 mg) d
e
f
g
c 2 mcg/Kg per minute IV - if CrCl is equal to or greater than 50 mL/min. d
e
f
g
c 1 mcg/Kg per minute IV - if CrCl is less than 50 mL/min. d
e
f
g
MAX RATE for continuous infusion dose = 15 mg/hr (250 mcg/minute) Nitrates Evidence Do NOT administer nitroglycerin if sildenafil (Viagra) or vardenafil (Levitra) have been taken in the past 24 hours, OR if tadalafil (Cialis) has been
taken in the past 48 hours HOLD if SBP is less than 90 mmHg nitroglycerin (NITRO-STAT) c 0.4 mg SL q5 minutes PRN chest pain - up to 3 doses d
e
f
g
nitroglycerin (NITRO-BID) c 1 inch applied topically q6h to anterior chest wall d
e
f
g
nitroglycerin 50 mg / 250 mL solution Evidence c 200 mcg/mL solution 5-10 mcg/minute continuous IV infusion PRN chest pain - Initiate at 5 mcg/minute. May titrate up to 200 mcg/minute if
d
e
f
g
needed as long as SBP remains greater than 100 mmHg. NON-ICU UNITS CANNOT TITRATE. Max rate for non-ICU cardiac units is
10mcg/min. Medications: Comfort Medications Protocol c Comfort Medications per Scott & White Protocol Source d
e
f
g
Physician Name (Type):
kcc rev 10/12 nmt 03/10/11 Page 3 of 5 Pager Number:
Physician Order Set UNSTABLE ANGINA/NON ST­SEGMENT ELEVATION MYOCARDIAL INFARCTION ADMISSION ORDERS PATIENT LABEL Stress Ulcer Prophylaxis Agents Stress ulcer prophylaxis recommended for patients who require mechanical ventilation for greater than 48 hours.
Evidence Prophylaxis also indicated for patients with ONE for the following: coagulopathy (or anticoagulated), history of recent GIB, spinal cord injury,
GLASCOW coma scale less than 11, burns covering greater than 35% body surface area, organ transplant, hepatic failure, multiple trauma,
short bowel syndrome Prophylaxis also indicated for patients with TWO of the following: sepsis, ICU stay greater than 1 week, occult bleeding for 6 days or more, use
of high dose steroids (hydrocortisone equivalent of greater than 250 mg/day). Avoid prophylaxis in patients who do not meet criteria
pantoprazole (PROTONIX) c 40 mg PO daily d
e
f
g
c 40 mg IV daily d
e
f
g
famotidine (PEPCID) c 20 mg PO q12h d
e
f
g
c 20 mg IV q12h d
e
f
g
Benzodiazepines: for anxiety or agitation Evidence ALPRAZolam (XANAX) c 0.5 mg PO q8h PRN agitation or anxiety - hold for sedation. d
e
f
g
LORazepam (ATIVAN) c 0.5 mg PO q6h PRN agitation or anxiety - hold for sedation d
e
f
g
Medications for Insomnia Evidence zolpidem (AMBIEN) c 5 mg PO qHS PRN insomnia d
e
f
g
c 10 mg PO qHS PRN insomnia d
e
f
g
temazepam (RESTORIL) c 15 mg PO qHS PRN insomnia d
e
f
g
Analgesics: Opioid Pain Medications Evidence Consider management of ischemic pain with an opioid analgesic Evidence NORCO 5-325 MG (hydrocodone-acetaminophen 5-325mg) c 1 tablet PO q4h PRN g
d
e
f
g
c Mild g
d
e
f
c Moderate g
d
e
f
c Severe Pain - May repeat dose within 4 hours if pain persists. d
e
f
NORCO 10-325 MG (hydrocodone-acetaminophen 10-325mg) c 1 tablet PO q4h PRN g
d
e
f
g
c Mild g
d
e
f
c Moderate g
d
e
f
c Severe Pain - May repeat dose within 4 hours if pain persists. d
e
f
* If patient is allergic to codeine/hydrocodone, consider using tramadol (ULTRAM) Tramadol (ULTRAM) c 50 mg PO q6h PRN g
d
e
f
g
c Mild g
d
e
f
c Moderate g
d
e
f
c Severe Pain - May repeat 50 mg dose within 6 hours if pain persists d
e
f
Morphine c 4 mg IV q2h PRN g
d
e
f
g
c Mild g
d
e
f
c Moderate g
d
e
f
c Severe Pain d
e
f
Fentanyl c 25 mcg IV q2h PRN g
d
e
f
g
c Mild g
d
e
f
c Moderate g
d
e
f
c Severe Pain d
e
f
Deep Venous Thrombosis Prophylaxis Protocol Link Laboratory Hematology c CBC with differential - in AM daily. Discontinue after day three blood draw d
e
f
g
c aPTT d
e
f
g
c PT / INR d
e
f
g
Physician Name (Type):
kcc rev 10/12 nmt 03/10/11 Page 4 of 5 Pager Number:
Physician Order Set UNSTABLE ANGINA/NON ST­SEGMENT ELEVATION MYOCARDIAL INFARCTION ADMISSION ORDERS PATIENT LABEL Chemistry A cardiac troponin should be used as the first-line cardiac biomarker for the diagnosis of acute MI; if troponin testing is not available, CK-MB
measured by mass assay, not by activity (%), should be used as an alternative Evidence c CK, CK-MB, and Troponin - I, at 6 and 12 hrs after initial set of cardiac enzymes obtained d
e
f
g
c B-type natriuretic peptide (BNP) d
e
f
g
c HbA1c - If not done in past three months d
e
f
g
Panels c CMP d
e
f
g
c BMP - In AM daily. Discontinue after day three blood draw d
e
f
g
c Fasting lipid profile in AM - (not needed if known or recently determined) d
e
f
g
Diagnostic Tests Cardiology An ECG should be ordered for all patients with chest pain of suspected cardiac etiology
Evidence c 12-lead ECG - on admission
d
e
f
g
c 12-lead ECG - in AM.
d
e
f
g
Evidence Evidence Reason
Consults b Consult to Cardiac Rehabilitation c
d
e
f
g
c Consult to cardiology d
e
f
g
b Consult to dietitian, adult - for heart healthy diet modification and education c
d
e
f
g
c If in CHF - consult Dietary - “Congestive Heart Failure, Salt & Fluid Restriction”. d
e
f
g
Medication Reconciliation Link Additional Orders
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Physician Name (Type):
Physician Signature (Required):_____________________ kcc rev 10/12 nmt 03/10/11 Page 5 of 5 Pager Number:
Date:______________Time______________ Print All