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Thrombolytic Administration for Acute Myocardial Infarction [30400000520] Height_____________________ Weight_____________________ Allergies____________________ General Vital Signs [X] Frequent vital signs Indication: Q15 minutes x (# of occurrences): 4 Q30 minutes x (# of occurrences): 8 Q1 hour x (# of occurrences): Q2 hours x (# of occurrences): Q4 hours x (# of occurrences): Then: Per unit routine Until discontinued, Starting today Notify Provider [X] Notify physician Routine, Until discontinued, Starting today Pulse greater than: Respiratory rate less than: Respiratory rate greater than: Temperature greater than (celsius): Urine output less than (mL/hr): Systolic BP greater than: Systolic BP less than: Diastolic BP greater than: Diastolic BP less than: Other: Of any chest pain, arrhythmias, ST segment changes noted on monitored ECG, changes in central nervous system status or new onset of back or leg pain Activity [X] Bed rest Routine, Until discontinued, Starting today, With bedside commode Diet [X] Diet Liquid [X] Advance diet as tolerated Diet effective now, Starting today Diet: __________________________________________ Required Additional Modifiers: Viscosity/Liquids: Diet Comments: Once, Starting today Target Diet: Diet Cardiac Nursing Assessment [X] Check temperature [X] Pulse Apical & Peripheral Pulses [X] Intake and Output [X] Weigh patient Routine, Every 4 hours, Starting today, On admission and every 4 hours. Note every 2 hours when elevated, or more often as indicated. Routine, Once, Starting today For 1 Occurrences, Apical pulse and peripheral pulses of all four extremities on admission Routine, Every shift, Starting today, Each shift and more often if indicated. Routine, Once, Starting today For 1 Occurrences, On admission unless contraindicated Provider Initial:______________ PATIENT INFORMATION Page 1 of 6 Thrombolytic Administration for Acute Myocardial Infarction [30400000520] PHYSICIAN ORDERS [X] Daily weights Routine, Daily, Starting today, Unless contraindicated Nursing Interventions [] Saline lock IV [X] Insert peripheral IV [] No arterial or venous punctures and no IM injections Routine, Once, Starting today For 1 Occurrences, Place IV Saline Lock Routine, Once, Starting today For 1 Occurrences, Start 2 peripheral IV sites. Priothr to drug administration. Reserve antecubital site for blood draws (if possible). All thrombolytic agents should infuse alone, but Alteplase may run with Lidocaine if necessary. Do not use filtered tubing. If delay in initiating thrombolytic therapy occurs due to difficult IV access, then place 1st IV site, initiate drug, and then complete 2nd IV site. Routine, Until discontinued, Starting today, For at least 24 hours after drug infusion has been completed (this includes punctures for ABGs). Respiratory Interventions [X] Oxygen therapy Routine, Continuous, Starting today O2 Delivery Method: Nasal cannula Titrate to saturation of: 92% Indications for O2: Hypoxemia Indicate LPM/FiO2: To keep SaO2 greater than 92%. Call physician if FiO2 greater than 40% or patient requires increasing FiO2. Labs SAH, SCH, SFH, SJMC & Harrison Admission Labs [] Troponin I [] CBC and differential [] Comprehensive metabolic panel [] Protime-INR [] Activated partial thromboplastin time [] CK total and CKMB Now then every 6 hours, Starting today For 3 Occurrences Draw at 6 hours and 12 hours after chest pain onset. Once, Starting today On admission Once, Starting today For 1 Occurrences On admission Once, Starting today For 1 Occurrences On Admission Once, Starting today For 1 Occurrences On admission Now then every 6 hours, Starting today On admission and every 6 hours until peak, then discontinue Highline IP Admission Labs Thrombo MI [] [] Troponin T CBC and differential [] Comprehensive metabolic panel [] Protime-INR [] Activated partial thromboplastin time [] CK total and CKMB Once, Starting today Once, Starting today On admission Once, Starting today For 1 Occurrences On admission Once, Starting today For 1 Occurrences On Admission Once, Starting today For 1 Occurrences On admission Now then every 6 hours, Starting today On admission and every 6 hours until peak, then discontinue Provider Initial:______________ PATIENT INFORMATION Page 2 of 6 Thrombolytic Administration for Acute Myocardial Infarction [30400000520] PHYSICIAN ORDERS Daily Labs [X] POCT occult blood stool [] CBC and differential [] POCT gastric occult blood [] Activated partial thromboplastin time Routine, 3 times daily PRN, Starting today, Guaiac all stools and emesis for 72 hours after thrombolytic administration. Notify physician if positive results obtained Daily, Starting today For 3 Occurrences Daily times 3 days after thrombolytic therapy, then follow lab per Heparin Infusion Titration - Weight Bases (Not For Use in Ischemic Stroke) Physician Order (#580) while patient is on Heparin Routine, 3 times daily PRN, Starting today, Guaiac all stools and emesis for 72 hours after thrombolytic administration. Notify physician if positive results obtained Daily, Starting today For 3 Occurrences Daily times 3 days after thrombolytic therapy, then follow lab per Heparin Infusion Titration - Weight Bases (Not For Use in Ischemic Stroke) Physician Order (#580) while patient is on Heparin Imaging Chest Imaging [] X-ray chest AP portable STAT, 1 time imaging, Starting today For 1 Reason for Exam: Chest Pain Is the patient pregnant? ___________________________ Required Pharmacy Consult Pharmacy Consult [] Pharmacy general consult - Heparin Routine, Once, Starting today For Until specified, Pharmacy to dose heparin Other Tests SAH, SCH, SFH, SJMC & Highline Cardiac Studies [X] ECG 12 lead [X] ECG 12 lead [X] ECG 12 lead STAT, Once, Starting today For 1 Occurrences Reason for Exam (Signs & Symptoms): ______________ Required On admission STAT, Daily, Starting today For 2 Occurrences Reason for Exam (Signs & Symptoms): ______________ Required Every 24 hours for 2 days following the completion of the thrombolytic therapy. STAT, As needed, Starting today Reason for Exam (Signs & Symptoms): ______________ Required Stat with any chest pain/arrhythmias Harrison Cardiac Studies [] ECG 15 lead [] ECG 15 lead [] ECG 15 lead STAT, Once, Starting today For 1 Occurrences Reason for Exam (Signs & Symptoms): ______________ Required On admission STAT, Daily, Starting today For 2 Occurrences Reason for Exam (Signs & Symptoms): ______________ Required Every 24 hours for 2 days following the completion of the thrombolytic therapy STAT, As needed, Starting today Reason for Exam (Signs & Symptoms): ______________ Required Stat with any chest pain/arrhythmias Provider Initial:______________ PATIENT INFORMATION Page 3 of 6 Thrombolytic Administration for Acute Myocardial Infarction [30400000520] PHYSICIAN ORDERS Thrombolytic Administration IV Thrombolytic Administration [] IV Alteplase Adjust per Heparin Infusion Titration-Weight Based (not for use in Ischemic Stroke) Physician Order #580. Do not reduce heparin infusion rate for first 12 hours as per item #10 [] A. alteplase (ACTIVASE) 15 mg bolus, then continue to B [] B. alteplase (ACTIVASE) injection 100 mg, then continue to C [] C. alteplase (ACTIVASE) injection 100 mg [] heparin (porcine) injection 1,000 units/mL [] heparin 50 units/mL standard infusion 500 mL 15 mg, IntraVENous, for 2 Minutes, Once, For 1 Doses A. 15 mg bolus over 1-2 minutes (pump setting 450 ml/hour; dose limit 15 ml) B. 0.75 mg/kg over 30 minutes ( maximum dose=50 mg) C. 0.5 mg/kg for the next 60 minutes (maximum dose=35 mg) D. Maximum dose = 100 mg (90 minutes total infusion time) After the completion of infusion, inject 30 ml sodium chloride (Normal Saline) into bag and continue infusion until empty to ensure complete administration of dose STAT 0.75 mg/kg, IntraVENous, Once, For 1 Doses A. 15 mg bolus over 1-2 minutes (pump setting 450 ml/hour; dose limit 15 ml) B. 0.75 mg/kg over 30 minutes ( maximum dose=50 mg) C. 0.5 mg/kg for the next 60 minutes (maximum dose=35 mg) D. Maximum dose = 100 mg (90 minutes total infusion time) After the completion of infusion, inject 30 ml sodium chloride (Normal Saline) into bag and continue infusion until empty to ensure complete administration of dose STAT 0.5 mg/kg, IntraVENous, Once, For 1 Doses A. 15 mg bolus over 1-2 minutes (pump setting 450 ml/hour; dose limit 15 ml) B. 0.75 mg/kg over 30 minutes ( maximum dose=50 mg) C. 0.5 mg/kg for the next 60 minutes (maximum dose=35 mg) D. Maximum dose = 100 mg (90 minutes total infusion time) After the completion of infusion, inject 30 ml sodium chloride (Normal Saline) into bag and continue infusion until empty to ensure complete administration of dose STAT 5,000 Units, IntraVENous, Once, For 1 Doses When Activase is begun, give heparin 5,000 units IV bolus, followed by a continuous infusion at 1,000 unit/hour (standard 50 units/ml concentration) STAT 15 Units/kg/hr, IntraVENous, Continuous When Activase is begun, give heparin 5,000 units, followed by a continuous infusion at 1,000 unit/hour (standard 50 units/ml concentration) STAT IV Infusion IV Fluids [X] sodium chloride 0.9 % flush [] [] [] sodium chloride infusion 0.9% lactated ringers infusion dextrose 5 % and sodium chloride 0.9 % infusion IntraVENous, Every 8 hours, Routine Dose: ________________________________________ Required 100 mL/hr, IntraVENous, Continuous, Routine 125 mL/hr, IntraVENous, Continuous, Routine 100 mL/hr, IntraVENous, Continuous, Routine Provider Initial:______________ PATIENT INFORMATION Page 4 of 6 Thrombolytic Administration for Acute Myocardial Infarction [30400000520] PHYSICIAN ORDERS Medications Other Medications [X] nitroglycerin (NITROSTAT) SL tablet [ ] Aspirin [ ] aspirin tablet [ ] aspirin EC tablet [ ] famotidine (PEPCID) tablet [ ] ALPRAZolam (XANAX) tablet [ ] magnesium hydroxide (MILK OF MAGNESIA) suspension 400 mg/5mL 0.4 mg, SubLINgual, Every 5 min PRN, chest pain, For 3 Doses If systolic blood pressure greater than 90 mmHg and call physician Routine "And" Linked Panel 325 mg, Oral, Now, For 1 Doses Aspirin should be chewed Routine 325 mg, Oral, Daily, Starting tomorrow, Routine 20 mg, Oral, 2 times daily, Routine 0.25 mg, Oral, Every 6 hours PRN, anxiety, Routine 30 mL, Oral, 2 times daily PRN, constipation, Routine IV/IM Analgesia [] morphine injection IntraVENous, Every 1 hour PRN, severe pain, Chest pain, For 48 Hours Dose: _________________________________________ Required IV every 1 hour PRN chest pain times 48 hours Routine Oral Analgesia [] acetaminophen (TYLENOL) tablet 325-650 mg, Oral, Every 4 hours PRN, mild pain When pain is under control and patient is tolerating oral intake, trial oral pain medications Routine Sedative/ Hypnotic [] temazepam (RESTORIL) capsule 15-30 mg, Oral, Nightly PRN, sleep Limit dose to 15 mg for patients age 65 and over Routine Nausea/ Vomiting [ ] Ondansetron - Promethazine Panel [ ] ondansetron (ZOFRAN) 4 mg/2 mL injection [] promethazine (PHENERGAN) 25 mg/mL injection [] promethazine (PHENERGAN) 25 mg/mL injection 4 mg, IntraVENous, Every 4 hours PRN, nausea, vomiting If ineffective, discontinue ondansetron and give promethazine. Routine 6.25-12.5 mg, IntraVENous, Every 4 hours PRN, nausea, vomiting Use 6.25-12.5 mg IV for patients age 65 and over. Give ondansetron first. If ineffective give promethazine. Routine 12.5-25 mg, IntraVENous, Every 4 hours PRN, nausea, vomiting Give ondansetron first. If ineffective give promethazine. Routine Oral ACEI/ARB [] [] [] [] enalapril (VASOTEC) tablet lisinopril (PRINIVIL,ZESTRIL) tablet captopril (CAPOTEN) tablet losartan (COZAAR) tablet 5 mg, Oral, Daily, Routine 5 mg, Oral, Daily, Routine 6.25 mg, Oral, Every 8 hours, Routine 50 mg, Oral, Daily, Routine Provider Initial:______________ PATIENT INFORMATION Page 5 of 6 Thrombolytic Administration for Acute Myocardial Infarction [30400000520] PHYSICIAN ORDERS Beta Blockers [] For patients on prior beta-blockers begin therapy (specify) [] [] [] [] [] [] [] [] atenolol (TENORMIN) tablet carvedilol (COREG) tablet labetalol (NORMODYNE) tablet metoprolol (LOPRESSOR) tablet metoprolol (TOPROL-XL) XL tablet propranolol (INDERAL) tablet Reason for no beta-blocker at discharge DO NOT give beta blocker [] Reason for no beta-blocker at discharge Routine, Until discontinued, Starting today, Beta blocker therapy MUST be reassessed for initiation on BOTH POD #1 and POD #2 25 mg, Oral, Daily, Routine 3.125 mg, Oral, 2 times daily with meals, Routine 100 mg, Oral, 2 times daily, Routine 25 mg, Oral, 2 times daily, Routine 25 mg, Oral, Daily, Routine 20 mg, Oral, 4 times daily, Routine Reason for no Beta Blocker during perioperative period? Routine, Until discontinued, Starting today Reason for not administering beta-blocker during perioperative period?________________________________________ Required Reason for not administering beta-blocker during perioperative period? _______________________________________ Required IV Infusions [ ] Lidocaine Bolus with Infusion [ ] lidocaine (cardiac) injection [ ] lidocaine 8 mg/mL in dextrose 5% infusion [ ] nitroglycerin in D5W infusion 200 mcg/mL [] DOPamine in D5W 400 mg/250 mL (1,600 mcg/mL) infusion 1 mg/kg, IntraVENous, Once, For 1 Doses IV bolus then begin infusion at 2 mg/minute, Repeat Lidocaine bolus 0.5 - 0.75 mg/kg IV in 10 minutes. For PVCs greater than 6 per minute R on T phenomena, couplets or greater, give additional Lidocaine 0.5 mg/kg IV bolus and increase infusion rate to 3-4 mg/minute. Routine 1 mg/min, IntraVENous, Continuous, Routine 10 mcg/min, IntraVENous, at 3 mL/hr, Titrated Titrate PRN chest pain to a maximum dose of 30-50 mcg/minute or until systolic BP less than 100 mmHg Routine IntraVENous, Titrated Titrate to maintain a systolic blood pressure greater 90mmHg or MAP greater than 60mmHg. Notify physician if this infusion is required. Routine Date:_______ Time:________ Printed Name of Ordering Provider:____________________________________________________________________ Provider Signature:_______________________________________________________________________________ Date:_______ Time:_______ RN Acknowledged: _______________________________________________________________________________ Provider Initial:______________ PATIENT INFORMATION Page 6 of 6 Thrombolytic Administration for Acute Myocardial Infarction [30400000520] PHYSICIAN ORDERS