Download Thrombolytic Administration for Acute Myocardial Infarction

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
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Saline lock IV
[X] Insert peripheral IV
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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
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Troponin I
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CBC and differential
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Comprehensive metabolic panel
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Protime-INR
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Activated partial thromboplastin time
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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
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Troponin T
CBC and differential
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Comprehensive metabolic panel
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Protime-INR
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Activated partial thromboplastin time
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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
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CBC and differential
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POCT gastric occult blood
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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
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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
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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
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ECG 15 lead
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ECG 15 lead
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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
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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
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A. alteplase (ACTIVASE) 15 mg bolus, then continue to B
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B. alteplase (ACTIVASE) injection 100 mg, then continue to C
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C. alteplase (ACTIVASE) injection 100 mg
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heparin (porcine) injection 1,000 units/mL
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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
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[]
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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
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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
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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
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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
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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
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promethazine (PHENERGAN) 25 mg/mL injection
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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
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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
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For patients on prior beta-blockers begin therapy (specify)
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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
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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