Download Order Set: Open Heart Post Op Plan -UNIV ONLY

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Physician Orders ADULT
Order Set: Open Heart Post Op Plan -UNIV ONLY
[R] = will be ordered
Open Heart Immediate Postop Op and POD #1 Phase
T= Today; N = Now (date and time ordered)
Admission Height (Actual): ___________cm Admission Weight (Actual): __________kg
[ ] No known allergies
Allergies:
[ ]Medication allergy(s):_____________________________________________________________________
[ ] Latex allergy
[ ]Other:__________________________________________________________________
ATTENTION SURGEON: Please discontinue Open Heart Pre Op orders prior to initiation of the Open Heart Post
Op Plan.
T;N
[R] Open Heart Postop Care Track
T;N, Qday, Pathway: Open Heart Post Op Clinical Pathway
[R] Clinical Pathway
Admission/Transfer/Discharge
T;N, Bed Type: Critical Care, Unit Location: CVICU
[ ] Transfer Patient
T;N, of room number on arrival to unit
[ ] Notify physician once
Primary Diagnosis: _____________________________________________________
Secondary Diagnosis: __________________________________________________
Operative Procedure:____________________________________________________
Surgeon:______________________________________________________________
Vital Signs
Vital Signs
T;N, T, P, R, BP, PA pressures and SaO2 q15min. x8, q30min. x4, q1h for a total of
12 hrs then q2h if patient hemodynamically stable. Comment: Continuous EKG, BP
[ ]
and SaO2 monitoring. Begin on arrival to CVICU.
Arterial Blood Pressure Monitoring T;N, connect to invasive pressure monitoring, if off vasoactives and inotropes
discontinue arterial line after 0400 lab draw on POD #1. Otherwise discontinue prior
[ ]
to transfer from CVICU.
Arterial Blood Pressure Monitoring T;N, connect to invasive pressure monitoring, discontinue prior to transfer from
[ ]
CVICU
CVICU.
Hemodynamic Parameters
T;N, SBP less than 160 mm Hg or greater than 90 mm Hg, Temperature greater
than or equal to 38.5 deg C, HR less than 120 bpm or greater than 60 bpm, Oxygen
[ ]
Saturation greater than 92%, MAP greater than 60 mm Hg or less than 100 mm Hg
[ ]
[ ]
[ ]
[ ]
Nursing Communication
Bedrest
Out of Bed
Bath
Activity
T;N, Nursing to follow the activity guidelines in the "Routine Care of Cardiac,
Thoracic and Vascular Surgery Patient" policy.
T;N, Routine, Comment: HOB elevated 30 degrees.
T;N, How: Up to Chair starting POD#1 or when hemodynamically stable, TID,
T;N. Qday, PRN, Comment: Bathe daily with chlorhexidine. Discontinue once
invasive lines removed.
*111*
CV SURG UNIV ONLY PILOT-Open Heart Post Op
Plan-20811-PP-QM0212 022912
Page 1 of 11
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Physician Orders ADULT
Order Set: Open Heart Post Op Plan -UNIV ONLY
[R] = will be ordered
Open Heart Immediate Postop Op and POD #1 Phase
T= Today; N = Now (date and time ordered)
Food/Nutrition
T;N
[ ] NPO
Advance Diet As Tolerated
T;N, Start clear liquid diet 4 hours after extubation and progress to AHA diet as
[ ]
tolerated
Advance Diet As Tolerated
T;N, If on insulin drip, start on glucose control supplement 4 hours after extubation
[ ]
and progress to 1800 ADA diet as tolerated.
Restrict Fluids
T;N, Routine, 1500 mL oral fluids q24h, Comment: Begin POD #1 for patients who
[ ]
underwent cardiopulmonary bypass (on-pump).
Patient Care
Cardiac Output Obtain
T;N, Routine, upon arrival to CVICU, q30min. x2, q1h x 6hrs and/or while titrating
vasoactive infusions, advance to q2h once patient hemodynamically stable, include
[ ]
hemodynamic profile.
Heat Apply
T;N, Apply To: Entire body, Apply Method: Forced Air Blanket, Comment: Apply if
core temperature less than 36 degrees Celsius. May remove once temperature
[ ]
greater than or equal to 37 degrees Celsius.
Chest Tube Care
T;N, Suction Strength: Low Continuous, To Suction At: -20cm, clean with
[ ]
chlorhexidine and sterile water daily
Intake and Output
T;N, Routine, q1h by indwelling catheter x 12hrs, then advance to q2hrs and PRN
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[
[
[
[
]
]
]
]
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[ ]
Indwelling Urinary Catheter Care
T;N, Routine, q-shift, PRN, to gravity
Indwelling Urinary Catheter Remove T;N, Routine, Discontinue on morning of 2nd post-op day, if unable to discontinue
notify cardiothoracic (CT) surgeon and document reason urinary catheter remains.
Incision Care
T;N, Routine, q24h(std), PRN, Initial operative CHEST DRESSING to remain intact
x 12 hours
hours, then cleanse incision with chlorhexidine 2% soap and sterile water
water, paint
with chloroprep, apply dry sterile dressing. Remove dressing when
incision no longer draining.
Incision Care
T;N, Routine, q24h(std), PRN, Initial operative LEG DRESSING to remain intact x
24 hours, then cleanse incision with chlorhexidine 2% soap and sterile water, paint
with chloroprep, apply dry sterile dressing. Remove dressing when
incision no longer draining.
Incision Care
T;N, Routine, q24h(std), PRN, Initial operative ARM DRESSING to remain intact x
24 hours, then cleanse incision with chlorhexidine 2% soap and sterile water, paint
with chloraprep, apply dry sterile dressing. Remove dressing when
incision no longer draining.
Incentive Spirometry NSG
T;N, Routine, q1h-Awake, and PRN
Cough and Deep Breathe
T;N, Routine, q1h-Awake, and PRN
Turn
T;N, Routine, Comment: Reposition q2h
Weight
T+1;0600, Routine, POD #1
Nasogastric Tube
T;N, NG Tube Type: ________________, NG Tube Size:______________,Suction
Strength: Low Intermittent, Suction Type: Nasal, To Suction at:______________
Irrigate with 30mL Normal Saline PRN. Insert NGT if patient is intubated greater
than 24 hours or PRN for nausea/vomiting.
Oral Gastric Tube Insert
T;N, Suction Strength: Low Intermittent, Suction Type: Oral, To Suction
at:______________
Irrigate with 30mL Normal Saline PRN.
Oral Gastric Tube Care
T;N, Suction Strength: Low Intermittent, Suction Type: Oral, Irrigate with 30mL
Normal Saline PRN.
CV SURG UNIV ONLY PILOT-Open Heart Post Op
Plan-20811-PP-QM0212 022912
Page 2 of 11
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Physician Orders ADULT
Order Set: Open Heart Post Op Plan -UNIV ONLY
[R] = will be ordered
Open Heart Immediate Postop Op and POD #1 Phase
T= Today; N = Now (date and time ordered)
Patient Care continued
T;N, Discontinue NG/OG tube following extubation once bowel sounds present.
[ ] Nursing Communication
Temporary Pacemaker Critical Care T;N, Pacing Wire Type: ______, Rate:________, Pacemaker Mode:________,
Milliamps: ______, Atrial Sensitivity:______, Ventricular Sensitivity: ______, AV
[ ]
Interval (milliseconds)
Pacing Wire Care
T;N, Routine, QDay, Connect Temporary Pacemaker and do not turn on. Connect to
[ ]
generator for symptomatic bradycardia and notify cardiothoracic surgeon,
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
Sternal Support Bra Apply
T;N, Apply to chest as soon as possible after surgery
Nursing Communication
Nursing Communication
T; N, If off vasoactives and inotropes, discontinue pulmonary artery catheter after
0400 lab draw on POD #1, Otherwise discontiue prior to transfer from CVICU.
Nursing Communication
T; N, discontiue PA catheter prior to transfer from CVICU.
Nursing Communication
T;N, If radial artery incision, elevate extremity, vascular checks with vital signs, no IV
or blood pressures in affected arm, no tape on affected arm
Respiratory Care
ABG - RT Collect
STAT, T;N,once
NOTE: If patient IS a candidate for ventilator weaning place the "CV Surgery Ventilator Weaning Orders" Careset
NOTE: If patient IS NOT a candidate for ventilator weaning place the "Ventilator Bundle - Sedation and Analgesia
Orders" Careset
Continuous Infusions
NOTE: If potassium level greater than or equal to 5 mmoL/L, do not order potassium chloride in IV fluids
Sodium Chloride 0.45%
1,000 mL, IV, Routine, 75 mL/hr
Sodium Chloride 0.45% with KCl 20 1,000 mL, IV, Routine, 50 mL/hr
mEq
Hemodynamic Managementand Vasoactive Infustion
DOBUTamine infusion
500 mg / 250 mL, IV, Routine, titrate, Comment: Continue rate set by anesthesia or
begin at 5 mcg/kg/min; titrate in increments of 2.5 mcg/kg/min as often as every 10
min to maintain CO/CI systolic blood pressure greater than _________. Max dose
equals 20mcg/kg/min, Conc: 2000mcg/mL
DOPamine infusion
400 mg / 250 mL, IV, Routine, titrate, Comment: Continue rate set by anesthesia or
begin at 5 mcg/kg/min; titrate in increments of 2.5 mcg/kg/min as often as every 10
min to maintain systolic BP greater than __________mmHg or MAP of 65 mmHg.
Max dose equals 20mcg/kg/min, Conc: 1600 mcg/mL
epinephrine Infusion
1 mg / 250 mL, IV, Routine, titrate, Comment: Continue rate set by anesthesia or
begin at ______ mcg/kg/min; titrate in increments of 1mcg/min as often as every 5
min to maintain systolic BP greater than ______________mmHg or MAP of 65
mmHg. Max dose equals 100 mcg/min. Conc: 4 mcg/mL
milrinone 20 mg/100 mL-D5%
intravenous solution
phenylephrine infusion
[ ]
20 mg / 100 mL,IV, Routine, titrate, Comment: Continue rate set by anesthesia or
begin at 0.5 mcg/kg/min titrate in increments of every 5 min to maintain CO/CI
greater than ________. Max dose equals 0.75 mcg/kg/min.
50 mg / 250 mL NS,IV, Routine, titrate, Comment: Continue rate set by anesthesia
or if MAP less than 75 mmHg and cardiac index greater 2.2, start at 50 mcg/min and
titrate by 10 mcg/min every 5 minutes to maintian SBPof _________ or MAP of
________. (Maximum dose 360 mcg/min)
CV SURG UNIV ONLY PILOT-Open Heart Post Op
Plan-20811-PP-QM0212 022912
Page 3 of 11
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Physician Orders ADULT
Order Set: Open Heart Post Op Plan -UNIV ONLY
[R] = will be ordered
Open Heart Immediate Postop Op and POD #1 Phase
T= Today; N = Now (date and time ordered)
Hemodynamic Managementand Vasoactive Infustion continued
niCARdipine infusion 200 mL
40 mg / 200mL, IV, Routine,T;N, titrate, Comment: Continue rate set by anesthesia
or begin at 5 mg/hr; titrate in 2.5mg/hr increments as often as every 15 min to
maintain systolic BP less than 140 but greater than 100 mmHg or MAP less than 95
[ ]
mmHg but greater than 60 mmHg. Max dose equals 15mg/hr. Conc: 0.2 mg/mL
nitroglycerin 50 mg/D5W infusion
250 mL
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
50 mg / 250 mL,IV, Routine,T;N, titrate, Comment: Continue rate set by anesthesia
or begin at 5 mcg/min, increase by 5 mcg/min increments every 3-5 min to maintain
systolic BP less than 140 but greater than 100 mmHg or MAP less than 95 but
greater than 60 mmHg. Max dose equals 200 mcg/min. Conc: 200 mcg/mL
nitroprusside 50mg + sod.
thiosulfate 500mg in D5W 250 ml
250 mL,IV, Routine, titrate, Comment: Continue rate set by anesthesia or begin at
0.5 mcg/kg/min increments every 5 min to maintain systolic BP less than 140 but
greater than 100 mmHg or MAP less than 95 but greater than 60 mmHg. Max dose
equals 10 mcg/kg/min, may double, triple or quadruple strength.
Continuous Infusions continued
Norepinephrine 16 mg/NS infusion 250 mL, IV, Routine, titrate, Comment: Continue rate set by anesthesia or begin at
______ mcg/kg/min: titrate in increments of 2mcg/min as often as every 5-10 min.to
maintain systolic BP greater than ___________mmHg or MAP of 65 mmHg. Max
dose equals 90mcg/min. Final concentration 64 mcg/mL.
Vasopressin infusion
50 units / 50 mL NS, IV, Routine, _____ units/min. Comment: Continue rate set by
anesthesia or begin 0.04 units/min. Maintain at this rate.
Electrolyte Replacement
Attention
Surgeon: D
Do nott order
the electrolyte
Att ti S
d any off th
l t l t replacement
l
t orders
d
ffor a patient
ti t with
ith a serum creatinine
ti i
greater than or equal to 2 mg/dL or for a patient with a history of adrenal insufficiency.
Nursing Communication
T;N, Prior to beginning any of the electrolyte replacement orders, discontinue any
other preoperative electrolyte replacement order(s).
Potassium Replacement - Serum Potassium less than or equal to 2.5 mmol/L
potassium chloride
20 mEq, IV Piggyback, IV Piggyback, N/A over 1 hour, PRN, PRN Reason:
Hypokalemia, Routine, Comment: x 3 doses. Give if potassium level less than or
equal to 2.5 mmol/L. Run at 10 mEq/hr if given peripherally.
Nursing Communication
T;N, Place order for Potassium Level 2 hours after completion of Potassium
replacement. Continue replacement guidelines until potassium level is greater than
or equal to 3.5 mmol/L.
Potassium Replacement - Serum Potassium 2.6 - 3 mmol/L
potassium chloride
20 mEq, IV Piggyback, IV Piggyback, N/A over 1 hour, PRN, PRN Reason:
Hypokalemia, Routine, Comment: x 2 doses. Give if potassium level 2.6 - 3 mmol/L.
Run at 10 mEq/hr if given peripherally.
Nursing Communication
T;N, Place order for Potassium Level 2 hours after completion of Potassium
replacement. Continue replacement guidelines until potassium level is greater than
or equal to 3.5 mmol/L.
CV SURG UNIV ONLY PILOT-Open Heart Post Op
Plan-20811-PP-QM0212 022912
Page 4 of 11
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Physician Orders ADULT
Order Set: Open Heart Post Op Plan -UNIV ONLY
[R] = will be ordered
Open Heart Immediate Postop Op and POD #1 Phase
T= Today; N = Now (date and time ordered)
Potassium Replacement - Serum Potassium 3.1 - 3.4 mmol/L
potassium chloride
20 mEq, IV Piggyback, IV Piggyback, over 1 hour, (1 dose), PRN, PRN Reason:
Hypokalemia, Routine, Comment: x 1 dose. Give if potassium level 3.1 - 3.4
[ ]
mmol/L. Run at 10 mEq/hr if given peripherally. Comment: May give PO if tolerating
fluids and if greater than 4 hours after extubation.
potassium chloride
40 mEq, Oral Soln, PO, N/A, PRN, PRN Reason: Hypokalemia, Routine, (total of 40
mEq Potassium Chloride), Comment: x 1 dose. If tolerating PO fluids and greater
[ ]
than 4 hours after extubation.
Nursing Communication
T;N, Place order for Potassium Level 2 hours after completion of Potassium
replacement. Continue replacement guidelines until potassium level is greater than
[ ]
or equal to 3.5 mmol/L.
Magnesium Replacement - Serum Magnesium less than or equal to 1.2 mg/dL.
Notify Physician-Continuing
T;N, Notify Who:cardiothoracic surgeon, Notify For: if magnesium level less than or
[ ]
equal to 0.5 mg/dL.
magnesium sulfate
4 g, Injection, IV Piggyback, over 4 hours, N/A, PRN, PRN Reason:
Hypomagnesemia, Routine, Comment: x 1 dose. Give if serum magnesium is less
[ ]
than or equal to 1.2 mg/dL.
Nursing Communication
T;N, Place order for magnesium level 8 hours after completion of magnesium
infusion. Continue replacement guidelines until magnesium level is greater than or
[ ]
equal to 1.8 mg/dL.
Magnesium Replacement - Serum Magnesium 1.3 - 1.7 mg/dL
magnesium sulfate
2 g, Injection, IV Piggyback, N/A, PRN, PRN Reason: Hypomagnesemia, Routine,
(infuse over 2 hr), serum magnesium 1.3 - 1.7 mg/dL, Comment: x 1 dose. May give
[ ]
PO if tolerating oral fluids and if greater than 4 hours after extubation
extubation.
magnesium oxide
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
800 mg, Tab, PO, N/A, PRN, PRN Reason: Hypomagnesemia, Routine, Comment:
x 1 dose for serum magnesium 1.3 - 1.7 mg/dL. If tolerating oral fluids and greater
than 4 hours after extubation.
Nursing Communication
T;N, Place order for magnesium level 8 hours after completion of magnesium
infusion. Continue replacement guidelines until magnesium level is greater than or
equal to 1.8 mg/dL.
Ionized Calcium Replacement - Ionized Calcium level less than or equal to 0.8 mmol/L
Notify Physician-Continuing
T;N, Notify cardiothoracic surgeon if Ionized Calcium level less than or equal to 0.8
mmol/L after 1 replacement dose.
calcium gluconate
2g, Injection, IV Piggyback, N/A, PRN, PRN Reason:Hypocalcemia x 1 dose (infuse
over 2 hr) ionized calcium level less than or equal to 0.8 mmol/L
Nursing Communication
T;N, Place order for ionized calcium level 2 hours post calcium replacement.
Comment: Continue replacement until ionized calcium level is greater than or equal
to 0.81 mmol/L.
Ionized Calcium Replacement - Ionized Calcium level 0.81 mmol/L to 1 mmol/L
calcium gluconate
1g, Injection, IV Piggyback, N/A, PRN, PRN Reason: Hypocalcemia, x 1 dose
(infuse over 1 hr) ionized calcium level between 0.81 mmol/L and 1 mmol/L
Nursing Communication
T;N, Place order for ionized calcium level 2 hours post calcium replacement.
Comment: Continue replacement until ionized calcium level is greater than or equal
to 0.93 mmol/L.
CV SURG UNIV ONLY PILOT-Open Heart Post Op
Plan-20811-PP-QM0212 022912
Page 5 of 11
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Physician Orders ADULT
Order Set: Open Heart Post Op Plan -UNIV ONLY
[R] = will be ordered
Open Heart Immediate Postop Op and POD #1 Phase
T= Today; N = Now (date and time ordered)
Serum Phosphorus Replacement - Serum Phosphate level less than or equal to 1 mg/dL
Nursing Communication
T;N, If serum phosphate level is less than or equal to 1 mg/dL and potassium level
is less than or equal to 3.5 mmol/L, give potassium phosphate plus potassium
[ ]
chloride, as replacement therapy. If the serum potassium level is greater than 3.5
mmol/L, then use sodium phosphate as replacement therapy.
Sodium phosphate
45 mmol, IV Piggyback, IV Piggyback, N/A, PRN, PRN Reason: Hypophosphatemia,
Routine, Comment: x 1 dose, over 6 hours. If serum phosphate level is less than or
equal to 1 mg/dL and potassium level is less than or equal to 3.5 mmol/L, give
[ ]
potassium phosphate plus potassium chloride, as replacement therapy. If the
serum potassium level is greater than 3.5 mmol/L, then use sodium phosphate as
replacement therapy.
POTASSIUM phosphate
45 mmol, IV Piggyback, IV Piggyback, N/A, PRN, PRN Reason: Hypophosphatemia,
Routine, Comment: x 1 dose, over 6 hours. If serum phosphate level is less than or
equal to 1 mg/dL and potassium level is less than or equal to 3.5 mmol/L, give
[ ]
potassium phosphate plus potassium chloride, as replacement therapy. If the
serum potassium level is greater than 3.5 mmol/L, then use sodium phosphate as
replacement therapy.
Nursing Communication
T;N, Place order for serum phosphate level 2 hours post serum phosphorus
treatment. Comment: Continue replacement until serum phosphate level is greater
[ ]
than or equal to 2.5 mmol/L.
Serum Phosphorus Replacement - Serum Phosphate level 1 to 1.9 mg/dL
Nursing Communication
T;N, If serum phosphate level is 1 - 1.9 mg/dL and potassium level is less than or
equal to 3.5 mmol/L, give potassium phosphate plus potassium chloride, as
[ ]
replacement therapy
therapy. If the serum potassium level is greater than 3
3.5
5 mmol/L
mmol/L, then
use sodium phosphate as replacement therapy.
Sodium phosphate
30 mmol, IV Piggyback, IV Piggyback, N/A, PRN, PRN Reason: Hypophosphatemia,
Routine, Comment: x 1 dose, over 4 hours. If serum phosphate level is 1 - 1.9
mg/dL and potassium level is less than or equal to 3.5 mmol/L, give potassium
[ ]
phosphate plus potassium chloride, as replacement therapy. If the serum
potassium level is greater than 3.5 mmol/L, then use sodium phosphate as
replacement therapy.
POTASSIUM phosphate
30 mmol, IV Piggyback, IV Piggyback, N/A, PRN, PRN Reason: Hypophosphatemia,
Routine, Comment: x 1 dose, over 4 hours. If serum phosphate level is 1 - 1.9
mg/dL and potassium level is less than or equal to 3.5 mmol/L, give potassium
[ ]
phosphate plus potassium chloride, as replacement therapy. If the serum
potassium level is greater than 3.5 mmol/L, then use sodium phosphate as
replacement therapy.
Nursing Communication
T;N, Place order for serum phosphate level 2 hours post serum phoshorus
replacement. Comment: Continue replacement until serum phosphate level is
[ ]
greater than or equal to 2.5 mmol/L.
Serum Phosphorus Replacement - Serum Phosphate level 2 to 2.4 mg/dL
Nursing Communication
T;N, If serum phosphate level is 2 - 2.4 mg/dL and potassium level is less than or
equal to 3.5 mmol/L, give potassium phosphate plus potassium chloride, as
[ ]
replacement therapy. If the serum potassium level is greater than 3.5 mmol/L, then
use sodium phosphate as replacement therapy.
CV SURG UNIV ONLY PILOT-Open Heart Post Op
Plan-20811-PP-QM0212 022912
Page 6 of 11
attach patient label here
Physician Orders ADULT
Order Set: Open Heart Post Op Plan -UNIV ONLY
[R] = will be ordered
Open Heart Immediate Postop Op and POD #1 Phase
T= Today; N = Now (date and time ordered)
Serum Phosphorus Replacement - Serum Phosphate level 2 to 2.4 mg/dL continued
Sodium phosphate
15 mmol, IV Piggyback, IV Piggyback, N/A, PRN, PRN Reason: Hypophosphatemia,
Routine, Comment: x 1 dose over 2 hours.If serum phosphate level is 2 - 2.4 mg/dL
and potassium level is less than or equal to 3.5 mmol/L, give potassium phosphate
[ ]
plus potassium chloride, as replacement therapy. If the serum potassium level is
greater than 3.5 mmol/L, then use sodium phosphate as replacement therapy
POTASSIUM phosphate
[ ]
15 mmol, IV Piggyback, IV Piggyback, N/A, PRN, PRN Reason: Hypophosphatemia,
Routine, Comment: x 1 dose over 2 hours. If serum phosphate level is 2 - 2.4 mg/dL
and potassium level is less than or equal to 3.5 mmol/L, give potassium phosphate
plus potassium chloride, as replacement therapy. If the serum potassium level is
greater than 3.5 mmol/L, then use sodium phosphate as replacement therapy
Nursing Communication
T;N, Place order for serum phosphate level 2 hours post serum phosphorus
replacement. Comment: Continue replacement until serum phosphate level is within
therapeutic range (3.1 - 5.6 mmol/L).
Antiplatelet Therapy - STS Requirement - Must Complete
VTE CABG and Valve SURGICAL Prophylaxis Plan (See separate order set for CABG and Valve VTE SURGICAL
[R]
Prophylaxis Orders - 25007.)
NOTE: Required element - Select order below to document contraindication
T;N
[ ] Contraindication - Aspirin
[ ] Aspirin allergy
[ ] GI bleed
[ ] Aspirin sensitivity
[ ] Gastritis
[ ] Risk of bleeding
[ ] Peptic Ulcer Disease
[ ] Intracranial bleed
[ ] Preadmission oral anticoagulation therapy
[ ] Blood disorder
325 mg, EC Tablet, PO, Qday,Routine, Comment: Begin POD #1.
[ ] aspirin
aspirin
325 mg, Tab, tube, once, Routine, Comment: Give 4 hours after admission to
CVICU. Hold if chest tube drainage greater than or equal to 500 mL in one hour or
[ ]
greater than or equal to 100 mL every hour x 4hr. Administer via OGT.
aspirin
300 mg, Supp, PR, once, Comment: Give 4 hours after admission to CVICU. Hold if
chest tube drainage greater than or equal to 500 mL in one hour or greater than or
[ ]
equal to 100 mL every hour x 4hr.
Beta Blocker Therapy - STS Requirement - Must Complete
NOTE: Required element - Select order below to document contraindication
T;N, Beta-Blocker Open Heart Surgery
[ ] Contraindication - Beta Blocker
[ ] Beta-Blocker Allergy
[ ] Second or third degree heart block without pacemaker
[ ] Symptomatic bradycardia
[ ] Symptomatic hypotension
[ ] Moderate/severe LV dysfunction
[ ] Shock/impaired perfusion
[ ] PR interval greater than 0.24 seconds on EKG
[ ] Heart Failure or cardiogenic shock
[ ] Active asthma/reactive airway disease
[ ] patient is supported by inotropes or vasopressors
metoprolol
2.5 mg, Injection, IV Push, q6h, Routine, Comment: Beta Blocker should be
administered within 6 hours of arrival to CVICU, HOLD if: HR less than 50 bpm,
[ ]
systolic BP less than 90mmHg, 1st degree AVB greater than 0.24, 2nd or 3rd
degree heart block. Hold if on inotropic or vasopressor support.
[ ]
CV SURG UNIV ONLY PILOT-Open Heart Post Op
Plan-20811-PP-QM0212 022912
Page 7 of 11
attach patient label here
Physician Orders ADULT
Order Set: Open Heart Post Op Plan -UNIV ONLY
[R] = will be ordered
Open Heart Immediate Postop Op and POD #1 Phase
T= Today; N = Now (date and time ordered)
Beta Blocker Therapy - STS Requirement - Must Complete continued
metoprolol
25 mg, tab, PO, bid, Routine, Comment: Beta Blocker should be administered within
6 hours of arrival to CVICU, HOLD if: HR less than 50 bpm, systolic BP less than
90mmHg, 1st degree AVB greater than 0.24, 2nd or 3rd degree heart block. Hold if
[ ]
on inotropic or vasopressor support. If unable to take PO, administer via OGT.
[ ]
[ ]
[ ]
[ ]
[ ]
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[ ]
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[ ]
[ ]
[ ]
Notify Physician-Continuing
Nursing Communication
T;N, Notify Who: Cardiothoracic (CT) surgeon, Notify For: if beta blocker held
T;N, When patient is tolerating PO, discontinue IV metoprolol and convert to
metoprolol 25 mg, Tab, PO, BID.
Statin Therapy - STS Requirement - Must Complete
NOTE: Required element - Select order below to document contraindication
Contraindication - Statin
T;N
[ ] Abnormal liver function tests
[ ] Patient Intolerance
atorvastatin
40mg, Tab, PO, hs, Routine, Comment: Start night of surgery, may give via OGT if
intubated or unable to tolerate PO
ACE Inhibitor/ARB STS Requirement - Must Complete
ACE - I / ARB if EF less than 40%
NOTE: Required element - Select order below to document contraindication
Contraindication-ACE-I / ARB
T;N
[ ] ACEI and ARB allergy
[ ] Pregnancy
[ ] Angioedema
[ ] Renal Artery Stenosis
[ ] Cough
[ ] Symptomatic Hypotension
[ ] Hyperkalemia
[ ] Worsening renal function / renal disease / dysfuction
[ ] Moderate to severe aortic stenosis [ ] Other: ______________________________________
lisinopril
2.5 mg, Tab, PO Qday, Routine, Comment: Begin POD #1. Hold if SBP less than
90 mmHg
lisinopril
5 mg, Tab, PO Qday, Routine, Comment: Begin POD #1. Hold if SBP less than 90
mmHg
valsartan
80 mg, Tab, PO, Qday, Routine, Comment: Begin POD #1. Hold if SBP less than 90
mmHg
Notify Physcian-Continuing
T;N, Notify Who: Cardiothoracic (CT) surgeon, Notify For: if ACE-I or ARB held.
Atrial Fibrillation Protocol
NOTE: Place separate careset orders for Post CV Surgery Diltiazem Atrial Fibrillation Protocol Orders (See
separate order sheet Post CV Surgery Diltiazem Atrial Fibrillation Protocol)
Antibiotic Prophylaxis
Cefazolin
2gms, IV Piggyback, IV Piggyback, q8hr, x 2 doses. Comment: time first of two post
op doses 8 hours after last dose, not to exceed past 48 hours postop from OR stop
time
OR
Cefuroxime (Zinacef)
1.5 g, IV Piggyback, IV Piggyback, q12hr, x 1 dose. Comment: time first post op
dose 12 hours after last dose, not to exceed past 48 hours postop from OR stop
time
PLUS
Vancomycin
1 g, IV Piggyback, IV Piggyback, q12hr, x 1 dose. Comment: time first post op dose
12 hours after last dose, not to exceed past 48 hours postop from OR stop time
CV SURG UNIV ONLY PILOT-Open Heart Post Op
Plan-20811-PP-QM0212 022912
Page 8 of 11
attach patient label here
Physician Orders ADULT
Order Set: Open Heart Post Op Plan -UNIV ONLY
[R] = will be ordered
Open Heart Immediate Postop Op and POD #1 Phase
T= Today; N = Now (date and time ordered)
Antibiotic Prophylaxis continued
If beta lactam allergic (anaphylaxis) history, order Vancomycin.
Vancomycin
1 g, IV Piggyback, IV Piggyback, q12hr, x 1 dose. Comment: time first post op dose
12 hours after last dose, not to exceed past 48 hours postop from OR stop time
[ ]
[ ]
[ ]
[ ]
[ ]
mupirocin topical 2% nasal ointment 1 application, Nasal, bid, Routine, Comment: Apply 1/2 inch both nares. Discontinue
w/applicator
if nasal culture negative.
Anti-Hyperglycemic
NOTE: If Insulin drip was NOT initiated in OR, place separate careset orders for Insulin Sliding Scale Protocol
Orders (See separate order set for PT Insulin Sliding Scale Protocol - 23025.)
Whole Blood Glucose Nsg
T;N, Routine, q2h with sliding scale insulin, If glucose result less than 150mg/dL for
24 hrs without administration of insulin, change bedside glucose monitoring to q4h
for 24 hours.
Whole Blood Glucose Nsg
T+1;0500, once, If result greater than or equal to 150 mg/dL, place the "ICU
Glycemic Control Protocol Orders" Careset and repeat blood glucose at 0600. If
0600 glucose greater than 150 mg/dL continue the "ICU Glycemic Control Protocol
Orders" Careset. When glucose is < 200 mg/dL change IV fluids to: D51/2NS with
40 mEq of KCL at 50 ml/hr.
Nursing Communication
T;N, If insulin drip was initiated in OR and is currently infusing, continue at current
rate, place careset orders "ICU Glycemic Control Protocol Orders" orderset
Nursing Communication
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
T;N, If glucose is greater than 150 mg/dL on two consecutive results, begin the ICU
Glycemic Control Protocol Orders. When glucose is < 200 mg/dL change IV fluids
to: D51/2NS with 40 mEq of KCL at 50 ml/hr.
Di
Diuretic
ti
furosemide
40 mg, Injection, IV Push, once, Routine, Comment: Begin POD #1 for patients who
underwent cardiopulmonary bypass (on-pump).
Analgesic/Sedation
acetaminophen-OXYcodone 325 mg- 1 tab, Tab, PO, q4h, PRN Pain, Mild (1-3), Routine, Comment: Administer when
5 mg oral tablet
taking Full Liquid and/or Regular diet, Not to exceed 4,000 mg acetaminophen in 24
hours.
acetaminophen-OXYcodone 325 mg- 2 tab, Tab, PO, q4h, PRN Pain, Moderate (4-7), Routine, Comment: Administer
5 mg oral tablet
when taking Full Liquid and/or Regular diet, Not to exceed 4,000 mg acetaminophen
in 24 hours.
morPHINE sulfate
2 mg, injection, IV Push, q 2 hours, PRN, pain, Moderate (4-7), Comment: If unable
to take PO.
morPHINE sulfate
4 mg, injection, IV Push, q 2 hours, PRN, pain, Severe (8-10)
acetaminophen - HYDROcodone
1 tab, Tab, PO, q4h, PRN Pain, Mild (1-3), Routine, Comment: Administer when
325 mg-5 mg oral tablet
taking Full Liquid and/or Regular diet, Not to exceed 4,000 mg acetaminophen in 24
hours.
acetaminophen - HYDROcodone
2 tab, Tab, PO, q4h, PRN Pain, Moderate (4-7), Routine, Comment: Administer
325 mg-5 mg oral tablet
when taking Full Liquid and/or Regular diet, Not to exceed 4,000 mg acetaminophen
in 24 hours.
Antidote
protamine
50 mg, Injection, IV Piggyback, once, (12 hour duration), (infuse over 10 min), PRN,
STAT, Comment: Administer if ACT greater than or equal to 130 seconds and chest
tube drainage greater than or equal to 150 mL/hr, ONLY while intubated.
Notify Physcian-Continuing
T;N, Notify cardiothoracic (CT) surgeon when Protamine administered.
CV SURG UNIV ONLY PILOT-Open Heart Post Op
Plan-20811-PP-QM0212 022912
Page 9 of 11
attach patient label here
Physician Orders ADULT
Order Set: Open Heart Post Op Plan -UNIV ONLY
[R] = will be ordered
Open Heart Immediate Postop Op and POD #1 Phase
T= Today; N = Now (date and time ordered)
Antipyretic
acetaminophen
650 mg, 1 Tab, PO, q4h, PRN temperature greater than 38.5 degrees Celsius,
[ ]
Routine, Comment: Not to exceed 4,000 mg acetaminophen in 24 hours.
acetaminophen
650 mg, 1 Supp, PR, q4h, PRN temperature greater than 38.5 degrees Celsius,
[ ]
Routine, Comment: Not to exceed 4,000 mg acetaminophen in 24 hours.
GI Prophylaxis
sucralfate
1 g, Tab, tube, q6h, Routine, Comment: Give via OGT. Discontinue once extubated.
[ ]
[ ]
ondansetron
[ ]
docusate sodium
albumin human (albumin, human
5%)
[ ]
[
[
[
[
[
[
[
]
]
]
]
]
]
]
[ ]
[ ]
CBC w/o Diff
Comprehensive Metabolic Panel
Magnesium Level
Phosphorus Level
C l i
I i d
Calcium
Ionized
Prothrombin Time (PT)
Partial Thromboplastin Time (PTT)
ISTAT Blood Gases (RT Collect)
Nursing Communication
Nursing Communication
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
CBC w/o Diff
Comprehensive Metabolic Panel
(CMP)
Magnesium Level
Phosphorus Level
CBC w/o Diff
Comprehensive Metabolic Panel
(CMP)
Magnesium Level
Phosphorus Level
ISTAT Blood Gases (RT Collect)
[ ]
Antiemetic
4 mg, Injection, IV Push ,q6h, PRN Nausea/Vomiting,Routine
Bowel Regime
100 mg, Cap ,PO, bid, Routine, Comment: Begin POD #1.
Medications
25 g, IV Piggyback N/A, PRN, Routine, Reason: hypovolemia, Infuse over 10 min. if
MAP less than 75 mmHg and Cardiac Index less than 2.2, may repeat x1 dose to
raise filling pressures to adequate levels. Notify cardiothoracic (CT) surgeon if MAP
and cardiac index not corrected within 30 min. of treatment or if indices deteriorate
during treatment.
Laboratory (Immediate PostOp)
STAT, T;N,once,Type: Blood, Nurse Collect
STAT, T;N,once,Type: Blood, Nurse Collect
STAT, T;N,once,Type: Blood, Nurse Collect
STAT, T;N,once,Type: Blood, Nurse Collect
STAT T;N,once,Type:
TN
T
Bl d Nurse
N
C ll t
STAT,
Blood,
Collect
STAT, T;N,once,Type: Blood, Nurse Collect
STAT, T;N,once,Type: Blood, Nurse Collect
T;N, STAT, once, Preferred Specimen Type: Mixed Venous, Special Instructions:
Nurse Collect
T;N, Comment: Place order for Ionized Calcium 2 hrs after 2nd unit of PRBC
transfused.
T;N, Comment: Place order for Hct/Hgb, Prothrombin Time (PT), Partial
Thromboplastin Time (PTT), Platelet Count, Activated Clotting Time (ACT) if chest
tube drainage is greater than or equal to 150mL/hr, ONLY while intubated.
Laboratory 6 hours After Admission to CVICU
Time Study, T;N+360, once, Type: Blood, Nurse Collect
Time Study, T;N+360, once, Type: Blood, Nurse Collect
Time Study, T;N+360, once, Type: Blood, Nurse Collect
Time Study, T;N+360, once, Type: Blood, Nurse Collect
Laboratory POD #1
T+1;0400, once,Type: Blood,Nurse Collect
T+1;0400, once,Type: Blood,Nurse Collect
T+1;0400, once,Type: Blood,Nurse Collect
T+1;0400, once,Type: Blood,Nurse Collect
T+1;0400, Routine q24h, Preferred Specimen Type: Mixed Venous, Special
Instructions: Nurse Collect, If oximetric swan remains in. Discontinue once
oximetric swan removed.
.
CV SURG UNIV ONLY PILOT-Open Heart Post Op
Plan-20811-PP-QM0212 022912
Page 10 of 11
attach patient label here
Physician Orders ADULT
Order Set: Open Heart Post Op Plan -UNIV ONLY
[R] = will be ordered
Open Heart Immediate Postop Op and POD #1 Phase
T= Today; N = Now (date and time ordered)
Diagnostic Tests (Immediate PostOp)
T;N,STAT, Reason for Exam: Line placement,Portable
[ ] Chest 1VW Frontal
T;N, STAT, Reason: Post Op
[ ] Electrocardiogram (EKG)
Nursing Communication
T;N, EKG PRN for rhythm or ST segment changes on telemetry or for chest pain,
[ ]
order EKG "STAT".
Diagnostic Tests POD #1
T+1, 0400, Routine, Reason: Post Op
[ ] Electrocardiogram (EKG)
Chest 1VW Frontal
T+1;0400, Routine, Reason for Exam: Other, Enter in Comment:,Other reason:
[ ]
Postop, Inspiratory, Portable
Consults/Notifications
Physician Consult
T;N, Consult Who: Cardiologist: ___________________, Reason for Consult:
[ ]
Patient known to you,
Physician Consult
T;N, Consult Who: PCP:______________________, Reason for consult: Patient
[ ]
known to you,
Physician Consult
T;N, Consult who: Nephrologist:____________________, Reason for Consult:
[ ]
Patient currently receiving dialysis,
Physician Consult
T;N, Consult Who: Pulmonologist:______________________, Reason for Consult:
[ ]
Patient seen pre op,
Physician Group Consult
T;N, Group: UTMG Endocrinology, Reason for Consult: Diabetic patient, blood
[ ]
glucose management, Comment: Post Op open heart surgery
Cardiac Rehab Consult/Doctor
T;N, Reason for Consult: Cardiac Rehab Phase I for ambulation Comment: Post Op
[ ]
Order
open heart surgery
T;N, Routine, Type of Consult: Nutrition management
[ ] Dietitian Consult
T;N, Special Instructions: Notify: Cardiothoracic (CT) surgeon,
[ ] Notify Physician of Chest Pain
Notfiy Physician- Continuing
T;N, Notify Who: Cardiothoracic (CT) surgeon, Notify For: Vitals sign outside of
[ ]
those listed on the "Hemodynamic Parameters" order provided.
Notify Physician-Continuing
T;N, Notify Who: Cardiothoracic (CT) surgeon, Notify For:Chest tube output greater
than or equal to 150 mL/hr x 2 hours, urine output less than or equal to 30 mL/hr x 2
[ ]
hours.
Notify Physician-Continuing
T;N, Notify Who: Cardiothoracic (CT) surgeon, Notify For: Symptomatic
[ ]
dysrhythmia, ST segment changes or Atrial Fibrillation.
Notify Physician-Continuing
T;N, Notify Who: Cardiothoracic (CT) surgeon, Notify for: If pain not adequately
[ ]
controlled.
Notify Physician-Continuing
T;N, Notify Who: Cardiothoracic (CT) surgeon, Notify For: CVP less than or equal to
18 mm Hg, PAD less than or equal to 18 mm Hg, Cardiac Index less than or equal
[ ]
to 2L/min/m2.
Notify Physician-Continuing
T;N, Notify Who: Cardiothoracic (CT) surgeon, Notify For: If MAP and cardiac index
not corrected within 30 minutes of albumin treatment or if indices deteriorate with
[ ]
treatment.
__________________
__________________
Date
Time
_________________________________________________
Physician's Signature
CV SURG UNIV ONLY PILOT-Open Heart Post Op
Plan-20811-PP-QM0212 022912
Page 11 of 11
__________________
MD Number