Download CARD SURG Cardiac Transplant Assessment PD 25 Nov 2016

CARD SURG
Assessment Cardiac Transplant
(Page 1 of 3)
DATE _____/_____/_______
DD
MM
YYYY
WEIGHT:_________ KG
TIME _________
BSA __________ M2
HEIGHT:_________ CM
ALLERGY CAUTION sheet reviewed
Status/Admit/Transfer/Discharge
Cardiologist: ____________________
Cardiac Surgeon: ____________________
Nurse Practitioner: ____________________
Patient Care
Measure weight
Measure height
Measure head circumference
Obtain a copy of the patient's immunization record
Mantoux Test (PPD) (*read 48hrs after)
Laboratory
Urinalysis (UA) with microscopy
Urine culture and sensitivity
Urine, albumin:creatinine ratio
Nuclear glomular filtration rate (GFR)
Routine Patient Bloodwork
regular lab req:
Complete blood cell count (CBC) differential, peripheral blood smear, reticulocyte count
Sodium level, serum
Potassium level, serum
Chloride, serum
Carbon dioxide, total (bicarbonate plus dissolved carbon dioxide)
Glucose, serum, random
Magnesium (Mg) level, serum
Calcium level, serum, total
Calcium level, ionized
Phosphate
Urea (BUN)
Creatinine (Cr), serum
Group and Screen
Ferritin
Iron
Transferrin saturation
Partial thromboplastin time (PTT)
International normalized ratio (INR)
Fibrinogen
Thyroid stimulating hormone (TSH)
Parathyroid hormone (PTH)
25-OH Vit D
Aspartate aminotransferase (AST)
Signature:_______________________________________ Print Name:____________________________________
College ID:______________________________________ Pager:________________________________________
PTN Review Date: November 15 2016
PTN# CTAv1
Exp Date: November 15 2019
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CARD SURG
Assessment Cardiac Transplant
(Page 2 of 3)
DATE _____/_____/_______
DD
MM
YYYY
WEIGHT:_________ KG
TIME _________
BSA __________ M2
HEIGHT:_________ CM
ALLERGY CAUTION sheet reviewed
Alanine aminotransferase (ALT)
Alkaline phosphatase, total
Gamma-glutamyl transferase (GGT)
Lactate dehydrogenase (LDH), serum
Bilirubin, total unconjugated and conjugated
Albumin
Cholesterol, total Fasting
Triglycerides
Cholesterol, HDL
Cholesterol, LDL
Brain natriuretic peptide (BNP)
Serology screening req:
Syphilis screen (TPS)
HIV (HIVB) - non-nominal reporting requested
Hepatitis B Screen - HBsAg, Anti-HBs, Anti-HBc Total (HBSAG)
Anti-hepatitis A Total (HAAT)
Anti-HCV (HEPCB)
Measles IgG (MIGB)
Mumps IgG (MUIGB)
Rubella IgG (RUBEB)
EBV IgG (EBGSB), EBV IgM (EBVSP)
EBV IgM (EBVSP)
EBV IgG (EBGSB)
CMV IgG (CMVIGB)
CMV IgM (CMVSP)
Varicella IgG (VZIGB)
HSV IgG (HSVIGB)
HTLV I/II (HTLVB)
Toxoplasma gondii IgG (zoonotics & emerging pathogens req)
VGH Histocompatability assessment booking form and req: sent to VGH immunology lab
HLA antibody screen (PRA) and HLA typing and ABO
Optional Bloodwork (Select all that apply)
Maternal Serology:
For patients LESS than 6 months or breatfeeding: Maternal serology
Culture, cytomegalovirus (CMV), blood
Epstein-Barr virus (EBV)
Hepatitis B (surface and core antibody)
HIV
Hepatitis A
Hepatitis C
Culture, herpes simplex virus (HSV)
Varicella
Signature:_______________________________________
Print
Name:____________________________________
College ID:______________________________________ Pager:________________________________________
PTN Review Date: November 15 2016
PTN# CTAv1
Exp Date: November 15 2019
Page 2 o f 3
CARD SURG
Assessment Cardiac Transplant
(Page 3 of 3)
DATE _____/_____/_______
DD
MM
YYYY
WEIGHT:_________ KG
TIME _________
BSA __________ M2
HEIGHT:_________ CM
ALLERGY CAUTION sheet reviewed
For females:
Beta-HCG, serum (post-menarche)
PAP testing (sexually active)
For patients less than 3 years:
Isohemagglutinin titre
For patients at risk for being carriers of Sickle Cell Anemia or Thalassemia:
Hb HPLC and Hemoglobin electrophoresis
For patients with obesity or at-risk for diabetes based on family history:
Glucose, serum, fasting
Oral glucose tolerance test (OGTT)
HbA1C
Medical Imaging
Chest xray (AP/LAT)
Abdominal and renal ultrasound
Echocardiogram
Ultrasound, head
Cardiac magnetic resonance imaging (MRI) OR computed tomography (CT)
Bone mineral density (DEXA scan) and Bone Age (Left hand x-ray)
Diagnostic Tests/Procedures
12-lead ECG
Holter monitor
Exercise test - bicycle ergometer with oxygen consumption OR treadmill OR 6 minute walk
Non-invasive cardiac output
24-hr ambulatory blood pressure monitoring (AMBP)
MIBI (stress, rest)
Multi gated acquisition study (MUGA)
Doppler - jugular, subclavian, femoral arteries and veins
Pulmonary function testing AND/OR V/Q scan
Consults
Standard Consults
Nephrology
Infectious Disease
Dentistry
Multi-organ transplant Dietitian
Multi-organ transplant psychosocial assessment (Social Work, Psychology, Psychiatry)
Occupational Therapy
Physiotherapy
Multi-organ transplant Pharmacist
Optional Consults (Select all that apply)
Neurology
Immunology
Metabolics
Adolescent medicine
Child life
Respirology
Hematology
Genetics
Dermatology
Spiritual care
Ophthalmology
Canuck place
Signature:_______________________________________
Print Name:____________________________________
College ID:______________________________________
Pager:________________________________________
PTN Review Date: November 15 2016
PTN# CTAv1
Exp Date: November 15 2019
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