PLACE LABEL HERE
POST CAROTID ANGIOGRAM and
STENT PLACEMENT
ORDERS
The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
1. Do you expect that the patient’s condition will require a hospital stay that will cross two midnights (includes the time spent in outpatient- ED, surgery, OBS) and the patient has medical necessity for an inpatient admission?
q Yes, admit as inpatient, proceed to # 2 q No, place in observation
2. If admitted as inpatient, Inpatient Physician Certification:
Diagnosis: ______
Level of Care: q Critical q Intermediate q Acute Care Location/Specialty Unit Preference______
3. q Telemetry: If patient Medical/Surgical, must complete form # 36084
4. q Isolation: q Contact q Droplet q Airborne For: ______
5. CBC and Chem 7 in am
6. SHEATH REMOVAL ACT GUIDELINES or PATIENT on ANGIOMAX (bivalirudin)
q For patient on Heparin: Remove sheath when ACT 180 secondsIf ACT is: / Recheck in:
≥ 180 but < 220 seconds
≥ 220 but < 250 seconds
≥ 250 but < 300 seconds
300 seconds / 45 minutes
1 hour
2 hours
3 hours
q For patient on Angiomax: Remove sheath 2 hrs after infusion discontinued, or per physician order
7. Vital signs, procedure site and neurovascular checks q 15 min x 4, then q 30 min x 2, then q hr until sheath is removed, then routine
8. Notify physician for: SBP < 90 or HR < 60 Visual changes
Change in neurological status Hematoma/bleeding
Decreased or absent distal pulses Itching, rash, or flushing
Extremity numbness, weakness, or pain Severe headache
9. q Insert Foley Catheter for inability to void; D/C when bed rest is complete
10. O2 per Protocol (seq # 34431)
11. Diet: Full liquids until sheath is out, then: q Cardiac q Diabetic _____ calorie q Renal
12. Activity: q Manual pressure: Bed rest x ____hrs with affected leg straight & HOB at 30°
q Vascular closure device placed: Bed rest x ____ hrs with affected leg straight & HOB at 30°
SCHEDULED MEDICATIONS
13. IV Fluids: ______IV at ______ml/hr for ______hours
14. If on metformin (Glucophage, Glucovance), hold for 48 hours post procedure
15. q Plavix (clopidogrel): q 300 mg po now or q 600 mg po now
q 75 mg po daily starting in am
q Aspirin: q 325 mg po daily
q 81 mg po daily
q Brilinta (ticagrelor): q 180 mg now
q 90 mg po bid starting this pm, use only with Aspirin 81 mg max daily dose
q Effient (prasugrel), avoid if > 75 y/o unless diabetic or hx of MI, < 60 kg, hx of TIA/Stroke, or likely to undergo CABG surgery):
q 60 mg po now
q 10 mg po daily starting in am
Copy to pharmacy Order writier’s initials ______
*3-3118* FORM 3-3118 REV. 06/2014 Page 1 of 2
PLACE LABEL HERE
POST CAROTID ANGIOGRAM and
STENT PLACEMENT
ORDERS
The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
16. Vasopressor:
q Neosynephrine (PHENYLephrine), 20-200 mcg/min.
Change rate: 20-60 mcg/min q 2 min to maintain MAP > 65 or SBP > 90
q DOPAmine, 2 mcg/kg/min to unit specific max.
Change rate: 2 mcg/kg/min q 5 min to maintain MAP > 65 and HR > 60 & < 120
q Levophed (NORepinephrine), 0.5-30 mcg/min.
Change rate: 2-10 mcg/min q 2 min to maintain MAP > 65 or SBP > 90
PRN MEDICATIONS See policy 520-06 for range orders and pain intensity guidelines
17. Symptomatic heart rate < 50/min: q Atropine 0.5-1 mg IV prn x 1 dose. After 5 min, may repeat x 1 dose
18. If patient receiving insulin, initiate Hypoglycemia Treatment Standing Orders (form # 2513)
19. If patient is in critical or intermediate care: initiate Insulin SQ Correction Dose in Critical Care Standing Orders (form # 21386)
20. Electrolyte Replacement Protocol (form # 21340)
21. Chest pain: Nitroglycerin 0.4 mg sublingual q 5 minutes x 3 doses prn
22. Severe Pain or Chest pain unrelieved with max IV or SL Nitroglycerin
Morphine 2 mg IV q 5 min prn (up to a max of 10 mg in 2 hrs), Hold for excessive sedation
or q DC Morphine. Dilaudid (HYDROmorphone) 0.5-1 mg IV q 15 min prn (max 2 mg in 30 min)
23. Moderate Pain:
Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn
or q DC Norco. Give Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn
24. Mild Pain, Temp >100.5°F, HA: Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
25. Nausea/Vomiting: Zofran (ondansetron) 4 mg IV or po q 6 hrs prn
q If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)
26. Sleep: q Ambien (zolpidem)5-10mg po at HS prn. If 5 mg given, may repeat x 1 dose after 2 hrs
If > 65 year old, begin with 5 mg po at HS prn, may repeat x 1 dose after 2 hrs
or q Other: ______
27. Anxiety : q Ativan (lorazepam) 0.5 - 1 mg po or IV q 8 hrs prn.
or q DC Ativan. Give Xanax (alprazolam) 0.25 - 0.5 mg po q 6 hrs prn.
28. Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
29. Stool Softener: Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
30. Constipation: Milk of Magnesia (MOM) 30 ml po daily prn
ADDITIONAL ORDERS:
______
______
______
Date Time Physician Signature PID Number
Copy to pharmacy
FORM 3-3118 REV. 06/2014 Page 2 of 2