Open Box indicates optional order, activated when checked R.

R Checked box indicates mandatory order unless crossed out.

Admit to monitored bed; if not available telemetry: Dr. ______to consult or assume MRP

Diagnosis: ______

Comorbidities: a) ______b) ______c) ______

Code Status: Full Resuscitation No Defibrillation

No CPR No Intubation

Defibrillation only Do Not Resuscitate

Family Physician: Same as MRP, or ______

Clinical Pathway: R Cerner order for Acute Coronary Syndromes Pathway

Consults

RClinical Nutrition Pharmacy Physiotherapy CCAC

Discharge Planning Occupational Therapy Social Work

Speech/Language Pathologist Cardiac Rehab Program Healthy Heart Program

CHF Clinic if Class II-IV

· Criteria for Congestive Heart Failure (CHF) Clinic: Patients with confirmed diagnosis of CHF

· Referral to CHF Clinic (519) 376-2648 or (888) 525-0553 Mon-Fri 0700 to 2000

Diet

Regular Diet Regular Diet, NPO after 2400 hrs NPO

May take meds with sips if NPO Energy Controlled Diet _____kcal

Healthy Heart Diet Other Diet: ______

Communication

R Follow Cardiac Activity Levels Protocol

Vital Signs

VS + O2 sats q4h x 24h, QID x 24h, then BID when stable

VS + O2 sats q4h VS + O2 sats qshift VS+ O2 sats q ______h

Respiratory

O2 to keep O2 sats greater than 92% COPD Patient: O2 to keep O2 sats 88% - 92%

O2 ______L/minute via NP O2 ______

Patient Care

Direct Care R Height and Weight on admission R Daily Weight

R Chart fluid intake and output x 24h then reassess

Tubes/Drains: Foley Catheter NG tube suction NG tube straight drain

POC: POC Capillary Glucose qid x 2 days POC Capillary Glucose daily

Laboratory

(Order details routine and blood unless otherwise noted)

On admission (if not already done in ER):

R CBC R APTT R INR

R Lytes, Creatinine, Glucose ABG R CK, Troponin Calcium, Magnesium

ALT, ALP AST

Culture Blood x 2 STAT Urinalysis Culture Urine Culture Sputum

Additional Labs______

Follow-Up After Initial Emergency Investigations:

R CK, Troponin, in 8 hours (6-9 if lab not available) if negative on admission – Date/Time______

Investigations Day 1 (first morning post admission):

R CK, Troponin, 24 hours post admission (if previous results negative) – Date/Time______

Digoxin levels on all patients taking Digoxin or who do not know the names of their pills

CBC APTT INR R Fasting Blood Glucose

Lytes, Creatinine Calcium, Magnesium

ALT, ALP, Bili AST Urinalysis Culture Urine

R 14h fasting lipid profile TSH

Additional Investigations:

CBC day 2 & 3

Culture blood if temp greater than 38.5° C

Diagnostic Tests

R ECG on admission R ECG daily x 2 and with recurrent pain

R CXR on admission

CT Scan ______Re: ______

Ultrasound ______Re: ______

2D Echo Re: ______Doppler US to R/O DVT

Other: ______

IV Solutions

Bolus IV: ______

After Bolus IV finished:

IV Fluid: 2/3 1/3 NS With 20 mmol KCl per L of IV fluid

Other ______With 40 mmol KCl per L of IV fluid

Rate ______mL/h

R Decrease IV to TKVO when drinking well. Discontinue IV if Pt not on any IV medications.

Saline Lock

Medications

Anticoagulation:

High risk ACS only (Cross out this section if not required)

Enoxaparin ______(1 mg/kg refer to protocol) Subcutaneous into abdomen

q12h. Physician to reassess at 48 hours. (Maximum dose 10,000 units/dose) (Dosage

adjustment required for severe renal dysfunction)

Dalteparin ______(120 units/kg) (HDH only)

R Physician to reassess at 48 hours. (Maximum dose 10,000 units/dose) (Dosage

adjustment required for severe renal dysfunction)

R Clopidogrel 300 mg PO STAT then 75 mg PO daily (Start tomorrow)

Unstable patient with refractory ischemia (Owen Sound site only) (Cross out this section if not required)

Vital Signs:R Monitor vital signs and neuros Q1H x 2 h, then Q2H x 2 h then Q4H

and PRN

Laboratory: R Group and Screen R CBC 2 hours post bolus of Tirofiban

R CBC, daily until 24 hours post discontinuation of Tirofiban

R Serum Creatinine daily, discontinue when Tirofiban discontinued

Anticoagulation: R Enoxaparin ______(1 mg/kg refer to protocol) Subcutaneous

into abdomen Q12H. Physician to reassess at 48 hours. (Maximum

dose 100 mg/dose) (Dosage adjustment required for severe renal

dysfunction)

Glycoprotein IIb/IIIa Inhibitor:

Tirofiban Infusion: (Refer to Tirofiban Protocol)

If Creatinine less than 175 mcmol/L (Refer to Weight Dose Chart):

IV bolus ______(0.4 mcg/kg/min) over 30 min

Continuous infusion ______(0.1 mcg/kg/min) over 48 hours

If Creatinine greater than 175 mcmol/L (Refer to Renal Dysfunction

Weight Dose Chart):

IV bolus ______(0.2 mcg/kg/min) over 30 min

Continuous infusion ______(0.05 mcg/kg/min) over 48 hours

Indeterminate risk ACS only (Cross out this section if not required)

Enoxaparin ______(1 mg/kg refer to protocol) Subcutaneous into abdomen q12h. Physician to reassess at 48 hours. (Maximum dose 100 mg/dose) (Dosage adjustment required for severe renal dysfunction)

Dalteparin ______(120 units/kg) (HDH only)

Physician to reassess at 48 hours. (Maximum dose 10,000 units/dose) (Dosage adjustment required for severe renal dysfunction)

Antiplatelets:

R ASA 160 mg PO STAT if not given previously

EC ASA 81 mg PO daily commencing Day 1 (Unless allergy or sensitivity to ASA)

ACE Inhibitors:

Ramipril 10 mg PO daily 5 mg PO daily 2.5 mg PO daily

Enalapril 10 mg PO daily 5 mg PO daily 5 mg PO Q12H

Angiotensin Receptor Blockers (ARB’s):

Candesartan (GBHS and SBGHC only) 4 mg PO daily 8 mg PO daily 16 mg PO daily

Losartan (GBHS and HDH only) 25 mg PO daily 50 mg PO daily 100 mg PO daily

Valsartan 80 mg PO daily 160 mg PO daily

Cardioselective ß Blockers:

Metoprolol 12.5 mg PO Q12H 25 mg PO Q12H 50 mg PO Q12H

bisoPROLOL (GBHS and SBGHC only) 2.5 mg PO daily 5 mg PO daily 10 mg PO daily

Carvedilol (SBGHC only) 3.125 mg PO Q12H 6.25 mg PO Q12H

Statins:

Atorvastatin 20 mg PO daily 40 mg PO daily

Rosuvastatin (SBGHC only) 10 mg PO daily 20 mg PO daily 40 mg PO Daily

Warfarin:

Target INR 2 - 3: ______mg PO today, then ______

Target INR 2.5 - 3.5 (mechanical valve): ______mg PO today, then daily order and daily INR

If already on Warfarin and INR therapeutic: Warfarin ______mg PO daily

Target INR ______- ______INR qMonday, Wednesday, Friday. Notify MD if INR not

in target range

PRN Medications **max total Acetaminophen 4000 mg/24hrs**

R Acetaminophen plain 325 – 650 mg po q4h PRN

R Aluminum Hydroxide/Magnesium Hydroxide 30 mL PO q4h prn

R Atropine 0.6 mg IV x 1 prn if symptomatic bradycardia less than 40 beats/minute

R dimenhyDRINATE 12.5 – 50 mg PO or IV q4h prn

Morphine 2 mg IV q5minutes until chest pain relieved (max 10mg/h)

Nitroglycerin spray 0.4 mg sublingual q5minutes x 3 prn

R Adult Potassium Oral Dosing Clinical Protocol

Bowel Care Clinical Protocol

New Diarrhea and Possible Melena Stools Clinical Protocol

Sedation: Zopiclone 3.75 - 7.5 mg PO qhs PRN OR

Lorazepam 1 mg PO or sublingual qhs PRN

Diabetes Management Protocols

R Hypoglycemia Management Clinical Protocol greater than or equal to 16 years

Adult Subcutaneous Insulin Order Set

Risk Level Assessment – Acute Coronary Syndromes (ACS)

Indeterminate Risk ACS (no High Risk features) / High Risk ACS (any one or more features)
Chest pain: single episode at rest, crescendo exertional angina
ECG: normal or non-specific abnormalities
Increased baseline risk: Diabetes, Elderly
May include patients with a history of known CAD or with risk factors for CAD / ECG: ST depression greater than 0.5-1 mm
Transient ST segment elevation
Deep (greater than 2mm) symmetrical
T wave inversions
Elevated Troponin 0.04-0.50 ng/mL
CK 35-200 mcg/L
Heart failure
Hypotension
Refractory ischemia with ECG changes

Cardiovascular Disease Classification Chart

Class / New York Heart Association Functional Classification
I / Patients have cardiac disease but without the resulting limitations of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea or anginal pain.
II / Patients have cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea or anginal pain.
III / Patients have cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnea or anginal pain.
IV / Patients have cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.

C/1/GBHN/CS/-/ACS/MD/07-07/v1/- Copyright © 2007 Grey Bruce Health Network

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