PLACE LABEL HERE

PRE-PROCEDURE ORDERS

Cardiac Catheterization Lab

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

Diagnosis: ______

1.Catheterization scheduled for: Date: ______Time: ______

Scheduled for:  Diagnostic Cath

 Cath w/ Possible PCI

 PCI

 Aortogram

 Renal Angiogram

 Fistulogram

Carotid Angiogram

2.Diagnostics, if not done in the last 72 hrs:

ECGReason:______Read by:______

CBC

Chem 7

Lipid Profile

Magnesium (Mg+)

PT/INR

PTT (if not on heparin or enoxaparin)

AntiXa (heparin level)

Quantitative HCG for any menustrating female ≥ 12 years of age, if not already done

Bedside glucose finger stick q 6 hrs x 2. If BG is > 180 mg/dL, notify physician

 Chest X-Ray  Portable  PA and Lateral Reason:______

3.Notify physician if INR 1.5 and/or creatinine 1.7

4.Clip hair on left and right groin areas

5.Mark the dorsalis pedis and posterior tibial pulses bilaterally

6.Diet: NPO

NPO after midnight, except for medications

 Clear liquid diet after midnight

7.Activity:  Up ad lib  Bed rest with BRP  Pt to void immediately prior to procedure

8.IV Access: Insert 2 large bore INTs, in left arm if possible (minimum size 20 gauge)

Copy to pharmacy Order writer’s initials______

*3-11833*FORM 3-11833 REV. 08/2014 Page 1 of 2

PLACE LABEL HERE

PRE-PROCEDURE ORDERS

Cardiac Catheterization Lab

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

SCHEDULED MEDICATIONS:

9.Diabetic Medications: Contact physician for the administration of insulin and other diabetic agents the morning of the procedure. NOTE: medications which contain metformin (i.e. Metaglip,Glucovance, Avandamet) must be withheld the morning of the procedure and 48 hrs following the procedure.

10. Aspirin: 81 mg mg po  162 mg po  325 mg po  300 mg PR x 1 dose at 0600, prior to cath

(hold any other scheduled Aspirin doses on day of cardiac cath procedure)

or Contraindicated due toAllergy Coagulopathy/Active Bleeding Other:______

orI have confirmed that Aspirin is a current medication order.

11.IV Fluids:  NS at ______ml/hr IV. on arrival or  ___ hrs prior to cath

½ NS at ______ml/hr IV. on arrival or  ___ hrs prior to cath

 Initate Prevention of Contrast Induced Nephropathy Orders (form # 18540)

12. Discontinue Lovenox (enoxaparin) at 2300 day prior to procedure

13.  Discontinue Heparin infusion on call to Cath Lab

or

Continue Heparin infusion until procedure

14.Patient has history of contrast reaction, give below meds as prophylaxis 30-60 min prior to procedure:

Benadryl (diphenhydramine) 25mg IV x 1 dose

Solu-Medrol (methylprednisolone) 125 mg IV x1 dose

Pepcid (famotidine) 20 mg IV x 1 dose

PRN MEDICATION:

15. Anti-anxiety: Ativan(lorazepam)0.5 - 1 mg po 1 hour prior to procedure prn x 1 dose

Informed consent for procedure must be signed prior to the administration of lorazepam

16. Electrolyte Replacement Protocol (form # 21340)

PATIENT EDUCATION:

17. Inpatient nursing or ARU to provide and document patient education using internet handouts about scheduled procedure.

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-11833 REV. 08/2014 Page 1 of2