PLACE LABEL HERE

ACUTE MYOCARDIAL INFARCTION

POST TENECTEPLASE (TNKase)

ORDERS

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).

Copy to pharmacyOrder writer’s initials ______

*3-18436*FORM 3-18436 REV. 10/2017 Page 1 of 2

PLACE LABEL HERE

ACUTE MYOCARDIAL INFARCTION

POST TENECTEPLASE (TNKase)

ORDERS

1. Is this a CMS inpatient only procedure?  Yes, admit as inpatient, proceed to # 3  No, proceed to # 2

2. 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? Yes, admit as inpatient, proceed to # 3No, place in observation

3. If admitted as inpatient, Inpatient Physician Certification:

Diagnosis: ______

Level of Care:  Critical  Intermediate  Acute Care Location/Specialty Unit Preference______

4. Telemetry: If patient Medical/Surgical, must complete form # 36084

5. Isolation:  Contact  Droplet  Airborne For: ______

6. Consult: Urgent  Routine, Consult with ______concerning ______

Cardiopulmonary Rehab, Phase I (if positive Myocardial Infarction)

Consult Nutritional Services for diet teaching

Physical Therapy for monitored progressive activity

Occupational Therapy for stress management

7. Phase I Cardiac Rehab

8. O2 per Protocol (form # 34431)

9. Smoking Cessation counseling, if patient smokes

10. Diagnostics:EKG q AM for 2 days

Repeat Troponin I in 8 hrs post TNKase (tenecteplase)

Fasting lipid profile in AM

11. INT and Vital signs per unit routine

12. ST segment monitoring per practice guidelines. Mount strips q 30 min post TNKase (tenecteplase) x 4

13. No further venipunctures, arterial punctures, IM injections x first 24 hrs post TNKase (tenecteplase)

14. Stat EKG and notify physician of any recurrent chest pain or ST elevation

Call MRT if suspected acute myocardial infarction, hemodynamic instability or unresolved chest pain despite intervention

15. NPO for 6 hrs then clear liquids; advance diet as tolerated to 30% calories from fat

16. Bedrest with bathroom privileges for 12 hrs, then up ad lib as tolerated

SCHEDULED MEDICATIONS:

17. Discontinue all NSAID (except aspirin) and COX-2 Inhibitors (i.e.,celecoxib)

18. Aspirin 160 mg (two x 81 mg chewable) po daily. Give first dose now if not given in ED

If unable to swallow, Aspirin 300 mg suppository per rectum STAT

Aspirin 81 mg (chewable) po daily. Give first dose now if not given in ED

If unable to swallow, Aspirin 150 mg suppository (1/2 of a 300 mg suppository) per rectum daily

19. Plavix (clopidogrel) 300 mg x 1 dose today (for patients < 75 y/o), then 75 mg po q am

Plavix (clopidogrel) 75 mg po q am

20.  Nitroglycerin (200 mcg/ml) IV infusion at 10 mcg/min; may titrate up to 100 mcg/min until relief of symptoms. Maintain SBP to 100 mm Hg

21. Anticoagulant:

Heparin Infusion Protocol, LOW Intensity (form # 39815):

Bolus with 60 units/kg (maximum bolus 4,000 units) No Bolus

Begin Heparin infusion at 12 units/kg/hr (maximum initial rate 1,000 units/hr)

Lovenox(enoxaparin)

75 yo: 1mg/kg SQ q 12 hr (max 100mg for first two SQ doses only)

75yo: 0.75mg/kg SQ q 12 hr (max 80 mg for first two SQ doses only)

GFR <30: 1mg/kg SQ q 24 hr

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).

22.Beta Blocker (for hypertensive patients only) without the following contraindications:

Copy to pharmacy

FORM 3-18436 REV. 10/2017 Page 1 of 2

PLACE LABEL HERE

ACUTE MYOCARDIAL INFARCTION

POST TENECTEPLASE (TNKase)

ORDERS

  • High risk for cardiogenic shock
  • 2nd or 3rd degree AV block
  • Severe COPD or active asthma
  • Evidence of low output state
  • Inferior MI
  • Bradycardia
  • Signs of heart failure

Copy to pharmacy

FORM 3-18436 REV. 10/2017 Page 1 of 2

PLACE LABEL HERE

ACUTE MYOCARDIAL INFARCTION

POST TENECTEPLASE (TNKase)

ORDERS

Lopressor (metoprolol tartrate) 25 mg po q____hrs, hold if SBP < 90 or HR < 60

Lopressor (metoprolol tartrate) 50 mg po q____hrs, hold if SBP < 90 or HR < 60

Coreg (carvedilol)______mg po twice daily, hold if SBP < 90 or HR < 60

23.Ace Inhibitor/Angiotensin Receptor Blocker:

Contraindication to Ace Inhibitor/Angiotensin Receptor Blocker:

AllergyHyperkalemiaHypotensionOther: ______

Prinivil (lisinopril) ______mg po q am starting in am. Hold if SBP < 90

Angiotensin receptor blocker: Cozaar (losartan) ______mg po daily.Hold if SBP < 90

Other: ______Hold if SBP < 90

24.Cholesterol lowering therapy:

Contraindication to Statin: Allergy Active or chronic liver disease Other______

Lipitor (atorvastatin) 40 mg po qHS. Baseline Liver Function Tests if not already done

Crestor (rosuvastatin) 20 mg po qHS. Baseline Liver Function Tests if not already done

 Other ______Baseline Liver Function Tests if not already done

PRN MEDICATIONS (See policy 520-06 for range orders and pain intensity guidelines)

  1. Electrolyte Replacement Protocol (form # 21340)
  2. Chest Pain:Chest pain: Nitroglycerin 0.4 mg sublingual q 5 minutes x 3 doses prn

Severe Pain or Chest pain unrelieved with 3 doses of SL or max IV Nitroglycerin

Morphine 2 mg IV q 5 min prn (up to a max of 10 mg in 2 hrs), Hold for excessive sedation.

DC if CrCl < 30. DC if Dilaudid ordered.

or  Dilaudid (HYDROmorphone) 0.25-0.5 mg IV q 15 min prn (max 2 mg in 30 min). If CrCl < 30, dose at 0.25 mg). Hold for excessive sedation. DC if Morphine ordered.

  1. Mild Pain, Temp>100.5F, HA:Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
  2. Moderate Pain:

Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered.

or If patient cannot take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po q 4 hrs prn instead of Norco. DC if Percocet ordered.

or Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Norco ordered.

  1. Nausea/Vomiting:Zofran (ondansetron) 4 mg IV or po q 6 hrs prn

If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)

  1. Sleep: Melatonin 5 mg po q HS prn

or Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn

  1. Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
  2. Stool Softener: Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
  3. Constipation: Milk of Magnesia (MOM) 30 ml po daily prn

If no BM after 48 hrs,  Dulcolax (biscodyl) 10 mg per rectum daily prn

and/orSenokot-S (docusate/senna) 2 tablets po at bedtime nightly

34.Cough: Robitussin (guaifenesin) 15 ml po q 4 hrs prn

35.Sore Throat: Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-18436 REV. 10/2017 Page 1 of 2