PLACE LABEL HERE

ICD/ PERMANENT PACEMAKER

POSTIMPLANTATION 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).

  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?

Yes, admit as inpatient, proceed to # 2No, place in observation No, outpatient, DC home in ____hrs

2.If admitted as inpatient, Inpatient Physician Certification:

Diagnosis: ______

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

  1. Telemetry: If patient Medical/Surgical, must complete form # 36084
  2. Isolation:  Contact  Droplet  Airborne For: ______
  3. Portable CXR STAT immediately post procedure. Reason: Post device implant, evaluate lead placement Radiologist to call CXR results with any signs of pneumothorax.
  4. ECG now Reason:Post device implant, evaluate lead placementRead by______

ECG in amReason: Post device implant, evaluate lead placement Read by______

7. Notify physician if: HR < 40 or > 100, SBP < 90 or MAP < 65, or signs of respiratory distress or pneumothorax

8. ACTIVITY: Bedrest x 2 hrs  4 hrs until the following morning.  May use bedside commode.

9. Apply shoulder immobilizer immediately post procedure.

10.PATIENT EDUCATION:

Instruct patient to wear immobilizer at all times for 2days 3 days

Do not elevate arm on operative side above head for 3 weeks.

11. DIET:NPO, call physician withCXR results to obtain diet order.

SCHEDULED MEDICATIONS:

12.Anti-Platelet/Anticoagulant:

Aspirin  81 mg or  325 mg po daily. Give first dose at ______

Eliquis (apixaban) _____mg po bid. Give first dose at ______

Xarelto (rivaroxaban) _____mg po daily. Give first dose at ______

Pradaxa (dabigatran) _____mg po bid. Give first dose at ______

Coumadin (warfarin)_____mg po daily Give first dose at ______

Plavix (clopidogrel) 300 mg or 600 mg loading dose NOW, then 75 mg po daily

OR Plavix (clopidogrel) 75 mg po daily

Brilinta (ticagrelor)  180 mg loading dose NOW, then 90 mg po BID

OR Brilinta (ticagrelor) 90 mg po BID (use with aspirin 81 mg max daily maintenance dose)

Effient (prasugrel)  60 mg loading dose NOW, then 10 mg po daily (avoid if > 75 y/o unless diabetic or hx of MI, < 60 kg, hx of TIA/Stroke; or likely to undergo CABG surgery):

OR Effient (prasugrel) 10 mg po daily (avoid if > 75 y/o unless diabetic or hx of MI, < 60 kg, hx of TIA/Stroke; or likely to undergo CABG surgery)

*3-8210* FORM 3-8210 REV. 01/2015 WHITE: Medical Record CANARY: Pharmacy Page 1 of 2

PLACE LABEL HERE

ICD/ PERMANENT PACEMAKER

POSTIMPLANTATION 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).

13. Antibiotics:

Ancef (cefazolin)1 gm  2 gmIV q 8 hrs x 2 doses

Ancef (cefazolin)1 gm  2 gmIV x 1 dose prior to discharge

Post-op IV antibiotic will be automatically stopped within 24 hrs unless indication is documented

Document indication for > 24 hrs: ______

ORREQUIRED: Rationale for using Vancomycin as an antimicrobial prophylaxis

History of MRSA/positive screen

 Betalactam Allergy (allergy to penicillin and cephalosporins)

 Vancomycin (give 12 hrs from initial dose) patient weight ______kg

If patient weight < 90 kg, 1 gm IV x 1 dose (infuse over 1 hr)

If patient weight 90 kg, 1.5 gm IV x 1 dose (infuse over 2 hrs)

Post-op antibiotic will be automatically stopped within 24 hrs unless indication documented

Document indication for > 24 hrs: ______

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

  1. Electrolyte Replacement Protocol (form # 21340)
  2. Mild Pain, Temp>100.5F, HA:Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
  3. 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 can not take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po q 4 hrs prn intead 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.

and/or  Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (15 mg if CrCl 31-50, > 65 y/o old or <50 kg) or 10 mg po q 6 hrs prn (max combined duration of IV and po ketorolac is 5 days). DC if CrCl < 30.

  1. Severe Pain (Begin when Epidural or PCA has been discontinued)

Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered.

or  Dilaudid (HYDROmorphone) 0.25-0.5 mg IV q 3 hrs prn. If CrCl < 30, dose at 0.25 mg. Hold for excessive sedation. DC if Morphine 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: Ambien (zolpidem)5 mg (female or males ≥ 65 y/o) or 5-10mg (male < 65 y/o) po at HS prn
  2. Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
  3. Stool Softener: Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
  4. 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

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

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

______

DateTimePhysician SignaturePID Number

FORM 3-8210 REV. 01/2015 WHITE: Medical Record CANARY: Pharmacy Page 2 of 2