PLACE LABEL HERE

POST-PROCEDURE and STEMI Admission 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).

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

2. If admitted as inpatient, Inpatient Physician Certification:

Diagnosis: ______

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

Impella patient: Level of care: Critical Care and CVICU bed only

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

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

5. Consults: Outpatient Cardiac Rehabilitation Services for PCI pts

 Physician: ______

 Case Management Referral

 Nutrition Services/Dietitian

Other:______

6. Diagnostics:

 Portable CXR STAT  Routine Reason: ______

 Portable CXR in AM Reason: ______

ECHO: STAT  Routine  In AM Reason:  Evaluate LV function  Other:______

Read by:______

 Post PCI Patient:

12-Lead ECG STAT immediately post procedureReason: Post PCI InterventionRead by:______

AM: CBC, Chem 7, Magnesium level

Order 12-Lead ECG STAT PRN, if patient complains of chest pain

Lipids with Direct LDL if not already done

 12-Lead ECG In AM Reason: ______Read by:______

CBC STAT

 Troponin T x 1 time or  q 8 hrs

CK  x 1 time or  q 8 hrs

 CKMB  x 1 time or  q 8 hrs

 Daily: CBC, Chem 7, Magnesium level

 Bedside glucose monitoring ac & hs and at 0300 (Call physician for BG > 180 mg/dL x2 consecutively)

7. Initiate Sleep Apnea Orders (form # 21266) if OSA screen is positive for suspected or reported sleep apnea

8. Diet: NPO  Full liquid, advance to Cardiac after sheath removed

 Resume:  Regular CardiacDiabetic ______calorie Renal

9. Place Foley catheter if pt is unable to void; remove Foley when bedrest is complete

POST PROCEDURE MONITORING:

10.Vital signs:

  • Sheath in place: vitals,procedure site, and neurovascular checks q 15 min x 4, then q 30 min x 2, then q 1 hr until removed
  • After Sheath Removal Hemostasis Achieved: vitals, procedure site, and neurovascular checks q 15 min x 2, then q 30 min x 4, then q hr x 4, then per unit routine or until discharge

11. Maintain INT until discharge

12. O2 per Protocol (form # 34431)

13. Continuous Cardiac Monitoring with ST segment monitoring in 2 leads

Copy to pharmacy Order writer’s initials______

*3-13217*FORM 3-13217 REV. 10/2017 Page 1 of 4

PLACE LABEL HERE

POST-PROCEDURE and STEMI Admission 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).

14.Sheath Removal Order:

 Sheath pulled in Cath Lab  Closure device applied  No closure device applied

15.  Femoral cath site: keep affected leg immobilized as needed; bedrest x ___hrs (Do not elevate HOB > 30° while on bedrest)

16.  Remove sheath per Sheath Removal Policy (#6670-23). Notify physician before sheath removal if BP >165/90.

17.Notify physician of the following:

  • Bleeding/hematoma
  • Temp > 38.4°C (101°F)
  • HR < 50 or > 130
  • Arrhythmias or angina
  • Symptomatic hypotension > 40 mmHg drop in systolic baseline and/or systolic pressure < 90
  • Systolic BP > 160 mmHg; Diastolic BP > 100 mmHg
  • Unrelieved chest, back, or leg pain, itching, rash or flushing
  • Peripheral vascular changes in affected extremity: numbness, tingling, decreased or absent pulses, and/or temperature change (if changed from the initial presentation)

18.SHEATH REMOVALACTGUIDELINESor PATIENT on ANGIOMAX (bivalirudin)

For patient on Heparin: Remove sheath when ACT < 180seconds
If 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
 For patient on Angiomax: Remove sheath 2 hrs after infusion discontinued, or per physician order

19. OUTPATIENT DISCHARGE ORDERS:

May go home 30-60 min after discharge criteria met and procedure site stable:

  • Able to tolerate PO fluids
  • PAR score ≥ 9 or at pre-procedure level. If PAR ≤ 8 discharge by Physician orders.
  • Ambulate with minimal assistance

Follow up with physician in _____ weeks

Notify physician if patient experiences any complications

Follow up with Primary Care Physician

SCHEDULED MEDICATIONS:

20. Continue IVF ______at ______ml/hr IV for ______hrs

21.If on metformin (Glucophage, Glucovance), hold for 48 hrs post procedure

22.Aspirin:

 81 mg po  325 mg po daily first dose tomorrow If unable to take po, give 300 mg rectally daily

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

OR DC Aspirin; contraindicated due to Allergy Coagulopathy/Active Bleeding Other______

23.Anti-Platelet:

Plavix (clopidogrel):

300 mg 600 mg po NOW if not already given, then 75 mg po daily starting in AM

 Effient (prasugrel), avoid in > 75 y/o unless diabetic or hx of MI, < 60 kg, Hx of TIA/Stroke, or CABG surgery likely

60 mg po NOW if not already given, then10 mg po daily starting in AM

 Brilinta (ticagrelor): use only with Aspirin 81 mg maximum daily maintenance dose

180 mg po NOW if not already given, then 90 mg po BID starting this PM

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).

24.Beta Blocker:

Contraindication to Beta-Blocker (please indicate):

Systolic BP < 902nd or 3rd Degree AV BlockInferior MI Bradycardia

Severe COPDSevere LV dysfunction with HFOther: ______

OR

Lopressor (metoprolol) 5 mg IV over 2 min (Hold if systolic BP < 90 or HR < 60)

Repeat dose q 5 min for 2 more doses. (Hold if systolic BP < 90 or HR < 60)

And after 10 min, give Lopressor (metoprolol) as ordered below:

Lopressor (metoprolol) ____ mg po bid, first dose now if not given in ED. (Hold if SBP < 90 or HR < 60)

Coreg (carvedilol) ____ mg po bid with meals, first dose now if not given in ED. (Hold if SBP < 90 or HR < 60)

I have confirmed that a beta blocker is a current medication order.

25.ACE Inhibitor: _____ EF% if known

Contraindication to ACE Inhibitor:

Allergy Hyperkalemia Hypotension  Worsening renal function Other: ______

OR

Vasotec (enalapril) 1.25 mg IV q 6 hrs (Hold if systolic BP < 90)

Prinivil (lisinopril) ____ mg po now and daily (Hold if systolic BP < 90)

Other: ______(Hold if systolic BP < 90)

I have confirmed that an ACE Inhibitor or Angiotensin Receptor Blocker (ARB) is a current medication order.

OR

26.Angiotensin Receptor Blocker (ARB): _____ EF% if known

Contraindication to Angiotensin Receptor Blocker:

Allergy Hyperkalemia Hypotension  Worsening renal function Other: ______

OR

 Cozaar (losartan) ____ mg po now and daily (Hold if systolic BP < 90)

Other: ______(Hold if systolic BP < 90)

I have confirmed that an Angiotensin Receptor Blocker (ARB) or ACE Inhibitor is a current medication order.

27.Cholesterol lowering therapy:

Contraindication:  Allergy  Active or chronic liver disease  Other: ______

OR

Lipitor (atorvastatin) ______mg po q pm.

Crestor (rosuvastatin) ______mg po q pm.

 Pravachol (pravastatin) ______mg po q pm.

Other: ______

I have confirmed that a cholesterol lowering agent is a current medication order.

28.Anticoagulants:

 DC Heparin infusion

 DC Lovenox

 DC Angiomax (bivalirudin)

 Continue Angiomax (bivalirudin) up to 4 hrs post-procedure or bag complete, whichever first or ______

 Heparin infusion Protocol: Low Intensity (form # 39815), start ____ hrs after sheath removal

 No bolus

29.Aggrastat (tirofiban)

DCAggrastat (tirofiban) now or  once bag completed.

Continue Aggrastat (tirofiban) infusion ______hrs post procedure, see Aggrastat Protocol (form # 35422)

Begin Aggrastat (tirofiban) infusion,seeAggrastat Protocol (form# 35422)

30. Glycemic control: Initiate Insulin Management Orders (form # 36796)

Copy to pharmacy Order writer’s initials______

FORM 3-13217 REV. 10/2017 Page 1 of 4

PLACE LABEL HERE

POST-PROCEDURE and STEMI Admission 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).

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

31.Vasovagal: Atropine 0.5-1 mg IV prn, may repeat after 5 minutes x 1 dose prn

NS 250 ml bolus IV x 1 dose, notify physician if blood pressure does not return to baseline

  1. 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. 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 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.

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: Melatonin 5 mg po q HS prn

orAmbien (zolpidem)5 mg (female or males ≥ 65 y/o) or 5-10mg (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

ADDITIONAL ORDERS:

______

______

______

______

DateTimePhysician SignaturePIN Number

Copy to pharmacy

FORM 3-13217 REV. 10/2017 Page 1 of 4