PLACE LABEL HERE
TRANS-ESOPHAGEAL ECHOCARDIOGRAM (TEE)
ORDERS
The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
1. Diagnosis: ______
2. PRE-TEE PROCEDURE:
Date of Procedure: ______
Trans-Esophageal Echocardiogram (TEE) Reason: ______Group to Read: ______
Venous Access: INT to right arm, if possible and no current IV access
Normal Saline IV at KVO rate, start immediately prior to procedure
NPO status:
q NPO now and confirm patient has been NPO after midnight (patient coming from home)
q NPO after midnight except medications for TEE tomorrow (patient in hospital)
q NPO now for TEE today (patient in hospital)
Cetacaine (benzocaine/tetracaine/butaben) spray to pharynx x 1 sec immediately prior to procedure x 1 dose
or q DC Cetacaine. Lidocaine 5% ointment, apply to tongue prn q 3 min up to three doses
q Urine hCG for any menstruating female ≥ 12 years of age
q Blood glucose finger stick prior to procedure (diabetic patient)
For ICU patients, nurse to implement moderate sedation flowsheet (form # 20000)
O2 per protocol (# 34431)
3. INTRA-TEE PROCEDURAL MEDICATIONS
q Versed (midazolam) 0.25 -1 mg IV q 2 min prn sedation during TEE procedure
q Fentanyl 25 - 50 mcg IV q 2 min prn sedation during TEE procedure
q Other: ______
4. q OUTPATIENT POST-TEE PROCEDURE ORDERS
NPO until 30 min after last dose of topical anesthetic
May go home when discharge criteria met:
· Able to tolerate PO fluids
· PAR score ≥ 9 or at pre-procedure level; If PAR ≤ 8 discharge by physician orders
· Able to ambulate with minimal assistance
5. q INPATIENT POST- TEE PROCEDURE ORDERS
NPO until 30 min after last dose of topical anesthetic
Return to floor when PAR score ≥ 9 or at pre-procedure level. If PAR ≤ 8, discharge by physician orders.
Vital signs upon returning to unit and per unit routine
Up with assist first time out of bed, then PRN, or resume previous activity level
______
Date Time Physician Signature PID Number
Copy to pharmacy
*1-1819* FORM 1-1819 REV. 07/2014 Page 1 of 1