PLACE LABEL HERE
UNSTABLE ANGINA / NSTEMI
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. 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? q Yes, admit as inpatient, proceed to # 2 q No, place in observation
2. If admitted as inpatient, Inpatient Physician Certification:
Diagnosis: ______
Level of Care: q Critical q Intermediate q Acute Care Location/Specialty Unit Preference___
3. q Telemetry: If patient Medical/Surgical, must complete form # 36084
4. q Isolation: q Contact q Droplet q Airborne For: ______
5. Consult: q Urgent, q Routine, Consult with ______concerning ______
Outpatient Cardiac Rehabilitation Services if positive for Myocardial Infarction
6. Diagnostics:
STAT labs (if not already drawn): CBC, Chem 7, PT/INR, PTT, Troponin (if 3-6 hrs from onset of chest pain)
Baseline Liver Function Tests
Fasting lipid profile in AM
q Troponin at 90 min after initial Troponin
q Troponin at 6 hours after initial Troponin
Portable CXR on admission STAT (if not done prior to arrival on unit)
EKG on admission (if not done prior to arrival in unit) and next AM (______to read all EKGs)
Stat EKG prn for chest pain unrelieved by Nitroglycerin sublingual x 3 doses, rhythm or ST changes
ECHO q Stat q Routine Reason: ______Read by: ______
Call MRT if suspected acute MI, hemodynamic instability or unresolved chest pain despite intervention
q Schedule ETT for AM q Schedule Lexiscan DIMPS for AM
q Schedule Stress DIMPS for AM q Schedule Dobutamine DIMPS for AM
q Cardiac catheterization (see pre-cath orders form # 11833)
7. Intake & Output; q shift
8. Daily weight
9. Continuous rhythm monitoring with ST monitoring for 72 hrs
q May not be off monitor for tests/transport (Consider transfer to Telemetry floor or GMC-D IMCU)
10. Vital signs per unit routine
11. Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)
12. O2 per Protocol (form # 34431)
13. Diet: 30% fat restriction q ______gm Na q ______cal consistent carbohydrate
14. Oral Nutrition Supplement Standing Order (form # 31417), initiate if patient meets criteria
15. Activity: (advance as tolerated) q Bed rest x 12 hrs q BSC q BRP q Up ad lib q May shower
16. INT
Copy to pharmacy Order writer’s initials ______
*3-11593* FORM 3-11593 REV. 07/2017 Page 1 of 4
PLACE LABEL HERE
UNSTABLE ANGINA / NSTEMI
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).
SCHEDULED MEDICATIONS:
17. Aspirin: q Contraindication to Aspirin: q Allergy q Coagulopathy/Active Bleeding q Other______
or
q Aspirin 324 mg (four x 81 mg chewable) po STAT if not done in ED
If unable to swallow, Aspirin 300 mg suppository per rectum STAT
Aspirin q 81 mg q 325 mg po daily, begin today unless already given.
If unable to swallow, Aspirin 300 mg suppository per rectum daily
q I have confirmed that Aspirin is a current medication order.
18. Antiplatelet:
q Plavix (clopidogrel) q 300 mg or q 600 mg loading dose NOW, then 75 mg po daily
q Plavix (clopidogrel) 75 mg po daily
q Brilinta (ticagrelor) q 180 mg loading dose NOW, then 90 mg po BID
q Brilinta (ticagrelor) 90 mg po BID (use with aspirin 81 mg max daily maintenance dose)
q Effient (prasugrel) q 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):
q Effient (prasugrel) 10 mg po daily
19. Vasodilator:
q Nitroglycerin (200 mcg/ml) IV infusion at 10 mcg/min; may titrate up to 100 mcg/min until relief of
symptoms. Maintain systolic BP to 100
or
q Nitroglycerin paste, q 0.5 inch q 1 inch q 2 inch topical q 6 hrs. Maintain systolic BP to 100
20. Anticoagulation: Weight ______kg
q Heparin Infusion Protocol, Low Intensity (form # 39815)
q Lovenox (enoxaparin) 1 mg/kg SQ q 12 hrs (round dose to nearest syringe size), (CrCl < 30, use q 24 hrs)
Patient’s Actual Weight / Give Lovenox (enoxaparin) / Patient’s Actual Weight / Give Lovenox (enoxaparin)< 50 kg / 40 mg q 12 hrs / 130-144 kg / 140 mg q 12 hrs
50-69 kg / 60 mg q 12 hrs / 145-154 kg / 150 mg q 12 hrs
70-89 kg / 80 mg q 12 hrs / 155-169 kg / 160 mg q 12 hrs
90-109 kg / 100 mg q 12 hrs / 170 kg / 180 mg q 12 hrs (maximum dose)
110-129 kg / 120 mg q 12 hrs
21. Glycoprotein IIB IIIA Inhibitor: q Aggrastat (tirofiban) Protocol (form # 35422)
22. Beta Blocker:
q Contraindication to Beta-Blocker (please indicate):
q Systolic BP < 90 q 2nd or 3rd Degree AV Block q Inferior MI q Bradycardia
q Severe COPD q Severe LV dysfunction with HF q Other: ______
or
q 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:
q Lopressor (metoprolol) ____ mg po bid, first dose now if not given in ED. (Hold if SBP < 90 or HR < 60)
q Coreg (carvedilol) ___ mg po bid with meals, first dose now if not given in ED. (Hold if SBP < 90 or HR < 60)
q I have confirmed that a beta blocker is a current medication order.
Copy to pharmacy Order writer’s initials ______
FORM 3-11593 REV. 07/2017 Page 2 of 4
PLACE LABEL HERE
UNSTABLE ANGINA / NSTEMI
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).
SCHEDULED MEDICATIONS (continued):
23. ACE Inhibitor: _____ EF% if known
q Contraindication to ACE Inhibitor:
q Allergy q Hyperkalemia q Hypotension q Worsening renal function q Other: ______
OR
q Vasotec (enalapril) 1.25 mg IV q 6 hrs (Hold if systolic BP < 90)
q Prinivil (lisinopril) ____ mg po daily (Hold if systolic BP < 90)
q Other: ______(Hold if systolic BP < 90)
q I have confirmed that an ACE Inhibitor or Angiotensin Receptor Blocker (ARB) is a current medication order.
OR
24. Angiotensin Receptor Blocker (ARB): _____ EF% if known
q Contraindication to Angiotensin Receptor Blocker:
q Allergy q Hyperkalemia q Hypotension q Worsening renal function q Other: ______
OR
q Cozaar (losartan) ____ mg po daily (Hold if systolic BP < 90)
q Other: ______(Hold if systolic BP < 90)
q I have confirmed that an Angiotensin Receptor Blocker (ARB) or ACE Inhibitor is a current medication order.
25. Cholesterol lowering therapy:
q Contraindication: q Allergy q Active or chronic liver disease q Other: ______
OR
q Lipitor (atorvastatin) ______mg po q pm
q Crestor (rosuvastatin) ______mg po q pm
q Pravachol (pravastatin) ______mg po q pm
q Other: ______
q I have confirmed that a cholesterol lowering agent is a current medication order.
PRN MEDICATIONS See policy 520-06 for range orders and pain intensity guidelines.
26. q Chest pain: Nitroglycerin 0.4 mg sublingual q 5 minutes x 3 doses prn
q Severe Pain or Chest pain unrelieved with 3 doses of SL or max IV Nitroglycerin
q 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 q 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.
27. q Electrolyte Replacement Protocol (form # 21340)
28. Mild Pain, Temp >100.5°F, HA: q Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
29. Moderate Pain:
q Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered.
or q 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 q Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn.
DC if Norco ordered.
and/or q 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.
Copy to pharmacy Order writer’s initials ______
FORM 3-11593 REV. 07/2017 Page 2 of 4
PLACE LABEL HERE
UNSTABLE ANGINA / NSTEMI
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).
PRN MEDICATIONS (continued):
30. Severe Pain (Begin when Epidural or PCA has been discontinued)
q Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered.
or q 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.
31. Nausea/Vomiting: q Zofran (ondansetron) 4 mg IV or po q 6 hrs prn
q If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)
32. Sleep: q Melatonin 5 mg po q HS prn
or q Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn
33. Indigestion: q Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
34. Stool Softener: q Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
35. Constipation: q Milk of Magnesia (MOM) 30 ml po daily prn
If no BM after 48 hrs, q Dulcolax (biscodyl) 10 mg per rectum daily prn
and/or q Senokot-S (docusate/senna) 2 tablets po at bedtime nightly
______
Date Time Physician Signature PID Number
Copy to pharmacy
FORM 3-11593 REV. 07/2017 Page 4 of 4