Perscriber Orders Finlay Watson DOB 15/06/1967
Orders
| Date/Time | Order | Order Category | Signature | ||||||
| 3 Days Ago 1030 | Non-St Elevation MI/Acute Coronary Syndrome Pre-Printed Orders (PPO): 1. ALLERGIES: See Allergy/ Adverse Reaction record 2.ADMISSION INSTRUCTIONS: Admit to: 7N MRP: M. Heart Diagnosis: NSTEMI Transfer to: Kelowna General Hospital when bed available 3. CODE STATUS: C2 4. INITIAL MANAGEMENT • Start oxygen if SPO2 less than 90%, titrate or wean for goal SPO2 between 90 to 94% • Insert IV and saline Lock IV line, flush with normal saline 0.9% Q12H OR IV fluid at 75 mL/ H • Bed rest with bedpan/ commode if ongoing chest pain or hemodynamic instability • Progress to chair with bathroom privileges when chest pain free. Once stable, activity as tolerated. (See for criteria) 5. DIET •Heart Healthy Diet as tolerated, if diabetic enter Diabetic diet ☐ Other: ________________________ 6. MONITORING (See for criteria) •Continuous cardiac monitoring x minimum 24H, then MRP to discontinue when appropriate ☒ May discontinue cardiac monitoring for short periods (ie: Shower or diagnostic testing) if clinically stable ☐ May discontinue cardiac monitoring for inter-facility transport • HR, RR, SPO2, BP (in both arms initially, then use arm with highest reading) Q1 H until stable, then follow VS policy appropriate for area (le. Critical Care Routines and Responsibilities or IH Vital Signs Monitoring Care Standard) • Temp Q4H until stable, then Q12H and PRN • Weight: Obtain baseline within 24 hours of admission. DAILY. weights if on diuretic therapy 7. LABORATORY • Troponin, Na, K, Cl, CO2 (lytes4), urea, creatinine, random glucose, AST, CBC, INR, PTT, STAT • Na, K, Cl, CO2 (lytes4), urea, creatinine, random glucose, CBC DAILY x 5 days • Hemoglobin A 1 C, lipid panel (draw with first daily bloodwork) • Troponin 6 and 18 hours after the first STAT troponin; to coincide with facility lab draws ☐ THS ☐ BNP ☐ALT, ALK, Phos, GGT, Billirubin ☐ Other: ______________________________ 8. DIAGNOSTICS • 12 lead ECG URGENT • 12 lead ECG QAM x 2 days and PRN for increase or recurrence of chest discomfort, chest pain unrelieved by nitroglycerin or for sustained rhythm changes • Chest X-ray (portable) on admission: 9. MANAGEMENT STRATEGY (See for anticoagulation and antiplatelet guidelines) ANTIPLATELETS • Acetylsalicylic acid [A.SA] chewable 160 mg (2 x 80 mg TAB) chewed STAT, then 81 mg EC PO DAILY • Select ONE of the following (see reverse of page 1 for antiplatelet selection) ☒ ticagrelor 180 mg PO STAT then 90 mg PO BID (FIRST CHOICE ☐clopidogrel 300 mg PO STAT then 75 mg PO DAILY (Conservative management or oral anticoagulant required) ANTICOAGULATION: Select ONE of the following: ☒ enoxaparin 1 mg/ kg 80 mg subcutaneously Q12H 10. MEDICATIONS • Notify MRP if nitrates, beta blocker, ACE-I/ ARB held per indications in each medication section NITRATES (see for contraindications/ precautions) nitroglycerin spray 0.4 mg sublingual Q5MIN PRN x 3 doses for ischemic symptoms (if unresolved after 3 doses, call physician and if ordered, start nitroglycerin infusion) BETA BLOCKER ☒ Metoprolol 25 mg PO BID ☐ Bisoprolol _____ mg PO DAILY ☐ Other: _________________ ANGIOTENSIN CONVERTING ENZYME INHIBITORS / ANGIOTENSIN RECEPTOR BLOCKERS ☒ Ramipril 10mg PO DAILY ☐ Perindopril __ mg PO DAILY ☐ Candesartan __ mg PO DAILY ☐ Other:_________________ ☐ No ACE-I or ARB. Reason:_________________________________________ **Hold ACE I/ ARB if symptomatic hypotension (dizziness, presyncope, syncope) LIPID LOWERING Atorvastatin 80 mg PO DAILY ☐ Other:_________________ ☐ No lipid lowering therapy. Reason: _________________________________ PRN MEDICATIONS • acetaminophen 325 to 975 mg PO O4H PRN (maximum 4 g / day) • antacid 30 ml PO Q6H PRN indigestion or heartburn • atropine 0.5 to 1 mg IV Q5MIN PRN for symptomatic heart rate less than 50 bpm (maximum 3 mg total dose) • morphine 2 to 5 mg IV Q5MIN PRN chest pain unresponsive to nitroglycerin or if nitroglycerin contraindicated (maximum 20 mg/hr) • If tobacco user, to complete NICOTINE REPLACEMENT THERAPY PPO # 829435. • Complete site specific bowel elimination protocol X☐ dimenhyDRINATE 50 mg PO or 25 mg IV Q6H PRN nausea X☐ LORazepam 0.5 mg sublingual Q6H PRN anxiety X☐ zopiclone 3.75 to 7.5 mg PO HS. PRN insomnia 11. OTHER • Transport personnel may continue Non-ST Elevation Ml/ Acute Coronary Syndrome PPO during inter-facility transport • Cardiac Rehab Referral | M.Heart | |||||||
