Patient Label Here
CHEST PAIN ADMIT PLAN A UMC Health System Performance Improvement Initiative for use in all units where patients with AMIs are admitted * Denotes guideline requirement for Core Measures 1.
Attending Physician:_____________________________________ Resident/Fellow:______________________________________ Notify ___________________________________________ upon arrival to floor of room number, for any further orders and any changes in patients condition, vital signs, questions or problems. Upon arrival care transfers to MD listed above. Consult:
Consult Cardiac Rehab for Inpatient Phase I evaluation and treatment
Arrange Outpatient Cardiac Rehab Phase II evaluation and treatment
Case Management at 775-8896 Other: ____________________________________________________________________ 2.
Status: Medical Floor CICU
3.
Diagnosis:__________________________________________________________________________________________________
4.
Code Status:
5.
Condition:
6.
Allergies: NKDA
7.
Co-Morbidities: ____________________________________________________________________________________________
Full Code Stable
ICC (5EAST)
_____ ICU
DNR/DNI Comfort Care Fair
Serious
Telemetry Full Admission
Observation
Other ____________________________________________
Critical
Allergic to: ___________________________________________________________________________
____________________________________________________________________________________________ 8.
NURSING: Vital Signs: per ICU Standards of Practice Other: ________________ Notify MD for: ______________________________ Weight on admission & daily Intake and output: per CICU Standards of Practice Diet:
NPO
Other: ______________________
NPO except ice chips NPO except medications Clear Liquids
Mechanical Soft
Regular
AHA
Full Liquids
Other____________________________________________________
Accu-Chek every ________ hours Activity: Bedrest Up with assist Bedside commode Bathroom privileges Ambulate___________________ 9.
LABORATORY/DIAGNOSTICS: (DO NOT REPEAT IF DONE IN THE EC UNLESS OTHERWISE INDICATED) CK
CK-MB on admit if not done in EC, then every __________ hours x 3.
Troponin T on admit if not done in EC, then every __________ hours x 2. CBC with differential; PT/PTT, BMP, & UA on admit. Do NOT repeat labs done in EC. Portable Chest X-ray if not done in EC. ECG on admit if not already done in EC & daily while in ICU or prn Chest Pain. Chest must be marked appropriately! ________________________________________________________________________________________________________
TO Read back Order taken by Signature: _________________________________________Date/Time: __________________________
Physician Signature ___________________________________________Date/Time__________________________ Page 1 of 5 - Chest Pain Admit Plan
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Patient Label Here 10. RESPIRATORY THERAPY: Respiratory Care Plan O2 @ ______ liters per nasal cannula or prn SaO2 Monitoring – 12 hours -- d/c if SaO2 consistently > 92% Incentive Spirometer Instruction
Frequency: ________________________________________________________
11. IV: Continuous IV fluids________________________________ to run at ________________________ml/hr INT for blood draws. Flush with NS q 4 hours and prn. Routine central line care and flushes 12. MEDICATIONS: Refer also to Admission Medication Reconciliation Form and Discomfort orders * Denotes guideline requirement for Core Measures. Contraindications must be documented. ACEI or ARB: *For EF < 40%, Unless contraindicated as listed here: ____________________________________________ ACEI: _______________________________________OR ARB: __________________________________________ Beta Blocker: Unless contraindicated as listed here: _____________________ (hold for SBP < ________ or HR < ________) Beta Blocker: ____________________________________________ Aspirin __________ mg PO NOW and daily * (Must be given within 24 hours of arrival) Unless contraindicated as listed here: ______________________________________________________________________ Clopidogrel (Plavix) ___________ mg PO NOW and __________ mg PO daily Heparin bolus __________ units, then Heparin gtt at _______ units per hour. a. ACT every _________ hours. b. If ACT greater than ________ stop Heparin for 1 hour, then restart drip @ 100 units/hour less than previous rate. c. If ACT less than _________ bolus with Heparin 200 units and increase drip by 100 units/hour. Enoxaparin (Lovenox) ______________ mg SQ ______________________ Enoxaparin (Lovenox) ______________ mg IV _______________________ Glycoprotein IIb / IIIa Inhibitor: Integrilin bolus 180 mcg/kg IV (Maximum 22.6 milligrams), then infuse drip at 2 mcg/kg/min IV for 18 hours (Maximum 15mg/hr) Reopro
For creatinine clearance less than 50 mL/minute, decrease infusion to 1mcg/kg/min (Max 7.5 mg/hr) 0.25 mg/kg IV bolus
10 mcg /min IV x 12 hours
Statin: Unless contraindicated as listed here: ___________________________________________________________________ Statin: ________________________
_________ mg PO________________
Nitroglycerin drip @ ________ mcg/minute – Increase by 5mcg/minute every 3-5 minutes for DBP> 100 or with chest pain (Note patient’s normal BP range). Decrease for SBP < 100. Pepcid 20 mg PO BID
TO Read back Order taken by Signature: _________________________________________Date/Time: __________________________
Physician Signature ___________________________________________Date/Time__________________________ Page 2 of 5 - Chest Pain Admit Plan
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Patient Label Here Chest Pain Control: For mild Chest Pain: (level 0-4) Stat ECG and NTG 0.4 mg SL (if SBP greater than 90) PRN every 5 minutes x 3 doses. Notify physician, label ECG “with chest pain” and stated pain level For moderate or severe chest pain (level 5 or >) ECG then Morphine Sulfate ____________ mg IV PRN every 10-15 minutes. Notify physician, label ECG “with chest pain” and stated pain level. 13. PROPHYLAXIS: SCDs
Foot Pumps
TED Hose
________________________________________________________________________________________________________ 14. ADDITIONAL ORDERS: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________
TO Read back Order taken by Signature: _________________________________________Date/Time: __________________________
Physician Signature ___________________________________________Date/Time__________________________ Page 3 of 5 - Chest Pain Admit Plan
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Patient Label Here PATIENT DISCOMFORT MEDICATION PLAN Indicate desired medications by checking appropriate box. If more than one box is checked for an indication, then use the ordered medications in the descending order. PAIN MANAGEMENT: (TARGET MAXIMUM OF 3000 MG OF ACETAMINOPHEN PER 24 HOURS FROM ALL SOURCES) (DO NOT EXCEED 4000MG OF ACETAMINOPHEN PER 24 HOURS) MILD PAIN (Pain Scale 1-3): Acetaminophen (Tylenol) 500–1000 mg PO every 4 hours PRN mild pain (Do not exceed 4,000 mg in 24 hours), if NPO use: Acetaminophen (Tylenol) 650 mg suppository PR every 4 hours PRN mild pain (Do not exceed 4,000 mg in 24 hours), if acetaminophen is ineffective/contraindicated use: Ibuprofen (Motrin) 400 mg PO every 6 hours PRN mild pain (Do not exceed 3,200 mg in 24 hours) Other___________________________________________________________________________________________ MODERATE PAIN (Pain Scale 4-7): Hydrocodone/acetaminophen (Lortab) 5/500 mg 1–2 tabs PO every 4 hours PRN moderate pain (Do not exceed 4 grams of acetaminophen in 24 hours), if ineffective/contraindicated or NPO use: Ketorolac (Toradol) 15–30 mg IV every 6 hours PRN moderate pain x 48 hours (May give IM if no IV access) Other___________________________________________________________________________________________ SEVERE PAIN (Pain Scale 8-10): Morphine 2–4 mg slow IV push every 4 hours PRN severe pain, if ineffective/contraindicated use: Hydromorphone (Dilaudid) 1 mg slow IV push every 4 hours PRN severe pain Other___________________________________________________________________________________________ NAUSEA/VOMITING: Promethazine (Phenergan) 25 mg PO every 4 hours PRN nausea/vomiting, if ineffective/contraindicated or NPO use: Ondansetron (Zofran) 4 mg IV every 8 hours PRN nausea/vomiting Other___________________________________________________________________________________________ BOWEL MANAGEMENT:
Docusate (Colace) 100 mg PO at bedtime PRN for constipation, if contraindicated or ineffective after 12 hours use: Bisacodyl (Dulcolax) 10 mg suppository PR daily PRN constipation, if contraindicated or ineffective after 6 hours use: Sodium phosphate enema (Fleet enema) PR daily PRN constipation (Do not use in renal patients) Other___________________________________________________________________________________________
INDIGESTION/GAS: Aluminum hydroxide/magnesium hydroxide (Maalox) 30 ml PO every 4 hours PRN indigestion Simethicone (Mylicon) 80–160 mg PO every 4 hours PRN gas/bloating Other___________________________________________________________________________________________ DIARRHEA: Loperamide (Imodium) 4 mg PO initially then 2 mg PO with each loose stool (Max 16 mg hours) Other___________________________________________________________________________________________ TO Read back Order taken by Signature: _________________________________________Date/Time: __________________________
Physician Signature ___________________________________________Date/Time__________________________ Page 4 of 5 - Chest Pain Admit Plan
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Patient Label Here
Indicate desired medications by checking appropriate box. If more than one box is checked for an indication, then use the ordered medications in the descending order. ANXIETY: Alprazolam (Xanax) 0.25 mg PO three times a day PRN anxiety, if ineffective/contraindicated or NPO use: Lorazepam (Ativan) 0.5 – 1 mg IV every 6 hours PRN anxiety Other____________________________________________________________________________________________ SLEEPLESSNESS: Zolpidem (Ambien) 5 mg PO at bedtime PRN sleeplessness, may repeat x 1 in one hour if ineffective Other____________________________________________________________________________________________ ALLERGIC REACTIONS: Diphenhydramine (Benadryl) 25 mg PO every 4 hours PRN itching, if ineffective or NPO use: Diphenhydramine (Benadryl) 25 mg IV every 4 hours PRN itching Other____________________________________________________________________________________________ COUGH / SORE THROAT: Phenol-menthol (Cepastat) 1 lozenge PO PRN sore throat (Do not exceed 6 lozenges in 24 hours) Guaifenesin/dextromethorphan (Robitussin DM) 10 ml PO every 4 hours PRN cough Other____________________________________________________________________________________________ TEMPERATURE: Acetaminophen (Tylenol) 500–1000 mg PO every 4 hours PRN fever (Do not exceed 4,000 mg in 24 hours), if ineffective/contraindicated use: Ibuprofen (Motrin) 200–400 mg PO every 4 hours PRN fever (Do not exceed 3,200 mg in 24 hours) Other____________________________________________________________________________________________ HEMORRHOIDS: Witch hazel/glycerin (Tucks) pads at bedside wipe affected area as PRN, if ineffective use: Mineral oil/petrolatum/phenylephrine (Preparation H) ointment apply to affected area every 6 hours PRN. If ineffective/contraindicated use: Pramoxine/hydrocortisone (Proctofoam HC) at bedside apply to affected area every 8 hours PRN MUCOSITIS: Dexamethasone/diphenhydramine/nystatin/NS (Fred’s Brew) 15 ml swish and spit every 2 hours while awake PRN mucositis. If ineffective/contraindicated use: Viscous lidocaine (Xylocaine) 15 ml swish and spit every 4 hours PRN mucositis BLADDER SCAN: Bladder scan as needed for patients complaining of urinary discomfort and/or bladder distention present OR 6 hours post-Foley removal and patient has not voided. If bladder scan volume is >250 ml please notify the physician. OTHER: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ TO Read back Order taken by Signature: _________________________________________Date/Time: __________________________
Physician Signature ___________________________________________Date/Time__________________________ Page 5 of 5 - Chest Pain Admit Plan
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