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: __________________________

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