Myocardial Infarction Order Set Date

Time

1. [ ] Inpatient:

[ ] CCU [ ] PCU/Telemetry [ ] ICU

2. Diagnosis: _____________________________________

Admit to: Dr. _______________________________

3. Code Status:

[ ] See Completed Code Sheet * Note: No Code verbal order may only be taken in emergency situations 4. Labs: [ ] CBC, U/A, BMP, PT, PTT [ ] CPK , CK-MB, Troponin on Admission , q6 hrs. x 4 [ ] BrNP

[ ] Fasting Lipid Profile (if not done as outpatient- within last 3 months)

[ ] If patient on Digoxin, obtain level if not done in ER

[ ] Other ______________________________

[ ] MRSA screens for all patients readmitted within 7 days, nursing home patients, personal care home residents and group home residents. (Maintain contact precautions until negative result obtained.) 5. Studies:

[ ] EKG

[ ] EKG in AM

[ ] EKG Daily X 3

[ ] EKG during episodes of Chest Pain.

[ ] ECHO (if not done in last 6 months) Reason:

(Obtain Previous ECHO result)

[ ] Portable Chest X-Ray on arrival if not done in ER 6. O2 via ____________________ ; 7.

SVNs:

______ L/min.; [ ] Continuous [ ] prn [ ] Maintain SaO2 __________ %

[ ] Duoneb Q _______ hr

[ ] W/A

[ ] prn

[ ] Other ________________________________________________Q ______hr

[ ] W/A [ ] prn

8. Vital Signs: [ ] ICU/CCU (q ¼ hr x 1; then q 2hr) [ ] PCU (q 2 hr x 4; then q.i.d.) 9. Activity: 10.

[ ] Absolute bed rest

[ ] B.S. Commode [ ] BRP [ ] Elevate HOB 45-90 ˚

Diet: __________________________ [ ] Fluid Restriction to _______________ [ ] PO [ ] IV [ ] PO & IV

11. [ ] Chart I & O 12. [ ] Weigh Daily 13. IV solution: _____________________________Rate ____________

[ ] Saline Lock with routine flush

14. Consults: [ ] Cardiology [ ] Dr_____________________________ [ ] Dietary [ ] SS [ ] PT [ ] OT 15. Cardiopulmonary: [ ] Smoking Cessation [ ] Outpatient Cardiac Rehab _________________________________________ Physician Signature

Allergies

Code Key

Patient Height __________

Rx

Prescription Bottle

?

Unsure or Questionable

Ph

Pharmacist Called

ER

ER Documentation

L

Written or Printed List

V

Verbalized List

Patient Weight ________ lbs = KG _________

Pre-existing

[ ] Renal Impairment

[ ] Hypertension

[ ] Diabetes Mellitus

Conditions:

[ ] Liver Impairment

[ ] Pregnant

[ ] Breast Feeding

Pre-admission Medications:

Date/Time

Include all over-the-counter and herbal medications. All Medications must be reviewed prior to discharge and circled Yes or No

C O D E

Continue while Inpatient Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Continue on Discharge

Standard Medications:

Date/Time

Continue on Discharge

Antacid:

[ ] Mylanta 30ml po prn tid

Y

N

Nausea:

[ ] Zofran 4 mg IV q 6 hr prn

Y

N

Headache/fever:

[ ] Tylenol 1000mg po q 6 hr prn

Y

N

Laxative:

[ ] MOM 30 ml po prn

Y

N

Sleep:

[ ] Ambien 5 mg po q hs prn

Y

N

Sedation:

[ ] Ativan 0.5 mg po q 4 hr prn

Y

N

[ ] Xanax 0.25 mg po q 4 hr prn

Y

N

[ ] NTG 0.4 mg SL q 5 min. x 3 prn and call MD.

Y

N

Y

N

Chest Pain:

Nicotine Replacement: [ ] Nicotine Patch 21 mg

[ ] 14 mg

[ ] 7 mg

Chest wall daily

Physician Signature ____________________________________________________

Myocardial Infarction Order Set Allergies

Medication Profile :

Date/Time

All Medications must be reviewed prior to discharge and circled Yes or No.

Continue on Discharge

[ ] Aspirin Chew 324mg on admission Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

[ ] Heparin bolus5000 units IV and start drip at 1000 units / hr and follow Nomogram .

Y

N

[ ] Heparin for patient less than 70 kg modify per MD.

Y

N

[ ] Nitroglycerine drip start at 10 mc /min and titrate for relief chest pain, maintain Sys BP _____mm Hg

Y

N

[ ] Morphine Sulfate 2mg IV q 5 minutes for chest pain not relieved with Nitroglycerin.

Y

N

[ ] Metoprolol 5mg IV q 5 min x 3 doses provided sys BP greater 90 mm Hg and HR greater 50 / min

Y

N

[ ] Diuretic IV:

Y

N

[ ] Aggrastat bolus and maintenance drip per protocol using kg. dose chart - normal renal function

Y

N

Y

N

Y

N

[ ] Integrilin bolus and maintenance drip per protocol, 180mcg/kg bolus followed by 1mcg/kg/min infusion. *If serum Creatinine is 2mg/dl to 4mg/dl

Y

N

[ ] Retavase 10 units bolus over 2 min repeat 10 unit bolus in 30 minutes

Y

N

Reason not Ordered:

[ ] Aspirin __________ mg po daily Reason not Ordered:

ACE1 / ARB: Reason not Ordered:

Beta Blocker: Reason not Ordered:

Nitrates: Reason not Ordered:

[ ] Lovenox 1 mg/kg Subcutaneous q ____ hours. *Adjust for age or renal insufficiency

IV MEDICATIONS

[ ] Aggrastat bolus & maintenance drip per protocol using kg. dose chart for impaired renal function (Creatinine clearance less then 30ml/min) [ ] Integrilin bolus & maintenance drip per protocol, 180mcg/kg bolus followed by 2mcg/kg/min

Allergies

Date & Time

GENERAL ORDERS

Date & Time

MEDICATION ORDERS

Continue on Discharge

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Discharge Orders Date

Time

1.

Discharge patient on all medications circled Yes and enter on Medication Card

2.

Discharge patient to: [ ] Home [ ] Home Health ___________________________________________________________ [ ] Hospice [ ] Other: _______________________________________________________________

3.

Discharge Instructions: Activity:

4.

Discharge Instructions: Diet: [ ] Low sodium diet [ ] If diabetic, ______________ Calorie ADA Diet [ ] Other: _______________________________________________

5.

Discharge Instructions: [ ] Weigh yourself daily and report gains of __________ lbs [ ] Restrict fluids ____________

6.

Treatments / Other

7.

Outpatient Lab: [ ] Yes

[ ] No

If yes Specify Type_________________________________

Date / Time ____________________________________________________________________________ 8.

Home Oxygen [ Oxygen Liter Flow

]

________________________________________________________________ ________ /min

9. Appointment with Dr. ____________________ Location _____________________________________ Please call office immediately to schedule a return visit in ___________ Phone Number _______________ 10. Report to Physician: [ ] Short of Breath [ ] Fever [

]Swelling [ ]Nausea [ ]Vomiting [ ]Pain

11. [ ] Fax Discharge Orders & Patient Medication List to office. 12. [ ] Patient and family discharge education 13. Vaccine Status: [ ] Follow-up in office for a vaccination if patient is a candidate and did not receive while in the hospital

Physician Signature