PLACE LABEL HERE

CHEST PAIN/CARDIAC SYNCOPE

OBSERVATION ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

  1. Status: Place in Observation for: ______
  2. Level of Care: Acute Care Location/Specialty Unit Preference 5 South
  3. Telemetry: If patient Medical/Surgical, must complete form # 36084
  4. Isolation:  Contact  Droplet  Airborne For: ______

5.Consults:______Notified by physician

______Notified by physician

Cardiology Consult: ______Notified by physician

6.Diagnostics

Fasting lipid profile in AM

6 hr Troponin T at _____ (enter time to be drawn)

6 hr EKG at _____ (enter time to be drawn) Reason: Chest PainRead by: ______

D-DimerSTAT

Echocardiogram STAT in AM,Reason: Chest Pain Read by: ______

PA & Lateral CXRSTAT Reason: Chest Pain

CT angiogram of chest STATReason: Chest Pain

Venous DopplerReason: ______

Right LeftBilateral

Upper Extremity Lower Extremity

Other: ______

EKG in AM Reason: Chest Pain Read by: ______

  1. STRESS TESTING:

AHA Selection Methodology

  • Exercise Treadmill Test (ETT) is recommended as initial test in patients < 55 years of age with lowtointermediaterisk, able to exercise, andhas normal or near normal ECG
  • Exclusion Criteria: LV hypertrophy with repolarization changes, significant ST or T wave changes including digoxin effect, biphasic or inverted T waves in anterior leads, LBBB
  • Pharmacologic Stress Test is indicated if patient is unable to exercise and/or meets exclusion criteria for ETT. May be useful to discuss with cardiologist for test of choice.

 Exercise Treadmill Test (ETT) Reason: Chest Pain Read by: ______ In AM  Now

 DIMPS Reason: Chest Pain Read by: ______ In AM  Now

 Dobutamine DIMPS Reason: Chest Pain Read by: ______ In AM  Now

 Lexiscan (regadenoson) DIMPS Reason: Chest Pain Read by: ______ In AM  Now

(Hold Aminophylline, Sudafed, or medications containing caffeine for Lexiscan DIMPS)

  1. Vital signs per unit routine

Chest Pain The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked. Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

  1. Nursing Chest Pain Guidelines:

Notify provider of recurrent chest pain

Notify provider of EKG changes

Notify provider of positive Troponin T or myoglobin

  1. Diet: NPO now for for stress test today

NPO after midnight foranticipated stress test

 Full liquid breakfast then NPO for anticipated stress test

RegularCardiacDiabetic ______caloriesRenal

No caffeine 6 hours before stress test on any diet.

11. Activity: Bed Rest  Bedside commode  Bathroom privileges

 Up ad lib  Up with assistance

  1. Maintain INT

SCHEDULED MEDICATION:

  1. Nitroglycerin (NTG)2%ointment:

 ½ inch topically q 6 hrs, remove NTG ointment prior to transport to Cardiology Dept for stress test

or 1 inch topically q 6 hrs, remove NTG ointment prior to transport to Cardiology Dept for stress test

  1. Aspirin:

Aspirin 324 mg (four x 81 mg chewables) po STAT

 Aspirin 325 mg po daily

  1. Anticoagulation:

Lovenox (enoxaparin) 1 mg/kg SQ q 12 hrs (If CrCl ≤ 30, give 1 mg/kg q 24 hrs) Weight____kg

Dose Rounding for 1 mg/kg,
if patient weighs: / For CrCl > 30, Give
Lovenox (enoxaparin)
< 50 kg / 40 mg q 12 hrs
50-69 kg / 60 mg q 12 hrs
70-89 kg / 80 mg q 12 hrs
90-109 kg / 100 mg q 12 hrs
110-129 kg / 120 mg q 12 hrs
130-144 kg / 140 mg q 12 hrs
145-154 kg / 150 mg q 12 hrs
155-169 kg / 160 mg q 12 hrs
170 kg / 180 mg q12 hrs (maximum dose),
notify Clinical Pharmacist

Copy to pharmacyOrder writer’s initials ______

FORM 3-37193 REV. 12/2014 Page 2 of 3

PLACE LABEL HERE

CHEST PAIN/CARDIAC SYNCOPE

OBSERVATION ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

PRN MEDICATIONS See policy 520-06 for range orders and pain intensity guidelines.

  1. Electrolyte Replacement Protocol (form # 21340)

17. Chest pain:

 Nitroglycerin 0.4 mg sublingual q 5 minutes x 3 doses prn

Severe Pain or Chest pain unrelieved with 3 doses of SL or max IV Nitroglycerin:

Morphine 2 mg IV q 5 min prn (up to a max of 10 mg in 2 hrs),

DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered.

or 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.

  1. Moderate Pain:

Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered.

or If patient can not take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po q 4 hrs prn intead of Norco. DC if Percocet ordered.

or Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Norco ordered.

and/or  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.

  1. Mild Pain, Temp>100.5F, HA:
  2. Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
  1. Nausea/Vomiting: Zofran (ondansetron) 4 mg IV or po q 6 hrs prn

If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)

  1. Sleep: Ambien (zolpidem)5 mg (female or males ≥ 65 y/o) or 5-10mg (male < 65 y/o) po at HS prn
  1. Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
  1. Stool Softener: Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
  1. Constipation: Milk of Magnesia (MOM) 30 ml po daily prn

If no BM after 48 hrs  Dulcolax (biscodyl) 10 mg per rectum daily prn

and/or Senokot-S (docusate/senna) 2 tablets po at bedtime nightly

26.Cough:Robitussin (guaifenesin) 15 ml po q 4 hrs prn

27.Sore Throat:Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn

ADDITIONAL ORDERS:

______

______

______

DateTimePhysician SignaturePID Number

Copy to pharmacyOrder writer’s initials ______

FORM 3-37193 REV. 12/2014 Page 2 of 3