PLACE LABEL HERE
ATRIAL FIBRILLATION / FLUTTER
ORDERS
The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
1. Do you expect that the patient’s condition will require a hospital stay that will cross two midnights (includes the time spent in outpatient- ED, surgery, OBS) and the patient has medical necessity for an inpatient admission?
q Yes, admit as inpatient, proceed to # 2 q No, place in observation
2. If admitted as inpatient, Inpatient Physician Certification:
Diagnosis: ______
Level of Care: q Critical q Intermediate q Acute Care Location/Specialty Unit Preference______
3. Telemetry: If patient Medical/Surgical, must complete form # 36084
4. q Isolation: q Contact q Droplet q Airborne For: ______
5. q Consults: ______
6. Diagnostics (if not done in ED): CBC, CMP, Magnesium level, PT/INR, PTT, TSH
q Digoxin level q ECHO Reason: ______Read by: ______
q CXR PA/lateral on admission q EKG now Reason: ______Read by: ______
Reason______q Other: ______
Stat ECG with significant chest pain and/or pain not relieved by nitroglycerin x 3 doses (see order on page 2)
Call MRT if suspected acute MI, hemodynamic instability, or unresolved chest pain despite intervention
7. Intake and output per unit routine
8. Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)
9. Sleep Apnea Orders (form # 21266) if OSA screen is positive for suspected or reported sleep apnea
10. Vital signs per unit routine
11. O2 per Protocol (form # 34431)
12. Diet: q NPO q NPO after midnight for possible cardioversion q Regular q Cardiac q Diabetic q Renal
q Nutrition Consult (warfarin diet)
13. Oral Nutrition Supplement Protocol (form # 31417), initiate if patient meets criteria
14. Activity (advance as tolerated):q Bed rest q Bedside Commode q Bathroom Privileges q Up ad lib q May shower
SCHEDULED MEDICATIONS:
15. INT q IVF: ______at ______ml/hr IV
16. Anticoagulation:
q Contraindication to anticoagulant: q Coagulopathy q Active bleeding q Other: ______
q Coumadin (warfarin) ____ mg po daily at 1700 and nurse to perform warfarin education
q Pradaxa (dabigatran)150 mg po BID (CrCl < 30 ml/min use 75 mg po BID)
q Xarelto (rivaroxaban) 20 mg po daily (CrCl 15-50 ml/min use 15 mg po daily)
q Eliquis (apixaban) 5 mg po BID (if 2 of these: age ≥ 80, weight ≤ 60, SCR ≥ 1.5, use 2.5 mg bid)
q Heparin Infusion Protocol, LOW Intensity (form # 39815)
q Lovenox (enoxaparin) 1 mg/kg SQ q 12 hrs (refer to Dose Rounding Chart below) (CrCl < 30, use q 24 hr)
Dose Rounding for 1 mg/kg,if patient weighs: / 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)
Copy to pharmacy Order writer’s initials______
*3-3149* FORM 3-3149 REV. 06/2017 Page 1 of 2
PLACE LABEL HERE
ATRIAL FIBRILLATION / FLUTTER
ORDERS
The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
17. Anti-arrhythmic:
Cordarone (amiodarone)
q Cordarone (amiodarone) 150 mg IV over 10 min x 1 dose.
Then continuous infusion 1 mg/min x 6 hrs, then 0.5 mg/min (complete form # 17044)
q Cordarone (amiodarone) ______po q ______
CardiZEM (diltiazem)
q CardiZEM (diltiazem) IV, Hold infusion for systolic BP < 90 or HR < 60
q no bolus q 10 mg IV over 2 minutes or q 20 mg IVP over 2 min,
q then start infusion at _____ mg/hr
q Titrate by 5 mg/hr to a max of 15 mg/hr for HR > ___ (critical, intermediate care and cardiac only)
q CardiZEM (diltiazem) oral _____ mg po q ______
Beta Blocker Option
q Lopressor (metoprolol) 5 mg IV over 2 min.
Repeat dose q 5 min for two more doses. Hold if systolic BP < 90 or HR < 60
And after 10 min, give Lopressor (metoprolol) as ordered below:
q Lopressor (metoprolol) oral ____ mg po two times daily. Hold if systolic BP < 90 or HR < 60
q Lopressor (metoprolol) ____ mg IV q 6 hrs, first dose now. (Hold if SBP < 90 or HR < 60)
q Coreg (carvedilol) ____ mg po bid with meals (Hold if SBP < 90 or HR < 60)
Digoxin: Loading: q Digoxin ___ mg IVP x 1 dose or q ___mg IVP q ____hrs x ____doses (max 1 mg)
Daily: q Digoxin ___ mg po daily or q Digoxin ____ mg IV daily
q Corvert (ibutilide) Protocol (form # 21578)
PRN MEDICATIONS See policy 520-06 for range orders and pain intensity guidelines.
18. q Electrolyte Replacement Protocol (form # 21340)
19. Chest pain: Nitroglycerin 0.4 mg sublingual q 5 minutes x 3 doses prn
20. Severe Pain or Chest pain unrelieved with 3 doses of SL or max IV Nitroglycerin
q Morphine 2 mg IV q 5 min prn (up to a max of 10 mg in 2 hrs), Hold for excessive sedation. DC if CrCl < 30. DC if Dilaudid ordered.
or q 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.
21. Moderate Pain:
q Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered.
or q If patient can not take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po q 4 hrs prn
instead of Norco. DC if Percocet ordered.
or q Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Norco ordered.
and/or q 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.
22. Mild Pain, Temp >100.5°F, HA: q Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
23. Nausea/Vomiting: q Zofran (ondansetron) 4 mg IV or po q 6 hrs prn
q If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)
24. Sleep: q Melatonin 5 mg po q HS prn
or q Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10mg (male < 65 y/o) po at HS prn
25. Indigestion: q Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
26. Stool Softener: q Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
27. Constipation: q Milk of Magnesia (MOM) 30 ml po daily prn
If no BM after 48 hrs: q Dulcolax (biscodyl) 10 mg per rectum daily prn
and/or q Senokot-S (docusate/senna) 2 tablets po at bedtime nightly
28. Cough: q Robitussin (guaifenesin) 15 ml po q 4 hrs prn
29. Sore Throat: q Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn
______
Date Time Physician Signature PID Number
Copy to pharmacy
FORM 3-3149 REV. 06/2017 Page 2 of 2