PLACE LABEL HERE
ACUTE MYOCARDIAL INFARCTION
POST TENECTEPLASE (TNKase) 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).
FORM 3-18436 REV. 11/2007 Send copy to pharmacy: ______(initials) Page 2 of 2
PLACE LABEL HERE
ACUTE MYOCARDIAL INFARCTION
POST TENECTEPLASE (TNKase)
ORDERS
1. Diagnosis Same as preprocedure plan ______(initials)
and Admit as Inpatient ______(reason for admission)
Status: Place in Observation ______(reason for observation)
2. Unit: q ICU q IMCU / PCU
3. Consult: q Urgent q Routine, Consult with ______concerning ______
q Respiratory Care for Cardiac Rehab, Phase I (if positive Myocardial Infarction)
q Consult Nutritional Services for diet teaching
q Physical Therapy for monitored progressive activity
q Occupational Therapy for stress management
4. q Phase I Cardiac Rehab
O2 per Respiratory Care Protocol (7504-10-01-03)
· Adjust O2 to maintain SpO2 92% or 88% in COPD. Call physician for O2 usage 4 L/min or 40%.
· Reassess daily, wean O2 to maintain SpO2 > 92% or 88% in COPD. Wean to room air if SpO2 is acceptable and patient has no known exclusions per 7504-10-01-03. May restart O2 as needed.
Smoking Cessation counseling, if patient smokes
5. Diagnostics: EKG q AM for 2 days
Repeat Troponin I in 8 hrs post TNKase (tenecteplase)
Fasting lipid profile in AM
6. INT and Vital signs per unit routine
7. ST segment monitoring per practice guidelines. Mount strips q 30 min post TNKase (tenecteplase) x 4
8. No further venipunctures, arterial punctures, IM injections x first 24 hrs post TNKase (tenecteplase)
9. Stat EKG and notify physician of any recurrent chest pain or ST elevation
Call MRT if suspected acute myocardial infarction, hemodynamic instability or unresolved chest pain despite intervention
10. NPO for 6 hrs then clear liquids; advance diet as tolerated to 30% calories from fat
11. Bedrest with bathroom privileges for 12 hrs, then up ad lib as tolerated
SCHEDULED MEDICATIONS:
12. Discontinue all NSAID (except aspirin) and COX-2 Inhibitors (i.e., celecoxib)
13. q Aspirin 160 mg (two x 81 mg chewable) po daily. Give first dose now if not given in ED
If unable to swallow, Aspirin 300 mg suppository per rectum STAT
q Aspirin 81 mg (chewable) po daily. Give first dose now if not given in ED
If unable to swallow, Aspirin 150 mg suppository (1/2 of a 300 mg suppository) per rectum daily
14. q Plavix (clopidogrel) 300 mg x 1 dose today (for patients < 75 y/o), then 75 mg po q am
q Plavix (clopidogrel) 75 mg po q am
15. q Nitroglycerin (200 mcg/ml) IV infusion at 10 mcg/min; may titrate up to 100 mcg/min until relief of symptoms. Maintain SBP to 100 mm Hg
16. Anticoagulant:
q Heparin Infusion LOW Cardiac Dose (initiate form # 28554 and flowsheet # 28557):
Bolus with 60 units/kg (maximum bolus 4,000 units) q No Bolus
Begin Heparin infusion at 12 units/kg/hr (maximum initial rate 1,000 units/hr)
q Lovenox (enoxaparin)
q < 75 yo: 1 mg/kg SQ q 12 hr (max 100 mg for first two SQ doses only)
q 75 yo: 0.75 mg/kg SQ q 12 hr (max 80 mg for first two SQ doses only)
q GFR < 30: 1 mg/kg SQ q 24 hr
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. Beta Blocker (for hypertensive patients only) without the following contraindications:
Send copy to pharmacy
FORM 3-18436 REV. 07/2012 Page 2 of 2
PLACE LABEL HERE
ACUTE MYOCARDIAL INFARCTION
POST TENECTEPLASE (TNKase)
ORDERS
· High risk for cardiogenic shock
· 2nd or 3rd degree AV block
· Severe COPD or active asthma
· Evidence of low output state
· Inferior MI
· Bradycardia
· Signs of heart failure
Send copy to pharmacy
FORM 3-18436 REV. 07/2012 Page 2 of 2
PLACE LABEL HERE
ACUTE MYOCARDIAL INFARCTION
POST TENECTEPLASE (TNKase)
ORDERS
q Lopressor (metoprolol) 25 mg po q ____hrs, hold if SBP < 90 or HR < 60
q Lopressor (metoprolol) 50 mg po q ____hrs, hold if SBP < 90 or HR < 60
q Coreg (carvedilol) ______mg po twice daily, hold if SBP < 90 or HR < 60
18. Ace Inhibitor/Angiotensin Receptor Blocker:
q Contraindication to Ace Inhibitor/Angiotensin Receptor Blocker:
q Allergy q Hyperkalemia q Hypotension q Other: ______
q Prinivil (lisinopril) ______mg po q am starting in am. Hold if SBP < 90
q Angiotensin receptor blocker: Cozaar (losartan) ______mg po daily. Hold if SBP < 90
q Other: ______Hold if SBP < 90
19. Cholesterol lowering therapy: (Statin for LDL-c 100mg/dl)
q Contraindication to Statin: q Allergy q Active or chronic liver disease q Other______
q Lipitor (atorvastatin) ______mg po q HS. Baseline Liver Function Tests if not already done
q Crestor (rosuvastatin) ______mg po q HS. Baseline Liver Function Tests if not already done
q Niaspan (niacin) ______mg po q HS. Baseline Liver Function Tests if not already done
q Vytorin (ezetimibe/simvastatin) _____ mg po q HS. Baseline Liver Function Tests if not already done
PRN MEDICATIONS (If > one drug is ordered for the same indication, clinical assessment will be used per policy 520-06)
20. If patient receiving insulin, initiate Hypoglycemia Treatment Protocol (form # 2513)
21. If patient is in ICU, IMCU or PCU: initiate Critical Care insulin Orders (form # 21386)
22. q Adult Electrolyte Replacement Orders (form # 21340)
23. Chest pain: Nitroglycerin 0.4 mg sublingual q 5 min x 3 doses prn (Hold if systolic BP is <100)
24. Severe chest pain unrelieved with max dose of IV Nitroglycerin or Nitroglycerin sublingual x 3 doses
q Morphine 2 mg IV q 5 min prn (max 10 mg in 2 hrs) Hold for excessive sedation
q Dilaudid (HYDROmorphone) 0.5 mg – 1 mg IV q 3 hr prn (if no epidural or PCA)
25. Moderate Pain: q Lortab (HYDROcodone/acetaminophen) 5/500 mg 1-2 tabs or 10/500 mg 1 tab po q 4 hrs prn
q Percocet (oxyCODONE/acetaminophen) 5/325 mg 1-2 tabs or 10/325 mg 1 tab po q 4 hrs prn
26. Mild Pain, Temp >100.5°F, HA: Tylenol (acetaminophen) 650 mg po q 4 hrs prn
27. Nausea/Vomiting: q Zofran (ondansetron) 4 mg IV or po q 6 hrs prn
q Reglan (metoclopramide) 10 mg IV or po q 6 hrs prn (5 mg if > 65 y/o)
28. Sleep: q Ambien (zolpidem)5-10mg po at HS prn. If 5 mg given, may repeat x 1 dose after 2 hrs
If > 65 year old, begin with 5 mg po at HS, may repeat x 1 dose after 2 hrs)
q Other: ______
29. Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
30. Stool Softener: Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
31. Constipation: Milk of Magnesia (MOM) 30 ml po daily prn
32. Anxiety: q Ativan (lorazepam) 0.5 - 1 mg po q 8 hrs prn
q Xanax (alprazolam) 0.25 - 0.5 mg po q 6 hrs prn
______
Date Time Physician Signature PID Number
Send copy to pharmacy
FORM 3-18436 REV. 07/2012 Page 2 of 2