PLACE LABEL HERE
CARDIOVASCULAR SURGERY
PRE-OP INPATIENT
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).
Allergies: ______
Date of Procedure: ______
Scheduled Procdure: q CABG q Valve q Other: ______
1. Is this a CMS inpatient only procedure? q Yes, admit as inpatient, proceed to # 3 q No, proceed to # 2
2. 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 # 3 q No, place in observation
3. If admitted as inpatient, Inpatient Physician Certification:
Diagnosis: ______
Level of Care: q Critical q Intermediate q Acute Care Location/Specialty Unit Preference ______
4. q Telemetry: If patient Medical/Surgical, must complete form # 36084
5. q Isolation: q Contact q Droplet q Airborne For: ______
6. Consults: Anesthesia (to include any management of permanent pacemaker / ICD)
q Other: ______
7. Diagnostics (Order if not done within the last 30 days. If done within 30 days , place copy of report on chart.)
CXR PA and Lateral q Already done (Date ______Time ______)
12-lead ECG q Already done (Date ______Time ______)
Bilateral Carotid Duplex Study q Already done (Date ______Time ______)
q Bilateral Radial Artery Study q Already done (Date ______Time ______)
q Bilateral Vein Mapping Study q Already done (Date ______Time ______)
Most recent cath report and diagram on chart. Must have CD or GMC system report.
Laboratory (Order STAT if < 24 hrs until time of surgery):
CV Surgery Rapid MRSA Screen
CBC with diff
CMP
Mg
PT/INR
PTT
Lipid Profile (if not done in the past 30 days)
Serum hCG per surgery policy (#6602-02)
HgbA1C
U/A
q Plavix inhibition assay
q Fibrinogen level
q Other: ______
Copy to pharmacy Order writer’s initials______
*3-40024* FORM 3-40024 REV. 01/2017 Page 1 of 4
PLACE LABEL HERE
CARDIOVASCULAR SURGERY
PRE-OP INPATIENT
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).
8. Planning for Blood Products:
_____ (initials) I confirmed the consent for transfusion has been obtained.
Type and Screen and HOLD
PRBC’s 2 units or ____ units
Platelets 2 units or ____ units
FFP 2 units or ____ units
Cryoprcipitate 2 units or ____ units
9. Respiratory
Incentive Spirometry pre-op instruction
PFT bedside spirometry per respiratory OR q Full PFT
10. CABG Surgical Prep: Night before surgery, patient to shower/bathe with 4% Chlorhexidine Solution
11. Diet: Cardiac diet, then NPO after midnight the night before surgery
NURSING:
12. Place 18 g peripheral IV in upper extremity, if radial artery harvest, use contralateral arm
13. VS q 4 hrs
14. Verify consent for surgery and blood administration obtained and on chart
15. Distribute Open Heart Education booklet to patient and/or family
16. Patient/family to view educational video
SCHEDULED MEDICATIONS:
17. Cardiac prophylaxis with Beta Blocker (for those patients on beta blockers at home):
q Continue current beta-blocker ______. Hold for HR < 60 or SBP < 90
q Lopressor (metoprolol tartrate) q 12.5 mg po bid or q 25 mg po bid. Hold for HR < 60 or SBP < 90
q Beta Blocker contraindicated because:
q Systolic BP < 90 q 2nd or 3rd degree heart block q Bradycardia (HR< 60)
q Severe COPD q CHF q Other: ______
18. Aspirin 81 mg PO daily
q DC Aspirin due to: q Allergy q Coagulopathy/Active Bleeding q Other: ______
19. q Heparin Protocol (form # 39815) Low Intensity, no bolus throughout therapy for CV surgery. Start 6 hrs after sheath removal.
20. q DC heparin infusion on call to OR, or on ______(date) at ______(time)
21. Cholesterol Lowering Therapy:
Lipitor (atorvastatin) 40 mg po q HS
OR q I have confirmed cholesterol lowering therapy is an active medication. DC Lipitor (atorvastatin).
OR q DC Lipitor (atorvastatin) due to: q Allergy q Active/chronic liver disease q Other: ______
Copy to pharmacy Order writer’s initials______
FORM 3-40024 REV. 01/2017 Page 2 of 4
PLACE LABEL HERE
CARDIOVASCULAR SURGERY
PRE-OP INPATIENT
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).
22. HOLD Medications All oral anti-coagulants now OR x _____ days starting on ______(date)
All oral anti-platelet (except aspirin) now OR x _____ days starting on ______(date)
Non-steroidal inflammatory drugs now OR x _____ days starting on ______(date)
Lovenox (enoxaparin) now OR x _____ hrs prior to surgery
Glucophage (metformin) now OR x _____ hrs prior to surgery
Ace-Inhibitor/ARB now OR x ______hrs prior to surgery
Other: ______
23. DO NOT ADMINISTER ANY ANTICOAGULANTS, ACE INHIBITOR/ARB’s, DIGOXIN, OR DIURETICS WITHOUT CHECKING WITH THE SURGEON.
PRN MEDICATIONS See policy 520-06 for range orders and pain intensity guidelines.
24. CV Care Unit Electrolyte Replacement Protocol (form # 40046)
25. Chest pain: Nitroglycerin 0.4 mg sublingual q 5 minutes x 3 doses prn and notify physician.
26. Hypertension: Hydralazine 10 mg IV prn x 1 dose if SBP > 150, recheck BP 1 hr after administration and call physician if SBP still > 150.
27. Sleep: q Melatonin 5 mg po q HS prn
q Other: ______
28. Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
29. 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
DAY OF SURGERY
30. Record: Height: ______Weight: ______(kg) BMI: ______(am of surgery)
31. Laboratory: CV Surgery Rapid MRSA Screen (If not already done)
q CBC with diff q Chem 7 q Mg q PT/INR q PTT
32. Assessment/Intervention/Monitoring:
Routine VS & record blood pressure in both upper extremities
Obtain POC finger stick glucose
33. Clip Surgical site for procedure as indicated
34. Prep patient with 2% chlorhexidine gluconate cloths
Copy to pharmacy Order writer’s initials______
FORM 3-40024 REV. 01/2017 Page 3 of 4
PLACE LABEL HERE
CARDIOVASCULAR SURGERY
PRE-OP INPATIENT
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).
DAY OF SURGERY SCHEDULED MEDICATIONS
35. Beta-blocker: Notify anesthesia if beta-blocker is held for HR < 60 or SBP < 90
Give current beta-blocker with a small sip of water at 0600 day of surgery (Hold for HR < 60 or SBP < 90)
If beta-blocker not currently ordered, give:
q Coreg (carvedilol) _____ mg PO x 1 dose with small sip of water at 0600 DOS (Hold for HR < 60 or SBP < 90)
q Lopressor (metoprolol tartrate) _____ mg PO x 1 dose with small sip of water at 0600 DOS (Hold for HR < 60 or SBP < 90)
OR q Beta-blocker contraindicated due to:
q Systolic BP < 90 q 2nd or 3rd degree heart block q Bradycardia (HR< 60)
q Severe COPD q Other: ______
36. q Aspirin 81 mg po at 0600 day of surgery
37. Bactroban (mupirocin) 2% ointment AM of surgery to inside of both nares (after nasal culture done)
38. Antibiotic:
q Ancef (cefazolin) 2 gm (or 3 gm if weight > 120 kg) IV pre-op to be administered by anesthesia
OR beta lactam (penicillin and cephalosporin) allergy only,
q Cleocin (clindamycin) 900 mg IV pre-op to be administered by anesthesia
OR q Vancomycin IV to be administered 1-2 hrs preoperatively
q If patient weight < 90 kg, 1 gm IV x 1 dose (infuse over 1 hr)
q If patient weight ≥ 90 kg, 1.5 gm IV x 1 dose (infuse over 1.5 hrs)
REQUIRED: Rationale for using Vancomycin as an antimicrobial prophylaxis
q History of MRSA/positive screen
q Allergy to penicillin and cephalosporins
ADDITIONAL ORDERS:
______
Date Time Physician Signature PID Number
Copy to pharmacy
FORM 3-40024 REV. 01/2017 Page 4 of 4