Physician'S Order Sheet - Acute Coronary Syndrome (Acs) printable pdf download

PHYSICIAN'S ORDER SHEET

ALL ORDERS WILL BE FULFILLED UNLESS CROSSED OUT

AFTER EACH ORDER IS PROPERLY CHECKED, FAX ORDER SHEET

TO PHARMACY WHETHER OR NOT ORDERS INVOLVE MEDICATION.

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Chest Pain, R/O MI ( First 12 hours )

Check ( )

√

Check ( )

Each

ACUTE CORONARY SYNDROME (ACS)

Pharmacy

Order As

Orders

Transcribed

Unstable Angina, Non-Q-Wave Infarct & Patients for PCI

(Percutaneous Coronary Intervention)

CHECK ALL APPROPRIATE BOXES:

Cardiac Monitor

Peripheral Lines x 1 - KVO NS

Chest X-ray (portable)

02 2 L N/C if pulse ox < 97%

EKG - 12 Lead STAT & Qam x 3 days. STAT PRN Chest Pain. Repeat EKG 2 hrs after first EKG.

Echocardiogram ( To be read by: ________________________________________ )

Labs CBC, CPK 0 - 4 - 8, CMP, PT / PTT, T&S, U / A ( Troponin included in CK0 & CK4 )

Beta Blocker for 6S Acute & ICU: IV and/or PO

Beta Blocker for 6S Tele, 6E Tele & 2S: PO ONLY

Aspirin 325 mgs P.O.

For chest pain, sublingual NTG 1/150 q 5 min x 3. Hold when pain is relieved.

NTG paste __________ ins topically q6H ( hold 0000 to 0600 )

NTG 50 mgs in 250 D5W Titrate to SBP ________ / DBP ________ and / or pain relief ( except 6E )

If Mg < 2mg / dl., give 2 grams of Mg in 100cc of NACL I.V. over ______ hr x ______ times.

CHECK ONLY 1 BOX:

HEPARIN INFUSION: For patients on Glycoprotein Inhibitor, 20000 units in 500 D5W. Select [1] or [2] ONLY:

_____ [1] Patients < 70 Kgs: Bolus 60 units / Kg IV: Infusion 12 units / Kg / hr IV.

_____ [2] Patients > 70 Kgs: Bolus 5,000 units IV: Infusion 1,000 units / hr IV.

HEPARIN INFUSION for Patient NOT on Glycoprotein Inhibitor: WEIGHT BASED HEPARIN PROTOCOL

ENOPROX (Lovenox): 1 mg / kg (max 183 mg) q 12 hr S.Q. [ok with or without Glycoprotein Inhibitor].

CHECK 1 BOX ONLY: [ ICU, 2S, 6S ONLY ]

EPTAFIBATIDE (Integrilin): Bolus from 10 mL vial. Infusion from 100 mL vial. Select [1], [2] or [3] ONLY:

_____ [1] Patient < 121 Kgs & Cr < 2.0 mg / dL - Bolus 180 mcg / Kg IV over 2 min.

Infusion 2 mcg / Kg / min (up to 72 hours) IV.

_____ [2] Patient > 121 Kgs & Cr < 2.0 mg / dL. Bolus 22.6 mg (11.3 mLs of 2 mg / ml IV) over 2 min.

Infusion 15 mg / hr (20 mls of 0.75 mg / ml IV).

_____ [3] Patients < 121 Kgs and Cr between 2.0 mg / dL & 4.0 mg / dL - Bolus 135 mcg / Kg IV over 2 min

Infusion 0.5 mcg / Kg / min (Do not use for pts with Cr > 4.0 mg / dL or pts. on dialysis).

TIROFIBAN: (Aggrastat) Select [1] or [2] ONLY:

_____ [1] Most Patients: 0.4 mcg / Kg / min for 30 min; then 0.1 mcg / Kg / min.

_____ [2] Patients with Severe Renal Impairment: 0.2 mcg / Kg / min for 30 min; then

0.05 mcg / Kg / min.

EPTAFIBATIDE: Inspect solutions. Do not use vials with visible particulate matter. May be administered in same

IV line as alteplase, atropine, dobutamine, midazolam, morphine, nitroglycerin, or verapmil. DO NOT infuse with

furosemide (Lasix). May be administered in 0.9% NaCl, D5 NaCL, or up to 60 mcq / L of potassium chloride.

FAXED BY/TIME:

TIME NOTED:

Date: ________________________

Time: ________________________

( Military Time )

Doctor's Signature _________________________________________________ MD

Military Time > >

Nurse's Signature / Title__________________________________________________

USE BALL POINT PEN ONLY - PRESS FIRMLY

PART OF THE MEDICAL RECORD

ACS Physicians Order_PHYSICIANS ORDER_MEDICAL AFFAIRS

PAGE 1 of 2

8850041 Rev 05/05

Physician'S Order Sheet - Acute Coronary Syndrome (Acs)

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