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UMC Health System Patient Label Here
CARD POST CARDIAC CATHETERIZATION PLAN
PHYSICIAN ORDERS
Diagnosis _____________________________________________________________________________________________________________
Weight ____________________________________________ Allergies ________________________________________________________
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
Patient Care
Intermittent Telemetry
Continuous Telemetry (Intermediate Care)
Vital Signs Per Unit Standards
POC ACT If arterial sheath in place and ACT greater than 131 seconds, connect to pressure monitor.
Notify Nurse (DO NOT USE FOR MEDS) If Brachial Approach: a. bed rest for 2 hrs, then up if BP stable with standing. b. leave forearm comfortable and mildly flexed. c. no circumferential dressing.
Notify Provider of VS Parameters SBP Greater Than 180 consistently, SBP Less Than 90 consistently, HR Greater Than 110
Discontinue Arterial Sheath Discontinue at ______. Continue flat time for ______ hours.
Discontinue Venous Sheath Discontinue at ______. Continue flat time for ______ hours.
Notify Nurse (DO NOT USE FOR MEDS) If closure device fails, apply pressure for 20 min, then flat time 4 hours per sheath Fr size. If closure device fails, apply pressure for 20 min, then flat time 6 hours per sheath Fr size.
Notify Nurse (DO NOT USE FOR MEDS) Check peripheral pulse and distal to the cath site. If pulse is absent, verify with Doppler and check Cath Lab Op Record and Progress Notes to see if this is a new finding.
Notify Provider (Misc) Reason: If pulse is absent and extremity is cool, report to physician.
Daily Weight
Patient Activity Bedrest, Bed Position: HOB Greater Than or Equal to 30 degrees, Bedrest x 6 hrs with leg straight. Patient may lie on side with leg straight. Bedrest, Bed Position: HOB Greater Than or Equal to 30 degrees, Bedrest x _____ hrs with leg straight. Patient may lie on side with leg straight.
Strict Intake and Output Per Unit Standards
Insert Urinary Catheter Foley, To: Dependent Drainage Bag, PRN Urinary Retention
Discontinue Dressing Located: Card Cath Site, Remove in shower if possible and apply band-aid
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Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Card Post Cardiac Catheterization Plan Version: 8 Effective on: 05/08/18
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UMC Health System Patient Label Here
CARD POST CARDIAC CATHETERIZATION PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
Convert IV to INT
Communication
Notify Provider/Primary Team of Pt Admit Notify: physician or applicable PA/NP of room number by calling the physician’s office, Upon Arrival to Unit
Dietary
Oral Diet Clear Liquid Diet Full Liquid Diet Regular Diet AHA Diet Clear Liquid Diet, Advance as tolerated to Regular Clear Liquid Diet, Advance as tolerated to AHA Clear Liquid Diet, Advance as tolerated to 1800 Calorie ADA
ADA Diet 1800 Calories, AHA 1600 Calories, AHA 1800 Calories, Renal 1600 Calories, Renal
IV Solutions
1/2 NS IV, 75 mL/hr IV, 125 mL/hr IV, 150 mL/hr IV, 200 mL/hr
D5 1/2 NS IV, 75 mL/hr IV, 125 mL/hr IV, 150 mL/hr IV, 200 mL/hr
D5NS IV, 75 mL/hr IV, 125 mL/hr IV, 175 mL/hr IV, 200 mL/hr
NS (Normal Saline) IV, 75 mL/hr IV, 125 mL/hr IV, 150 mL/hr IV, 200 mL/hr
NS (Normal Saline Bolus) 500 mL, IVPB, iv soln, ONE TIME, Infuse over 1 hr 1,000 mL, IVPB, iv soln, ONE TIME, Infuse over 1 hr
MedicationsMedication sentences are per dose. You will need to calculate a total daily dose if needed.
***Medication Sentences are per dose. You will need to calculate a total daily dose if needed.***
Glycoprotein IIb/IIIa Inhibitors
***Patient must be on telemetry while receiving tirofiban (Aggrastat)***
Bolus:
tirofiban 25 mcg/kg, IVPush, inj, ONE TIME, Use actual body weight even in obese patients. IVPush over 5 minutes or less
Maintenance Infusion:
tirofiban 5 mg/100 mL
TO Read Back Scanned Powerchart Scanned PharmScan
Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Card Post Cardiac Catheterization Plan Version: 8 Effective on: 05/08/18
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UMC Health System Patient Label Here
CARD POST CARDIAC CATHETERIZATION PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
IV, x 18 hr Final concentration = 0.05 mg/mL (50 mcg/mL). Usual maintenance dose is 0.15 mcg/kg/min. If creatinine clearance is less than 60 mL/min, use 0.075 mcg/kg/min. **Patient must be on telemetry while receiving tirofiban (Aggrastat)** Start at rate:______________mcg/kg/min
Anti Platelets
Loading Dose
ticagrelor 180 mg, PO, tab, ONE TIME
prasugrel 60 mg, PO, tab, ONE TIME
clopidogrel 300 mg, PO, tab, ONE TIME 600 mg, PO, tab, ONE TIME
Maintenance Dose
ticagrelor 90 mg, PO, tab, BID
prasugrel 10 mg, PO, tab, Daily 5 mg, PO, tab, Daily
clopidogrel 75 mg, PO, tab, Daily
aspirin 81 mg, PO, tab ec, Daily 325 mg, PO, tab, Daily
Beta Blockers
Contraindications Beta Blocker Allergy or Sensitivity Bradycardia or Heart Block Chronic Lung Disease -- Asthma Severe Hypotension Other (specify below in other reason)
metoprolol 25 mg, PO, tab, BID 50 mg, PO, tab, BID 100 mg, PO, tab, BID
carvedilol 6.25 mg, PO, tab, BID Administer with breakfast and dinner. 12.5 mg, PO, tab, BID Administer with breakfast and dinner. 25 mg, PO, tab, BID Administer with breakfast and dinner.
Ace Inhibitors
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Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Card Post Cardiac Catheterization Plan Version: 8 Effective on: 05/08/18
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UMC Health System Patient Label Here
CARD POST CARDIAC CATHETERIZATION PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
Contraindications ACEI or ARB Allergy to Both Allergy to One-Must Try the Other Angioedema Caused by an ACE or ARB Hyperkalemia Hypotension Moderate or Severe Aortic Stenosis Renal Artery Stenosis Worsening Renal Function Other (specify below in other reason)
captopril 6.25 mg, PO, tab, TID Administer 1 hour before meals 12.5 mg, PO, tab, TID Administer 1 hour before meals 25 mg, PO, tab, TID Administer 1 hour before meals
lisinopril 2.5 mg, PO, tab, Daily 5 mg, PO, tab, Daily 10 mg, PO, tab, Daily 20 mg, PO, tab, Daily
ramipril 2.5 mg, PO, cap, Daily 5 mg, PO, cap, Daily 10 mg, PO, cap, Daily
Statins
Contraindications Statins Hypersensitivity Intolerance(myopathy, myalgia, myositis) Liver disease or elevated transaminases Pregnancy or breastfeeding
atorvastatin 10 mg, PO, tab, Nightly 20 mg, PO, tab, Nightly 40 mg, PO, tab, Nightly 80 mg, PO, tab, Nightly
pravastatin 10 mg, PO, tab, Nightly 20 mg, PO, tab, Nightly 40 mg, PO, tab, Nightly 80 mg, PO, tab, Nightly
rosuvastatin 5 mg, PO, tab, Nightly 10 mg, PO, tab, Nightly 20 mg, PO, tab, Nightly 40 mg, PO, tab, Nightly
simvastatin 5 mg, PO, tab, Nightly 10 mg, PO, tab, Nightly 20 mg, PO, tab, Nightly 40 mg, PO, tab, Nightly 80 mg, PO, tab, Nightly
Laboratory
Basic Metabolic Panel Routine, T;N
CBC Routine, T;N
CBC with Differential Routine, T;N
TO Read Back Scanned Powerchart Scanned PharmScan
Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Card Post Cardiac Catheterization Plan Version: 8 Effective on: 05/08/18
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UMC Health System Patient Label Here
CARD POST CARDIAC CATHETERIZATION PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
Comprehensive Metabolic Panel Routine, T;N
CK Routine, T;N, q8h 3 times
Troponin T High Sensitivity Routine, T;N, q8h for 3 times
Diagnostic Tests
DX Chest Portable
EKG-12 Lead
EKG-12 Lead Every AM 3 days
Respiratory
Oxygen Therapy Via: Nasal cannula, Keep sats greater than: 92% Via: Simple mask, Keep sats greater than: 92% Via: Nonrebreather mask, Keep sats greater than: 92%
Consults/Referrals
Consult Cardiac Rehab Cardiac Rehab for Inpatient Phase I evaluation and treatment. Arrange Outpatient Cardiac Rehab Phase II evaluation and treatment.
...Additional Orders
This patient is allergic to penicillin. CefoTEtan is a(n) cephalosporin and may show allergic cross-reactivity to penicillin.
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Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Card Post Cardiac Catheterization Plan Version: 8 Effective on: 05/08/18
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UMC Health System Patient Label Here
DISCOMFORT MED PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
Patient Care
Perform Bladder Scan Scan PRN, If more than 250, Then: Call MD, Perform as needed for patients complaining of urinary discomfort and/or bladder distention present OR 6 hrs post Foley removal and patient has not voided.
MedicationsMedication sentences are per dose. You will need to calculate a total daily dose if needed.
benzocaine-menthol topical (Chloraseptic 6 mg-10 mg mucous membrane lozenge) 1 lozenge, mucous membrane, lozenge, q4h, PRN sore throat
dextromethorphan-guaiFENesin (dextromethorphan-guaiFENesin 20 mg-200 mg/10 mL oral liquid) 10 mL, PO, liq, q4h, PRN cough
dexamethasone-diphenhydrAMIN-nystatin-NS (Fred’s Brew) 15 mL, swish & spit, liq, q2h, PRN mucositis While awake
Analgesics
acetaminophen 500 mg, PO, tab, q6h, PRN pain-mild (scale 1-3) ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF acetaminophen ineffective/contraindicated, USE ibuprofen if ordered:***** 1,000 mg, PO, tab, q6h, PRN pain-mild (scale 1-3) ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF acetaminophen ineffective/contraindicated, USE ibuprofen if ordered:***** 650 mg, rectally, supp, q4h, PRN pain-mild (scale 1-3) ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF acetaminophen ineffective/contraindicated, USE ibuprofen if ordered:*****
ibuprofen 400 mg, PO, tab, q6h, PRN pain-mild (scale 1-3) ***Do not exceed 3,200 mg of ibuprofen from all sources in 24 hours***. Give with food.
Select either HYDROcodone-acetaminophen or acetaminophen-codeine #3, but not both
HYDROcodone-acetaminophen (HYDROcodone-acetaminophen 5 mg-325 mg oral tablet) 1 tab, PO, tab, q4h, PRN pain-moderate (scale 4-7) Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours ****IF HYDROcodone-acetaminophen ineffective/contraindicated or the patient is NPO, USE ketorolac if ordered**** 2 tab, PO, tab, q4h, PRN pain-moderate (scale 4-7) Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours ****IF HYDROcodone-acetaminophen ineffective/contraindicated or the patient is NPO, USE ketorolac if ordered****Continued on next page....
TO Read Back Scanned Powerchart Scanned PharmScan
Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Card Post Cardiac Catheterization Plan Version: 8 Effective on: 05/08/18
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UMC Health System Patient Label Here
DISCOMFORT MED PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
acetaminophen-codeine (acetaminophen-codeine (Tylenol with Codeine) 300 mg-30 mg oral tablet) 1 tab, PO, tab, q4h, PRN pain-moderate (scale 4-7) Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours.***** If acetaminophen-codeine #3 ineffective/contraindicated or NPO, USE ketorolac if ordered.***** 2 tab, PO, tab, q4h, PRN pain-moderate (scale 4-7) Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours.***** If acetaminophen-codeine #3 ineffective/contraindicated or NPO, USE ketorolac if ordered.*****
ketorolac 15 mg, IVPush, inj, q6h, PRN pain-moderate (scale 4-7), x 48 hr ***May give IM if no IV access*** 30 mg, IVPush, inj, q6h, PRN pain-moderate (scale 4-7), x 48 hr ***May give IM if no IV access***
morphine 2 mg, Slow IVPush, inj, q4h, PRN pain-severe (scale 8-10) *****IF morphine is ineffective/contraindicated, USE HYDROmorphone if ordered***** 4 mg, Slow IVPush, inj, q4h, PRN pain-severe (scale 8-10) *****IF morphine is ineffective/contraindicated, USE HYDROmorphone if ordered*****
HYDROmorphone 0.2 mg, Slow IVPush, inj, q4h, PRN pain-severe (scale 8-10) 0.4 mg, Slow IVPush, inj, q4h, PRN pain-severe (scale 8-10) 0.6 mg, Slow IVPush, inj, q4h, PRN pain-severe (scale 8-10)
Antiemetics
promethazine 25 mg, PO, tab, q4h, PRN nausea/vomiting *****IF promethazine is ineffective/contraindicated or patient is NPO, USE ondansetron if ordered*****
ondansetron 4 mg, IVPush, soln, q8h, PRN nausea/vomiting
Gastrointestinal Agents
docusate 100 mg, PO, cap, Nightly, PRN constipation *****IF docusate is contraindicated or ineffective after 12 hours, USE bisacodyl if ordered*****
bisacodyl 10 mg, rectally, supp, Daily, PRN constipation *****IF bisacodyl is contraindicated or ineffective after 6 hours, USE Fleet Enema if ordered*****
sodium biphosphate-sodium phosphate (Fleet Enema) 1 ea, rectally, enema, Daily, PRN constipation
loperamide 4 mg, PO, cap, ONE TIME, PRN diarrhea Initial dose after first loose stool 4 mg, PO, liq, ONE TIME, PRN diarrhea Initial dose after first loose stool
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Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Card Post Cardiac Catheterization Plan Version: 8 Effective on: 05/08/18
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UMC Health System Patient Label Here
DISCOMFORT MED PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
loperamide 2 mg, PO, cap, as needed, PRN diarrhea 2 mg after each loose stool, up to 16 mg per day 2 mg, PO, liq, as needed, PRN diarrhea 2 mg after each loose stool, up to 16 mg per day
Antacids
Al hydroxide-Mg hydroxide-simethicone (aluminum hydroxide-magnesium hydroxide-simethicone 200 mg-200 mg-20 mg/5 mL oral suspension) 30 mL, PO, susp, q4h, PRN indigestion Administer 1 hour before meals and nightly.
simethicone 80 mg, PO, tab chew, q4h, PRN gas 160 mg, PO, tab chew, q4h, PRN gas
Sedatives
ALPRAZolam 0.25 mg, PO, tab, TID, PRN anxiety *****IF ALPRAZolam is ineffective/contraindicated or patient is NPO, USE LORazepam if ordered*****
LORazepam 1 mg, IVPush, inj, q6h, PRN anxiety 0.5 mg, IVPush, inj, q6h, PRN anxiety
zolpidem 5 mg, PO, tab, Nightly, PRN insomnia may repeat x1 in one hour if ineffective
Antihistamines
diphenhydrAMINE 25 mg, PO, cap, q4h, PRN itching *****IF diphenhydrAMINE PO is ineffective or patient is NPO, USE diphenhydrAMINE inj if ordered*****
diphenhydrAMINE 25 mg, IVPush, inj, q4h, PRN itching
Anti-pyretics
acetaminophen 500 mg, PO, tab, q4h, PRN fever ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF acetaminophen is ineffective/contraindicated, USE ibuprofen if ordered***** 1,000 mg, PO, tab, q6h, PRN fever ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF acetaminophen is ineffective/contraindicated, USE ibuprofen if ordered*****Continued on next page....
TO Read Back Scanned Powerchart Scanned PharmScan
Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Card Post Cardiac Catheterization Plan Version: 8 Effective on: 05/08/18
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UMC Health System Patient Label Here
DISCOMFORT MED PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
ibuprofen 200 mg, PO, tab, q4h, PRN fever Do not exceed 3,200 mg in 24 hours. Give with food. 400 mg, PO, tab, q4h, PRN fever Do not exceed 3,200 mg in 24 hours. Give with food.
Anorectal Preparations
witch hazel-glycerin topical (witch hazel-glycerin 50% topical pad) 1 app, topical, pad, as needed, PRN hemorrhoid care Wipe affected area *****IF witch hazel-glycerin ineffective/contraindicated, USE phenylephrine ointment if ordered*****
phenylephrine topical (phenylephrine 0.25%-3% rectal ointment) 1 app, rectally, oint, q6h, PRN hemorrhoid care Apply to affected area *****IF phenylephrine ointment ineffective/contraindicated, USE hydrocortisone-pramoxine foam if ordered*****
TO Read Back Scanned Powerchart Scanned PharmScan
Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Card Post Cardiac Catheterization Plan Version: 8 Effective on: 05/08/18
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UMC Health System Patient Label Here
HEPARIN INFUSION MED PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
Patient Care
Heparin Infusion Guidelines ***See Reference Text***
Communication
Notify Nurse (DO NOT USE FOR MEDS) Obtain Xa Heparin (Anti-Xa) Level 6 hours after starting infusion and 6 hours after every rate change.
Notify Provider (Misc) Reason: 2 consecutive Xa Heparin (Anti-Xa) levels are greater than 0.9 or less than 0.2
Notify Provider (Misc) Reason: If platelet count decreases by 50% of baseline or drops below 100,000 (100 K/uL)
Notify Provider (Misc) Reason: If Hemoglobin decreases by 2 g/dL or more.
Notify Provider (Misc) Reason: If signs of bleeding occur.
MedicationsMedication sentences are per dose. You will need to calculate a total daily dose if needed.
.Medication Management Start date T;N Discontinue all other orders for heparin products (i.e. heparin subcutaneous, enoxaparin).
Venous Thromboembolic Disorder
Deep Vein Thrombosis, Pulmonary Embolism
heparin 80 units/kg, IVPush, inj, ONE TIME For Bolus. Recommended maximum dose is 10,000 units.
heparin 25,000 units/250 mL D5W IV Initiate at rate of 18 units/kg/hr. Initial maximum rate is 18 mL/hr (1,800 units/hr). Final concentration = 100 unit/mL. Refer to heparin protocol for specific dosing instructions. Start at rate:______________units/kg/hr
Cardiac
Unstable angina, ST elevation MI, non-ST elevation MI
heparin 60 units/kg, IVPush, inj, ONE TIME For Bolus. Recommended maximum dose is 5,000 units, or 4,000 units for ST elevation MI with thyrombolytics.
heparin 25,000 units/250 mL D5W IV Initiate at rate of 12 units/kg/hr. Initial maximum rate is 10 mL/hr (1,000 units/hr). Final concentration = 100 unit/mL. Refer to heparin protocol for specific dosing instructions.Continued on next page....
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Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Card Post Cardiac Catheterization Plan Version: 8 Effective on: 05/08/18
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UMC Health System Patient Label Here
HEPARIN INFUSION MED PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
Start at rate:______________units/kg/hr
Neurological
Ischemia/strokes with a suspected embolic source in which thrombolytics have NOT been given and a CT has confirmed NO cerebral hemorrhage
No intial heparin bolus recommended.
heparin 25,000 units/250 mL D5W IV Initiate at rate of 12 units/kg/hr. Initial maximum rate is 12 mL/hr (1,200 units/hr). Final concentration = 100 unit/mL. Refer to heparin protocol for specific dosing instructions. Start at rate:______________units/kg/hr
Antidote
See heparin infusion guidelines reference text for dosing.
protamine mg, IVPush, inj, ONE TIME, PRN
Laboratory Baseline Labs
CBC STAT
PTT STAT
Prothrombin Time with INR STAT
Daily Labs
CBC Next Day in AM, T+1;0300, Every AM for 3 days
Therapeutic Monitoring
Anti Xa Level
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Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Card Post Cardiac Catheterization Plan Version: 8 Effective on: 05/08/18
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UMC Health System Patient Label Here
SLIDING SCALE INSULIN REGULAR PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
Patient Care
POC Blood Sugar Check Per Sliding Scale Insulin Frequency AC & HS AC & HS 3 days TID BID q12h q6h q6h 24 hr q4h q2h
Sliding Scale Insulin Regular Guidelines Follow SSI Regular Reference Text
MedicationsMedication sentences are per dose. You will need to calculate a total daily dose if needed.
insulin regular (Low Dose Insulin Regular Sliding Scale) 0-10 units, subcut, inj, AC & nightly, PRN glucose levels - see parameters Low Dose Insulin Regular Sliding Scale If blood glucose is less than 70 mg/dL and patient is symptomatic, initiate hypoglycemia guidelines and notify provider.
70-139 mg/dL - 0 units 140-180 mg/dL - 2 units subcut 181-240 mg/dL - 3 units subcut 241-300 mg/dL - 4 units subcut 301-350 mg/dL - 6 units subcut 351-400 mg/dL - 8 units subcut If blood glucose is greater than 400 mg/dL, administer 10 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dL, then resume normal POC blood sugar check and insulin regular sliding scale. 0-10 units, subcut, inj, BID, PRN glucose levels - see parameters Low Dose Insulin Regular Sliding Scale If blood glucose is less than 70 mg/dL and patient is symptomatic, initiate hypoglycemia guidelines and notify provider.
70-139 mg/dL - 0 units 140-180 mg/dL - 2 units subcut 181-240 mg/dL - 3 units subcut 241-300 mg/dL - 4 units subcut 301-350 mg/dL - 6 units subcut 351-400 mg/dL - 8 units subcut If blood glucose is greater than 400 mg/dL, administer 10 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dL, then resume normal POC blood sugar check and insulin regular sliding scale.Continued on next page....
TO Read Back Scanned Powerchart Scanned PharmScan
Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Card Post Cardiac Catheterization Plan Version: 8 Effective on: 05/08/18
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UMC Health System Patient Label Here
SLIDING SCALE INSULIN REGULAR PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
0-10 units, subcut, inj, TID, PRN glucose levels - see parameters Low Dose Insulin Regular Sliding Scale If blood glucose is less than 70 mg/dL and patient is symptomatic, initiate hypoglycemia guidelines and notify provider.
70-139 mg/dL - 0 units 140-180 mg/dL - 2 units subcut 181-240 mg/dL - 3 units subcut 241-300 mg/dL - 4 units subcut 301-350 mg/dL - 6 units subcut 351-400 mg/dL - 8 units subcut If blood glucose is greater than 400 mg/dL, administer 10 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dL, then resume normal POC blood sugar check and insulin regular sliding scale. 0-10 units, subcut, inj, q6h, PRN glucose levels - see parameters Low Dose Insulin Regular Sliding Scale If blood glucose is less than 70 mg/dL and patient is symptomatic, initiate hypoglycemia guidelines and notify provider.
70-139 mg/dL - 0 units 140-180 mg/dL - 2 units subcut 181-240 mg/dL - 3 units subcut 241-300 mg/dL - 4 units subcut 301-350 mg/dL - 6 units subcut 351-400 mg/dL - 8 units subcut If blood glucose is greater than 400 mg/dL, administer 10 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dL, then resume normal POC blood sugar check and insulin regular sliding scale. 0-10 units, subcut, inj, q4h, PRN glucose levels - see parameters Low Dose Insulin Regular Sliding Scale If blood glucose is less than 70 mg/dL and patient is symptomatic, initiate hypoglycemia guidelines and notify provider.
70-139 mg/dL - 0 units 140-180 mg/dL - 2 units subcut 181-240 mg/dL - 3 units subcut 241-300 mg/dL - 4 units subcut 301-350 mg/dL - 6 units subcut 351-400 mg/dL - 8 units subcut If blood glucose is greater than 400 mg/dL, administer 10 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dL, then resume normal POC blood sugar check and insulin regular sliding scale.Continued on next page....
TO Read Back Scanned Powerchart Scanned PharmScan
Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Card Post Cardiac Catheterization Plan Version: 8 Effective on: 05/08/18
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UMC Health System Patient Label Here
SLIDING SCALE INSULIN REGULAR PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
0-10 units, subcut, inj, q2h, PRN glucose levels - see parameters Low Dose Insulin Regular Sliding Scale If blood glucose is less than 70 mg/dL and patient is symptomatic, initiate hypoglycemia guidelines and notify provider.
70-139 mg/dL - 0 units 140-180 mg/dL - 2 units subcut 181-240 mg/dL - 3 units subcut 241-300 mg/dL - 4 units subcut 301-350 mg/dL - 6 units subcut 351-400 mg/dL - 8 units subcut If blood glucose is greater than 400 mg/dL, administer 10 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dL, then resume normal POC blood sugar check and insulin regular sliding scale.
insulin regular (Moderate Dose Insulin Regular Sliding Scale) 0-12 units, subcut, inj, AC & nightly, PRN glucose levels - see parameters Moderate Dose Insulin Regular Sliding Scale If blood glucose is less than 70 mg/dL and patient is symptomatic, initiate hypoglycemia guidelines and notify provider.
70-139 mg/dL - 0 units 140-180 mg/dL - 3 units subcut 181-240 mg/dL - 4 units subcut 241-300 mg/dL - 6 units subcut 301-350 mg/dL - 8 units subcut 351-400 mg/dL - 10 units subcut If blood glucose is greater than 400 mg/dL, administer 12 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dL, then resume normal POC blood sugar check and insulin regular sliding scale. 0-12 units, subcut, inj, BID, PRN glucose levels - see parameters Moderate Dose Insulin Regular Sliding Scale If blood glucose is less than 70 mg/dL and patient is symptomatic, initiate hypoglycemia guidelines and notify provider.
70-139 mg/dL - 0 units 140-180 mg/dL - 3 units subcut 181-240 mg/dL - 4 units subcut 241-300 mg/dL - 6 units subcut 301-350 mg/dL - 8 units subcut 351-400 mg/dL - 10 units subcut If blood glucose is greater than 400 mg/dL, administer 12 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dL, then resume normal POC blood sugar check and insulin regular sliding scale.Continued on next page....
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Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Card Post Cardiac Catheterization Plan Version: 8 Effective on: 05/08/18
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14 of 19
UMC Health System Patient Label Here
SLIDING SCALE INSULIN REGULAR PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
0-12 units, subcut, inj, TID, PRN glucose levels - see parameters Moderate Dose Insulin Regular Sliding Scale If blood glucose is less than 70 mg/dL and patient is symptomatic, initiate hypoglycemia guidelines and notify provider.
70-139 mg/dL - 0 units 140-180 mg/dL - 3 units subcut 181-240 mg/dL - 4 units subcut 241-300 mg/dL - 6 units subcut 301-350 mg/dL - 8 units subcut 351-400 mg/dL - 10 units subcut If blood glucose is greater than 400 mg/dL, administer 12 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dL, then resume normal POC blood sugar check and insulin regular sliding scale. 0-12 units, subcut, inj, q6h, PRN glucose levels - see parameters Moderate Dose Insulin Regular Sliding Scale If blood glucose is less than 70 mg/dL and patient is symptomatic, initiate hypoglycemia guidelines and notify provider.
70-139 mg/dL - 0 units 140-180 mg/dL - 3 units subcut 181-240 mg/dL - 4 units subcut 241-300 mg/dL - 6 units subcut 301-350 mg/dL - 8 units subcut 351-400 mg/dL - 10 units subcut If blood glucose is greater than 400 mg/dL, administer 12 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dL, then resume normal POC blood sugar check and insulin regular sliding scale. 0-12 units, subcut, inj, q4h, PRN glucose levels - see parameters Moderate Dose Insulin Regular Sliding Scale If blood glucose is less than 70 mg/dL and patient is symptomatic, initiate hypoglycemia guidelines and notify provider.
70-139 mg/dL - 0 units 140-180 mg/dL - 3 units subcut 181-240 mg/dL - 4 units subcut 241-300 mg/dL - 6 units subcut 301-350 mg/dL - 8 units subcut 351-400 mg/dL - 10 units subcut If blood glucose is greater than 400 mg/dL, administer 12 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dL, then resume normal POC blood sugar check and insulin regular sliding scale.Continued on next page....
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Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Card Post Cardiac Catheterization Plan Version: 8 Effective on: 05/08/18
1201
15 of 19
UMC Health System Patient Label Here
SLIDING SCALE INSULIN REGULAR PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
0-12 units, subcut, inj, q2h, PRN glucose levels - see parameters Moderate Dose Insulin Regular Sliding Scale If blood glucose is less than 70 mg/dL and patient is symptomatic, initiate hypoglycemia guidelines and notify provider.
70-139 mg/dL - 0 units 140-180 mg/dL - 3 units subcut 181-240 mg/dL - 4 units subcut 241-300 mg/dL - 6 units subcut 301-350 mg/dL - 8 units subcut 351-400 mg/dL - 10 units subcut If blood glucose is greater than 400 mg/dL, administer 12 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dL, then resume normal POC blood sugar check and insulin regular sliding scale.
insulin regular (High Dose Insulin Regular Sliding Scale) 0-14 units, subcut, inj, AC & nightly, PRN glucose levels - see parameters High Dose Insulin Regular Sliding Scale If blood glucose is less than 70 mg/dL and patient is symptomatic, initiate hypoglycemia guidelines and notify provider.
70-139 mg/dL - 0 units 140-180 mg/dL - 4 units subcut 181-240 mg/dL - 6 units subcut 241-300 mg/dL - 8 units subcut 301-350 mg/dL - 10 units subcut 351-400 mg/dL - 12 units subcut If blood glucose is greater than 400 mg/dL, administer 14 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dL, then resume normal POC blood sugar check and insulin regular sliding scale. 0-14 units, subcut, inj, BID, PRN glucose levels - see parameters High Dose Insulin Regular Sliding Scale If blood glucose is less than 70 mg/dL and patient is symptomatic, initiate hypoglycemia guidelines and notify provider.
70-139 mg/dL - 0 units 140-180 mg/dL - 4 units subcut 181-240 mg/dL - 6 units subcut 241-300 mg/dL - 8 units subcut 301-350 mg/dL - 10 units subcut 351-400 mg/dL - 12 units subcut If blood glucose is greater than 400 mg/dL, administer 14 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dL, then resume normal POC blood sugar check and insulin regular sliding scale.Continued on next page....
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Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Card Post Cardiac Catheterization Plan Version: 8 Effective on: 05/08/18
1201
16 of 19
UMC Health System Patient Label Here
SLIDING SCALE INSULIN REGULAR PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
0-14 units, subcut, inj, TID, PRN glucose levels - see parameters High Dose Insulin Regular Sliding Scale If blood glucose is less than 70 mg/dL and patient is symptomatic, initiate hypoglycemia guidelines and notify provider.
70-139 mg/dL - 0 units 140-180 mg/dL - 4 units subcut 181-240 mg/dL - 6 units subcut 241-300 mg/dL - 8 units subcut 301-350 mg/dL - 10 units subcut 351-400 mg/dL - 12 units subcut If blood glucose is greater than 400 mg/dL, administer 14 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dL, then resume normal POC blood sugar check and insulin regular sliding scale. 0-14 units, subcut, inj, q6h, PRN glucose levels - see parameters High Dose Insulin Regular Sliding Scale If blood glucose is less than 70 mg/dL and patient is symptomatic, initiate hypoglycemia guidelines and notify provider.
70-139 mg/dL - 0 units 140-180 mg/dL - 4 units subcut 181-240 mg/dL - 6 units subcut 241-300 mg/dL - 8 units subcut 301-350 mg/dL - 10 units subcut 351-400 mg/dL - 12 units subcut If blood glucose is greater than 400 mg/dL, administer 14 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dL, then resume normal POC blood sugar check and insulin regular sliding scale. 0-14 units, subcut, inj, q4h, PRN glucose levels - see parameters High Dose Insulin Regular Sliding Scale If blood glucose is less than 70 mg/dL and patient is symptomatic, initiate hypoglycemia guidelines and notify provider.
70-139 mg/dL - 0 units 140-180 mg/dL - 4 units subcut 181-240 mg/dL - 6 units subcut 241-300 mg/dL - 8 units subcut 301-350 mg/dL - 10 units subcut 351-400 mg/dL - 12 units subcut If blood glucose is greater than 400 mg/dL, administer 14 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dL, then resume normal POC blood sugar check and insulin regular sliding scale.Continued on next page....
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Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Card Post Cardiac Catheterization Plan Version: 8 Effective on: 05/08/18
1201
17 of 19
UMC Health System Patient Label Here
SLIDING SCALE INSULIN REGULAR PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
0-14 units, subcut, inj, q2h, PRN glucose levels - see parameters High Dose Insulin Regular Sliding Scale If blood glucose is less than 70 mg/dL and patient is symptomatic, initiate hypoglycemia guidelines and notify provider.
70-139 mg/dL - 0 units 140-180 mg/dL - 4 units subcut 181-240 mg/dL - 6 units subcut 241-300 mg/dL - 8 units subcut 301-350 mg/dL - 10 units subcut 351-400 mg/dL - 12 units subcut If blood glucose is greater than 400 mg/dL, administer 14 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dL, then resume normal POC blood sugar check and insulin regular sliding scale.
insulin regular (Blank Insulin Sliding Scale) See Comments, subcut, inj, PRN glucose levels - see parameters If blood glucose is less than ____mg/dL , initiate hypoglycemia guidelines and notify provider.
70-139 mg/dL - ____ units 140-180 mg/dL - ____ units subcut 181-240 mg/dL - ____ units subcut 241-300 mg/dL - ____ units subcut 301-350 mg/dL - ____ units subcut 351-400 mg/dL - ____ units subcut If blood glucose is greater than 400 mg/dL, administer ____ units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat ____ units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dL, then resume normal POC blood sugar check and insulin regular sliding scale.
HYPOglycemia Guidelines
HYPOglycemia Guidelines ***See Reference Text***
glucose 15 g, PO, gel, as needed, PRN glucose levels - see parameters Use if patient is symptomatic and able to swallow. See hypoglycemia guidelines.
glucose (D50) 25 g, IVPush, syringe, as needed, PRN glucose levels - see parameters Use if patient is symptomatic and unable to swallow / NPO with IV access. See hypoglycemia guidelines.
glucagon 1 mg, IM, inj, as needed, PRN glucose levels - see parameters Use if patient is symptomatic and unable to swallow / NPO WITHOUT IV access. See hypoglycemia guidelines.
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Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Card Post Cardiac Catheterization Plan Version: 8 Effective on: 05/08/18
1201
18 of 19
UMC Health System Patient Label Here
VTE PROPHYLAXIS PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
Patient Care
VTE Guidelines See Reference Text for Guidelines
***If VTE Pharmacologic Prophylaxis not given, choose the Contraindications for VTE below and complete reason contraindi cated***
Contraindications VTE Active/high risk for bleeding Treatment not indicated Patient or caregiver refused Other anticoagulant ordered Anticipated procedure within 24 hours Intolerance to all VTE chemoprophylaxis
Apply Elastic Stockings Apply to: Bilateral Lower Extremities, Length: Knee High Apply to: Left Lower Extremity (LLE), Length: Knee High Apply to: Right Lower Extremity (RLE), Length: Knee High Apply to: Bilateral Lower Extremities, Length: Thigh High Apply to: Left Lower Extremity (LLE), Length: Thigh High Apply to: Right Lower Extremity (RLE), Length: Thigh High
Apply Sequential Compression Device Apply to Bilateral Lower Extremities Apply to Left Lower Extremity (LLE) Apply to Right Lower Extremity (RLE)
Apply Pedal Pump Apply to Bilateral Feet Apply to Left Foot Apply to Right Foot
MedicationsMedication sentences are per dose. You will need to calculate a total daily dose if needed.
***Recommended Trauma Dose = 30 mg, subcut, q12h*** ***Recommended Dose for Morbidly Obese Patients = 40 mg, subcut, q12h***
enoxaparin (enoxaparin for weight 40 kg or GREATER) 40 mg, subcut, syringe, q24h, Pharmacy to Adjust Dose per Renal Function 30 mg, subcut, syringe, q12h, Pharmacy to Adjust Dose per Renal Function 30 mg, subcut, syringe, q24h, Pharmacy to Adjust Dose per Renal Function 40 mg, subcut, syringe, q12h, for BMI greater than 39, Pharmacy to Adjust Dose per Renal Function
heparin 5,000 units, subcut, inj, q12h 5,000 units, subcut, inj, q8h
fondaparinux 2.5 mg, subcut, syringe, q24h
rivaroxaban 10 mg, PO, tab, In PM 20 mg, PO, tab, In PM
warfarin 5 mg, PO, tab, In PM
aspirin 81 mg, PO, tab chew, Daily 325 mg, PO, tab, Daily
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Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Card Post Cardiac Catheterization Plan Version: 8 Effective on: 05/08/18
1201
19 of 19
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