Clinical Pathway_Acute Coronary Syndrome_021

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Note: this following symbol mean = Met X = not met N/A = not applicable

Day 1 : CCU วันท …………………………. D E N

1.Assessment Emergency or OPD assessment 1.Assessment IPD assessment

Day 1: EMERGENCY DEPARTMENT / OPD ER / OPD

ast-tract c est pa n a n assessment

V/S with O2 sat. (Record initial BP V/S on admission then every 1 hr

in both arms) Assess for thrombolytic contraindication

Record Intake and output every 8 hrs

2.Investigation EKG 12 Leads stat and with chest 2.Investigation Lab as order

pain CXR : Portable

(EDTA, Clot blood and PTT) pain and following pain relief.

Echocardiogram

Coronary angiogram

3.Intervention EKG and O2saturation monitoring 3.Intervention EKG and O2saturation monitoring

MONA Oxygen therapy maintain O2sat > 94%

IV fluid as order IV Fluid as order

Consult Cardiologist stat in case Clopidogrel

of STEMI Heparin/ LMWH

Activate Cath lab in case of primary GP IIb/IIIa (High risk, PCI)

PCI

Nitroglycerine Implement Pre/ Post cath order Uptitrates b-blocker

ACIE/ ARB if LVEF < 40%

Review Patient's own medications

Referfusion PCI Thrombolytic

Bleeding precautions with stool quaiacs

if on anticoagulants

If recurrent pain , consider cath or recath

4.Nutrition NPO 4.Nutrition NPO until seen by cardiology Attending

5.Activity & Absolute Bed Rest 5.Activity & Bedrest until sheaths out or if hemodynamic

Rehabilitation Rehabilitation unstable

Otherwise bedside commode.

6.PFE Explain plan of care and treatment 6.PFE Orient to surroundings , equipment , testing

to patient and family Explain and give patient copy of patient

pathway and PI

7.Discharge Transfer To 7.Discharge Assessment for Discharge planning to

plan Cath lab for urgent Cath plan establish need for home services or interim

CCU replacement

From Cath lab tranfer to CCU See progress note / Physician orders for

reflection pathway integration

F/M-02.1-HEART-021 Rev.0 (21/11/2011)

s gna ure s gna ure

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Day 2 : CCU วันท …………………………. D E N Day 3 : วันท …………………………. D E N1.Assessment Smoking Assessment 1.Assessment V/S and O2 sat. every 4 hrs and with

V/S and O2 sat. every 1-2 hrs and episodes of chest pain

with e isodes of chest ain ecor every r

Record I/O every 8 hr

Daily weight by 7.00 am

2.Investigation Cardiac monitor 2.Investigation Cardiac monitor

Echocardiogram (If not done Day 1) Labs : per patient need

Consider whether stress test Obtain EKG with all episodes of chest pain

appropriate and what type to done and following pain relief.

Obtain EKG with all episodes of

chest pain and following pain relief.

3.Intervention D/C Oxygen if chest pain free and 3.Intervention IV saline lock

O2sat > 94% on Room air b-blocker

IV Fluid or IV saline lock ACIE/ ARB

ACIE/ ARB if LVEF < 40% Lipid lowering agent

Clopidogrel Bleeding precautions with stool quaiacs

Nitro l cerine if on anticoagulants

Uptitrates b-blocker

Heparin/ LMWH

Bleeding precautions with stool

quaiacs if on anticoagulants

4.Nutrition Nutrition consult for cardiac prudent 4.Nutrition Cardiac diet teaching by Nutritionistdiet teaching Low chol. and low salt diet

Low chol. and low salt diet (No concentrated sweets).

(No concentrated sweets)

5.Activity & Consult PT consult for Phase I 5.Activity & Progressive ambulation per Phase I

Rehabilitation cardiac Rehab Rehabilitation cardiac rehab (Target 200 ft.)

Progress activity per Phase I

cardiac Rehab

6.PFE Reinforce patient pathway 6.PFE Discuss cardiac medications their use

Discuss cardiac medications their and actions.

use and actions For active smokers, reevaluate patient ‘s

7.Discharge Transfer to ward if pain free response to discussion of smoking cessation

plan hemodinamically and electrically and response to not smoking in hospital

stable Give patient information document

Establish discharge plan : 7.Discharge Confirm discharge plans and services with

* PCI patient who is revascularized and plan team.

hemodinamically stable without significant Confirm how prescription will be obtained,

comorbidities target Day 3-4 discharge how patient will get home and contact

with no additional non invasive testing. appropriate resources if need facilitate this.

* All other patient target : Day 4-5 See progress note/ Physician orders for

discharge (If stable) reflection pathway integration

See progress note/ Physician orders

for reflection pathway integration

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Day 4 : วันท …………………………. D E N Day Disharge วันท …………………………. D E N

1.Assessment V/S and O2 sat. every 4 hrs and with 1.Assessment V/S and O2 sat. every 4 hrs

episodes of chest pain

Record I/O every 8 hr

2.Investigation Cardiac monitor 2.Investigation Notify cardiologist if RA sat less than 95%

Labs : per patient need Labs : per patient need

Obtain EKG with all episodes of

chest pain and following pain relief.

3.Intervention IV saline lock 3.Intervention IV saline lock

Meds : chest pain protocol. Consider Meds : chest pain protocol. Consider

Once daily dosing of appropriate Once daily dosing of appropriateagent agent

Bleeding precautions with stool Bleeding precautions with stool

quaiacs if on anticoagulants quaiacs if on anticoagulants

4.Nutrition Diet teaching by Nutritionist 4.Nutrition Diet teaching by Nutritionist

Low chol. and low salt diet Low chol. and low salt diet

o concen rae swee s

5.Activity & Cleared by PT for discharge 5.Activity & Cleared by PT for discharge

Rehabilitation Progressive ambulation per Phase I Rehabilitation Progressive ambulation per Phase I

cardiac rehab cardiac rehab

6.PFE Continue risk factor modification 6.PFE Review discharge instruction :

teaching Compleate ACS patient

Review discharge instruction : perception survey

Compleate ACS patient

perception survey

7.Discharge May D/C if 48 hrs sine last episode of 7.Discharge See progress note/ Physician orders

plan chest pain, no dysrhythymias and plan for reflection pathway integration

no CHF

ee progress no e ysc an or ers

for reflection pathway integration

RN signature RN signature

F/M-02.1-HEART-021 Rev.0 (21/11/2011) Page 3/ 3

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Clinical Pathway_Acute Coronary Syndrome_021