Patient Care Orders - Cardiology

Non ST Elevation - Acute Coronary Syndrome (ACS)

NSTEMI/Unstable Angina Admission Orders
< Consider enrollment in a Clinical Trial

o Yes o No

Date (yyyy-Mon-dd) Allergies (List or o Refer to Caution Sheet)

Pt Weight

Time (hh:mm)

oMeasured

kg

o Self-Reported

GRACE Risk Score

o On presentation to ED

Pt Height
cm
oMeasured
o Self-Reported
Admission / Discharge Planning
Admitting Diagnosis
o Unstable Angina
o NSTEMI
Refer to Form #18292 Risk Stratication and Management Guidelines (to be completed at presentation)
Risk Category

o High Risk o Non Low Risk (Intermediate)

o Low Risk
(Online calculator available at http://www.outcomes-umassmed.org/grace/acs_risk/acs_risk_content.html)

pl

< Is Goals of Care Designation documented? o Yes (Order placed on chart)

o No, engage in process and place Order on chart

OR
Resuscitation Status (until Goals of Care Designation policy in place):

Admit to Dr

Sa
m

Physician Consult

RAAPID time called

Unit

Callback

Transferred to/time

Anticipated Date of Discharge

< Notify Family Physician regarding admission

< Discharge Planning Coordinator Assessment
< Identify next-of-kin contact person
Name
General Care

Name

<Oxygen per nasal cannula adjust to keep SpO2 saturation greater than 90%
o ABGs
o Establish IV (left arm preferred) - 250 mL NS TKVO; saline lock IV when stable
< Vital signs every 8h and PRN
O2 saturation monitoring as per unit protocol
Do bilateral manual baseline BP, Right Arm
Left Arm
< Notify physician if greater than 20 mmHg difference
< Continuous ECG monitoring
< 12 Lead ECG (with recurrent chest pain/hemodynamic change)
< Weigh patient on admission as baseline
o Intake and Output
o Capillary Glucose Monitoring QID if diabetic OR random glucose greater than 11mmol/L
Alert physician if patient shows signs of bleeding, dysrhythmia, abnormal vital signs, or has persistent
pain.
Prescribers Name (print)
18834(2013-10)

Prescribers Signature
White - Chart

Canary - Pharmacy

Date (yyyy-Mon-dd)
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Patient Care Orders - Cardiology

Non ST Elevation - Acute Coronary Syndrome (ACS)
NSTEMI/Unstable Angina Admission Orders
Activity
o Bedrest if patient hemodynamically unstable or has angina
o Activity as tolerated as per unit protocol if hemodynamically stable and no angina
Diet
o Heart Healthy
o Renal Diet
o Hemodialysis Diet

o Low Sodium (2000mg)

o Diabetic

o NPO

o Peritoneal Dialysis Diet

o No Dialysis Diet

Laboratory

Sa
m

pl

On admission (Collect stat, if not already done in ED)

o Random glucose
o HbA1C (if not done within the last 3 months)
o ALT
o Magnesium
o PT(INR), PTT
o Fasting lipid prole in AM (Must be drawn within 24h of symptom onset regardless of fasting status)
o Troponin Stat (if not already done in ED)
o Troponin at 8h
o Troponin at 24h
o Troponin Daily x 3
o Other
On admission (if not already done)
o CBC
o Electrolytes (Na, K+, Cl, CO2)
o Urea/Creatinine
o Fasting Glucose
Optional
o CK every 6h x 3 (until level peaks, then daily x 3) o TSH
o Urinalysis
Diagnostic Imaging

o CXR on admission (if not already done in ED)

Cardiac Imaging and Testing
Prescriber to complete requisition
o Exercise Stress Test
o Cardiac Catherization
o Transthoracic Echocardiogram (TTE)
o Myocardial Perfusion Imaging (MIBI/MPI)

o Dobutamine Stress Echocardiography (DSE)

o ECG on admission, then daily x 3, and with angina
o Other
Prescribers Name (print)
18834(2013-10)

Prescribers Signature
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Canary - Pharmacy

Date (yyyy-Mon-dd)
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Patient Care Orders - Cardiology

Non ST Elevation - Acute Coronary Syndrome (ACS)
NSTEMI/Unstable Angina Admission Orders
Medications

o IV uid
at
mL/hr x
hrs
o Saline lock as per protocol
o Other
Antiplatelet Therapy
o Acetylsalicylic Acid 160 mg PO chew and swallow x 1, (give if loading dose not already administered within last 24h or if
patient not on a routine dose) then Enteric coated Acetylsalicylic Acid 81 mg PO daily
AND
o Ticagrelor 180 mg PO loading dose x 1 (if loading dose not already given) then Ticagrelor 90 mg PO BID
OR
o Clopidogrel 300 mg PO loading dose x 1, (if loading dose not already given) then Clopidogrel 75 mg PO daily

or Enoxaparin if eGFR less than 30mL/min)

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Anticoagulation Therapy
** Consider using unfractionated Heparin if cardiac catheterization is imminent within 12h (Do not use Fondaparinux
o Fondaparinux 2.5 mg subcutaneous now (if not already given) then Fondaparinux 2.5 mg subcutaneous daily.

Sa
m

(Ensure 12h between initial and subsequent dose)

OR
o Enoxaparin (caution in patients 75 years or older and consider dose adjustment.)
o Enoxaparin _____ mg (1mg/kg rounded to nearest 5 mg) subcutaneous now and then every 12h
o Clarify dose if weight greater than 100 kg (caution, review dose beyond 72h)
OR
o Unfractionated Heparin - as per facilitys Heparin Nomogram
Nitroglycerin (please circle weight-based OR non-weight-based dosing)
o IV Nitroglycerin start at ______ mcg/min OR ______ mcg/kg/min then increase by ______ mcg/min OR
______ mcg/kg/min every 5 minutes until relief of angina
o Stop titration if systolic blood pressure less than _____ mmHg OR MAP less than _____ mmHg
o Nitroglycerin patch _____ mg/h topical daily
Apply at _____ h and remove at _____ h (on 12h/off 12h)
(Not routinely used in combination with Nitroglycerin drip. May be required for minimum 30 minutes while Nitroglycerin drip is
weaned)

Beta Blocker
o BisoPROLol ______ mg PO daily (Target dose = 10 mg daily)
o MetoPROLOL _____ mg PO BID (Target dose = 100 mg BID)
o
mg PO
o Contraindication to Beta Blocker (specify)
Prescribers Name (print)
Prescribers Signature

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Patient Care Orders - Cardiology

Non ST Elevation - Acute Coronary Syndrome (ACS)
NSTEMI/Unstable Angina Admission Orders
Medications

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Angiotensin-Converting Enzyme (ACE) Inhibitor

o Perindopril _____ mg PO daily (Target dose = 8 mg daily)
o Ramipril _____ mg PO ______________ (daily or BID) (Target dose =10 mg daily)
o ____________________ mg PO ___________________________________________________________
o Contraindication to ACE Inhibitor (specify) ______________________________________________________________
OR
Angiotensin Receptor Blocker (ARB) (If ACE inhibitor-induced cough, rash or other intolerance)
o Candesartan _____ mg PO daily (Target dose = 32 mg daily)
o Valsartan _____ mg PO BID (Target dose = 160 mg BID)
o ____________________________________ mg PO __________________________________________
o Contraindication to ARB (specify) _________________________________________________________________________

Sa
m

Lipid Lowering Therapy

o Atorvastatin _____ mg PO daily (usual ACS dose = 80 mg)
o Rosuvastatin _____ mg PO daily (usual ACS dose = 40 mg)
o ___________________________ mg PO daily
o Contraindication to statins (specify) ____________________________________________
Analgesics
o Nitroglycerin spray 0.4 mg sublingual every 5 minutes x 3 PRN angina (notify MD)
o Morphine 2-4 mg direct IV q 2h PRN (for angina not resolved with Nitroglycerin)
o If allergic to morphine; give FentaNYL 25 - 50 mcg IV PRN every _____ minutes
o Acetaminophen 325-650 mg PO every 4h PRN for pain (maximum total daily dose of acetaminophen = 4 g)
Bowel Routine
o Docusate Sodium 100 mg PO bid
o Sennosides 17.2 mg PO at bedtime PRN for constipation
Antinausea/Antidyspepsia
o DimenhyDRINATE 50 mg PO, PR or IV every 4h PRN (caution in elderly)
o Aluminum/magnesium hydroxide liquid (Each mL provides 40 mg aluminum hydroxide and 40 mg magnesium hydroxide)
15 to 30 mL PRN for heartburn
o Pantoprazole 40 mg PO daily (consider in patients on dual antiplatelet therapy, over 75 years of age or at risk for GI bleeding)

Prescribers Name (print)

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Prescribers Signature

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Date (yyyy-Mon-dd)
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Patient Care Orders - Cardiology

Non ST Elevation - Acute Coronary Syndrome (ACS)
NSTEMI/Unstable Angina Admission Orders
Medications
Sedation
o Zopiclone 3.75 - 7.5 mg PO at bedtime PRN
OR
Anti-anxiety
o LORazepam 0.5 - 1 mg sublingual TID and HS PRN
o _____________________________ mg PO __________________ PRN
o For smokers, refer to Nicotine withdrawl treatment order sheet if available.

Other Orders

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______________________________________________________________________________________
______________________________________________________________________________________

Sa
m

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Referrals
Book Referrals Before Patient Leaves Hospital

Date (yyyy-Mon-dd)

Place for Referral

o Cardiac Rehabilitation
o Smoking Cessation
o Dietitian
o Pharmacy
o Social Work

o Occupational Therapist
o Physical Therapist
o Pastoral Care
o Other
o Other
Patient Education
o Tobacco Cessation Education

o Diabetes Education

o Medication Education

o Nutrition Education

Prescribers Name (print)

Prescribers Signature

18834 (2013-10)

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Date (yyyy-Mon-dd)

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