Unique Plan Description: Cards ACS MI High Risk-Heart Score 7-10
Plan Selection Display: Cards ACS MI High Risk-Heart Score 7-10
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2011-10-17 20:51:06
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2023-12-13 07:48:46
Available at all facilities: Yes

Cards ACS MI High Risk-Heart Score 7-10
Admit/Discharge/Transfer
		HEART Score 7-10: Use this order set for ACS, MI (STEMI, NSTEMI, Unstable Angina) patients with an Intermediate/High Risk for Adverse Cardiac Event (ACE)(NOTE)*
	Admit to Inpatient Status
		T;N, Anticipated LOS 2 midnight or more
	Admit to Observation Status
		T;N
Vital Signs
	Vital Signs
		T;N, Routine
Activity
	Bedrest
		T;N
			Comment: If patient has chest pain, SOB, or symptomatic SBP< 90
	Activity-As Tolerated
		T;N
			Comment: If patient denies chest pain, SOB or asymptomatic SBP >90
	Bedrest with Bathroom Privileges
		T;N
	Up in Chair
		T;N, TIDWM
			Comment: If pain free
Diet
	NPO
		T;N, NPO Except for: Medications, Until seen by cardiologist.
	Cardiac Diet
		T;N
	Diabetic Diet
		T;N
Laboratory
	CBC with Diff
		T;N, Stat, spec type = Blood
			Comment: if not done in ED
	Comprehensive Metabolic Panel
		T;N, Stat, spec type = Blood
			Comment: if not done in ED
	ProBNP
		T;N, Stat, spec type = Blood
	Hemoglobin A1C
		T;N, Stat, spec type = Blood
	PTT - MH/WH/JE
		T;N, Stat, spec type = Blood
			Comment: if not done in ED
	Partial Thromboplastin Time (PTT) - FH
		T;N, Stat, spec type = Diagnostic Blood
	INR - MH/WH/JE
		T;N, Stat, spec type = Blood
			Comment: if not done in ED
	Prothrombin Time (PT) - FH
		T;N, Stat, spec type = Diagnostic Blood
		T;N, Stat, spec type = Therapeutic Blood
	Lipid Panel
		T+1;0400, Routine, spec type = Blood
			Comment: if not done in ED
	hs Troponin T - MH/WH/JE
		T;N, Stat, spec type = Blood
		T;N+360, Timed, spec type = Blood
		T;N+720, Timed, spec type = Blood
	hs Troponin I - FH
		T;N, Stat, spec type = Blood
		T;N+360, Timed, spec type = Blood
		T;N+720, Timed, spec type = Blood
	CBC with Diff
		T+1;0400, Routine, spec type = Blood
	Basic Metabolic Panel
		T+1;0400, Routine, spec type = Blood
Diagnostic Tests
	ECG
		T;N, Stat, Indication: ACS Rule Out
			Comment: if not completed already
		T+1;0600, Routine, Indication: ACS Rule Out, DAILY, 2, Dose(s)/Time(s)
	Echo w Doppler resting
		T;N, Routine
	Chest 1 View
		T;N, Stat, Pain/Chest
IV Solutions
	Sodium Chloride 0.9%
		1,000 mL, IV, 20 ml/hr
		1,000 mL, IV, 125 ml/hr
	Sodium Chloride 0.45%
		1,000 mL, IV, 100 ml/hr
	nitroglycerin 50 mg/D5W 250 mL Premix IV
		250 mL, drug form: IV Large Volume, route of administration: IV, pharmacy order priority: Routine, requested start date/time T;N, Maintain Parameter: SBP> Parameter Goal: 90, Increment Dose Increase: 5 mcg/min, Increment Dose Decrease: 5 mcg/min, Incremen
			Comment: If no response at 20mcg/min, may increase by 10mcg/min every 5 min.  If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached.  IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that maintained Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation.
		50 mg, EVERY BAG, 5 mcg/min
Medications
	No NSAIDS (non steroidal anti-inflamatory)
		Discontinue all NSAIDS except ASA
	aspirin
		325 mg, Tablet-Enteric-Coated, BY MOUTH, Once, NOW
			Comment: if not given in ED
		81 mg, Tablet-Chew, BY MOUTH, DAILY, T+1; 0900
	Plavix
		75 mg, Tab, By Mouth, DAILY, T+1;0900
			Comment: Verify patient received loading dose of Plavix  in the ED before starting maintenance dose the next day. Notify cardiologist if patient has not received loading dose
		600 mg, Tab, By Mouth, Once, T;N
			Comment: If not given in ED
		OPTION TWO(NOTE)*
	aspirin
		81 mg, Tablet-Enteric-Coated, BY MOUTH, DAILY, T+1; 0900
		81 mg, Tablet-Chew, BY MOUTH, DAILY, T+1; 0900
	Brilinta (ticagrelor)
		180 mg, Tab, By Mouth, Once, NOW
		90 mg, Tab, By Mouth, Q12H, T;N+720
	Nitrostat
		0.4 mg, Tab, SUBLINGUAL, Q5MIN, PRN, chest pain
	lisinopril
		2.5 mg, Tab, BY MOUTH, DAILY
			Comment: Do not give if SBP <90
		5 mg, Tab, BY MOUTH, DAILY
			Comment: Do not give if SBP <90
		10 mg, Tab, BY MOUTH, DAILY
			Comment: Do not give if SBP <90
	Cozaar
		25 mg, Tab, BY MOUTH, DAILY
			Comment: Do not give if SBP <90
		50 mg, Tab, BY MOUTH, DAILY
			Comment: Do not give if SBP <90
		100 mg, Tab, BY MOUTH, DAILY
			Comment: Do not give if SBP <90
	benazepril
		20 mg, Tab, BY MOUTH, BID
			Comment: Do not give if SBP <90
		40 mg, Tab, BY MOUTH, DAILY
			Comment: Do not give if SBP <90
	Protonix
		40 mg, Tablet-Enteric-Coated, BY MOUTH, DAILY
	Pepcid
		20 mg, Tab, BY MOUTH, BID
	sodium chloride 0.9% flush injectable soln
		10 mL, Syringe, IV PUSH, BID, PRN, IV line flush
		10 mL, Syringe, IV Push, Q5MIN, PRN, IV line flush
PRN
	Tylenol
		650 mg, Tab, BY MOUTH, Q4H, PRN, headaches
			Comment: or temperature greater than 100.6
	morphine  IV
		1 mg, IV Push, Q1H, PRN, chest pain
			Comment: For chest pain not relieved by Nitro. Do not give if SBP <90, or resp <12
		2 mg, IV Push, Q1H, PRN, chest pain
			Comment: For chest pain not relieved by Nitro. Do not give if SBP <90, or resp <12
	Xanax
		0.25 mg, Tab, By Mouth, TID, PRN, anxiety
			Comment: hold if sedated
	Ambien
		5 mg, Tab, By Mouth, QHS, PRN, insomnia
			Comment: if 65 years or older; Do not repeat
	aluminum hydroxide/magnesium hydroxide/simethicone 200 mg-200 mg-20 mg/5 mL oral susp
		15 mL, Suspension-Oral, By Mouth, Q6H, PRN for indigestion
Anticholesterol Medication
	Lipitor
		80 mg, Tab, BY MOUTH, DAILY
		10 mg, Tab, BY MOUTH, DAILY
		40 mg, Tab, BY MOUTH, DAILY
Beta Blockers
	Toprol-XL
		25 mg, Tablet, Extended-Release, By Mouth, DAILY
		50 mg, Tablet, Extended-Release, By Mouth, DAILY
		100 mg, Tablet, Extended-Release, By Mouth, DAILY
	Lopressor
		25 mg, Tab, BY MOUTH, BID
		50 mg, Tab, BY MOUTH, BID
		100 mg, Tab, BY MOUTH, BID
		5 mg, Solution-Injection, IV Push, Q5MIN, duration: 3 Dose(s)/Time(s)
	Coreg
		3.125 mg, Tab, By Mouth, BIDWM
		6.25 mg, Tab, By Mouth, BIDWM
		12.5 mg, Tab, By Mouth, BIDWM
		25 mg, Tab, By Mouth, BIDWM
Patient Care

	Resuscitation Status
		T;N, Full Code
		T;N, No Code
	VTE Advisor
		Medical
	Order ECG
		T;N, PRN Stat with new onset or episode of chest pain
	Cardiac Telemetry Monitoring
		T;N, Telemetry Indications: ACS/Arrhythmia/QTc
			Comment: Continuously
	Notify MD
		T;N, if HR < 60 or > 100, SBP <90 or >160, DBP >100, SPO2 < 90%
		T;N, STAT of chest pain or chest pain equivalent, ST segment changes, unstable vital signs, arrhythmias
Therapies
Consults/Follow-up
	Consult Cardiac Rehab: Inpatient
		T;N
			Comment: indications: MI chest pain
	Consult Cardiac Rehab: Outpatient
		T;N
			Comment: indications: MI chest pain
	Consult Cardiologist

Oxygen Protocol
Therapies
Respiratory Therapy
	Oxygen Therapy
		T;N
	Pulse Oximetry Spot Check RT
		T;N, BID
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID

Nicotine Replacement/Tobacco Cessation
Medications

		Nicotine Replacement Warnings (Physician to determine risk vs benefit): Severe/life-threatening arrhythmias, severe/worsening angina pectoris, immediate postmyocardial infarction period (2 weeks), accelerated hypertension(NOTE)*
		Precautions:  pregnancy, breastfeeding; PUD, CAD, PVD, HTN, Hepatic disease, severe renal impairment, diabetes, previous allergy, sensitivity, or reaction to nicotine patch or gum; microvascular free flaps (immediate postop) and arthrodesis.(NOTE)*
		If patient is breastfeeding or pregnant, consider using OB Nicotine/Tobacco Cessation(NOTE)*
	nicotine
		2 mg, Gum, TransMUCOSAL, Q1H, PRN, smoking cessation
			Comment: <25 cigarettes/day; max 24 pieces/24 hours
		4 mg, Gum, TransMUCOSAL, Q1H, PRN, smoking cessation
			Comment: >25 cigarettes/day; max 24 pieces/24 hours
	Ativan
		0.5 mg, Tab, By Mouth, Q8H, PRN, anxiety
		1 mg, Tab, By Mouth, Q8H, PRN, anxiety
	Xanax
		0.25 mg, Tab, BY MOUTH, TID, PRN, anxiety
		0.5 mg Tab BY MOUTH TID, PRN anxiety
	Wellbutrin SR 150 mg/12 hours oral tablet, extended release
		150 mg, Tablet-Extended-Release, By Mouth, DAILY, 3 Day(s)
		150 mg, Tablet-Extended-Release, By Mouth, BID, 11 week(s)
	triamcinolone 0.1% topical cream
		1 appl, Cream, TOPICAL, TID, PRN, see comment
			Comment: for skin irritation from patch.
		nicotine 14 mg/24 hr Patch - For patients who smoke <10 cigarettes/day, 1 cigar per day, or uses < 1 can/pouch per week, but daily use, patients weighing less than 100lb, or patients with a history of cardiovascular disease.(NOTE)*
	nicotine
		14 mg, Patch, TOPICAL, DAILY
	nicotine Patch Removal
		Patch Removal, Patch, TOPICAL, DAILY, T+1;0900
	Medication patch site check
		T;N+720, Q12H
		nicotine 21 mg/24 hr Patch - For patients who smoke > 10 cigarettes/day; more than 1 cigar per day, or uses > 1 can or pouch/week). Weight>100lb. Do not use 21 mg for patients with history of cardiovascular disease.(NOTE)*
	nicotine
		21 mg, Patch, TOPICAL, DAILY
	nicotine Patch Removal
		Patch Removal, Patch, TOPICAL, DAILY, T+1;0900
	Medication patch site check
		T;N+720, Q12H
		nicotine 7 mg/24 hr Patch - For patients who don't use nicotine daily(NOTE)*
	nicotine
		7 mg, Patch, TOPICAL, DAILY
	nicotine Patch Removal
		Patch Removal, Patch, TOPICAL, DAILY, T;N+1440
	Medication patch site check
		T;N+720, Q12H

Peripheral Lock - Access
	sodium chloride 0.9% flush injectable soln
		10 mL Syringe IV PUSH BID
		10 mL, Syringe, IV PUSH, Q5MIN, PRN, IV line flush
	lidocaine 1% injectable solution (MH/WH/FH)
		0.1 mL, IntraDermal, Q1H, PRN, see comment
			Comment: For IV start
	sodium chloride bacteriostatic 0.9% injectable soln
		0.1 mL, Injection, IntraDermal, Q1H, PRN, see comment
			Comment: For IV start, use if patient has lidocaine allergy.
	Sodium Chloride 0.9% IVPB Flush
		25 mL, IVPB, Q1H, PRN, IV line flush, 5 min(s)
			Comment: Use if medication not compatible with primary line or there is no primary line;  infuse 25mL.
Patient Care
	Peripheral Lock-Insert
		T;N

Pain Constipation Nausea Protocol </= to 65 EKM
Medications
		Select only one medication in each category(NOTE)*
Mild Pain
	Tylenol
		650 mg, Tab, By Mouth, Q4H, PRN, see comment
			Comment: discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient
		650 mg, Suppository, RECTALLY, Q6H, PRN, see comment
			Comment: discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient
	ibuprofen
		600 mg, Tab, By Mouth, Q6H, PRN, pain-mild
			Comment: pain rating 1-3
		800 mg, Tab, By Mouth, Q8H, PRN, pain-mild
			Comment: pain rating 1-3
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-mild
			Comment: pain rating 1-3
	Percocet 5 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-mild
			Comment: pain rating 1-3
	Dilaudid Injectable
		0.2 mg, Injection, IV Push, Q2H, PRN, pain-mild
			Comment: for pain rating 1-3 and if NPO
	morphine  IV
		2 mg, Syringe, IV Push, Q2H, PRN, pain-mild
			Comment: for pain rating 1-3 and if NPO
Moderate Pain
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	acetaminophen-hydrocodone 325 mg-7.5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	acetaminophen-hydrocodone 325 mg-10 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	Percocet 5 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	Percocet 7.5 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	Percocet 10 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	Roxicodone
		5 mg, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	morphine  oral immediate release
		15 mg, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: Pain rating 4-6
	Dilaudid Injectable
		0.2 mg, Injection, IV Push, Q2H, PRN, pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
		0.4 mg, Injection, IV Push, Q2H, PRN, pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
	morphine  IV
		2 mg, Syringe, IV Push, Q2H, PRN, pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
		4 mg, Syringe, IV Push, Q2H, PRN, pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
	ketorolac injectable
		15 mg, Injection, IV Push, Q6H, PRN, pain-moderate, 48 hr
			Comment: For pain rating 4-6.
Severe Pain
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	acetaminophen-hydrocodone 325 mg-7.5 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Percocet 5 mg-325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Percocet 7.5 mg-325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Percocet 10 mg-325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Roxicodone
		10 mg, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	morphine  oral immediate release
		30 mg, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Dilaudid Injectable
		0.4 mg, Injection, IV Push, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10 if NPO or for breakthrough pain if on oral analgesics. Use 0.4mg if over age 70.
		0.5 mg, Injection, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10 if NPO or for breakthrough pain if on oral analgesics. Use 0.4mg if over age 70.
		0.6 mg, Injection, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10 if NPO
		0.8 mg, Injection, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10 if NPO
		1 mg, Injection, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10 if NPO
	morphine  IV
		4 mg, Syringe, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10; may give if NPO or for breakthrough pain if on oral analgesics.
		6 mg, Syringe, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10; may give if NPO or for breakthrough pain if on oral analgesics.
		Opiate Reversal(NOTE)*
	Narcan
		0.2 mg, Injection, IV Push, Q2MIN, PRN for see comment
			Comment: if patient has received opiate agents in the past 24 hours and/or if patient becomes somnolent with minimal or no response to stimuli or respiratory rate is 10 or less per minute.  RN may administer naloxone prior to contacting MD.  Notify MD immediately upon administration of naloxone.  May give 0.2mg every 2 min up to 1mg total dose.
Constipation
	docusate
		100 mg, Capsule, By Mouth, DAILY
			Comment: Hold for diarrhea
	Senokot S 50 mg-8.6 mg oral tablet
		2 TAB, Tab, By Mouth, QHS
	MiraLax oral powder for reconstitution
		17 gm, Packet, By Mouth, Q12H, PRN, constipation
			Comment: Mix in 6 oz juice or water
		17 gm, Packet, By Mouth, DAILY, PRN, constipation
			Comment: Mix in 6 oz juice or water
	Milk of Magnesia 8% oral suspension
		30 mL, Suspension, By Mouth, DAILY, PRN for constipation
			Comment: If Miralax not effective; do not use if creatinine clearance or GFR < 30mL/min
		30 mL, Suspension, By Mouth, Q12H, PRN for constipation
			Comment: If Miralax not effective; do not use if creatinine clearance or GFR < 30mL/min
	Dulcolax
		10 mg, Suppository, RECTALLY, DAILY, PRN, constipation
			Comment: If MOM ineffective or if patient NPO
		10 mg, Suppository, RECTALLY, Q12H, PRN, constipation
			Comment: If MOM ineffective or if patient NPO
	Fleet Enema 19 gm-7 gm rectal enema
		1 EA, Enema, RECTALLY, Q12H, PRN, constipation
			Comment: If bisacodyl ineffective
	Enema-Administer
		Tap water, Q1H, constipation
			Comment: if suppository ineffective
Nausea Vomiting
	ondansetron
		4 mg, Injection, IV PUSH, Q6H, PRN for nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN for nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED
		Select either promethazine or prochlorperazine orders(NOTE)*
	prochlorperazine
		10 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures.
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures, give if IV access not available.
	Phenergan (MH/WH)
		25 mg, Tab, By Mouth, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures.
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
		6.25 mg, Injection, IM-Intramuscular, Q6H, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Phenergan (FH)
		12.5 mg, INT, IVPB, Once, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
		25 mg, INT, IVPB, Once, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Phenergan (JE)
		25 mg, Tab, By Mouth, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Reglan
		10 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron and phenothiazine ineffective; avoid in patients > 65 y/o.
		10 mg, Injection, IM-Intramuscular, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron and phenothiazine ineffective; avoid in patients > 65 y/o.
Patient Care

	Notify MD
		If patient develops itching
		if no results from enema.

Insulin Sliding Scale - NovoLOG
Laboratory
	Glucose POC - RN
		T;N, QIDACHS
		T;N, 15 minutes after carbohydrate source or medication administered
	Hemoglobin A1C
		T+1;0400, Routine, spec type = Blood
	Order Lab
		T;N
			Comment: Blood Glucose (POC) as needed for signs and symptoms of hypoglycemia for patients with diabetic medication orders or known diabetic.
Medications
	Standard Dose NovoLOG
		2 - 12 units, Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale, Routine
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 2 units,200 - 249 = 4 units,250 - 299 = 6 units,300 - 349 = 8 units,350 - 399 = 10 units.Over 399 = 12 units,<< Sliding Scale Comments >> Check  POC in 3 hours; notify physician if repeat POC  greater than or equal to 400mg or less than or equal to 100.  Do not give insulin based on repeat POC value.  RN may change sliding scale insulin order and POC glucose order to every 6 hours if patient is NPO or not on oral diet (tube/enteral feedings, TPN, etc).  Enter as Q6H-SCH  PRN
	Moderate Dose NovoLOG
		4 - 24 units, Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 4 units,200 - 249 = 8 units,250 - 299 = 12 units,300 - 349 = 16 units,350 - 399 = 20 units.Over 399 = 24 units,<< Sliding Scale Comments >> Check  POC in 3 hours; notify physician if repeat POC  greater than or equal to 400mg or less than or equal to 100.  Do not give insulin based on repeat POC value.  RN may change sliding scale insulin order and POC glucose order to every 6hours if patient is NPO or not on oral diet (tube/enteral feedings,TPN, etc). Enter as Q6H-SCH PRN
	High Dose NovoLOG
		5 - 30 units, Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 5 units,200 - 249 = 10 units,250 - 299 = 15 units,300 - 349 = 20 units,350 - 399 = 25 units.Over 399 = 30 units, << Sliding Scale Comments >>Check  POC in 3 hours; notify physician if repeat POC  greater than or equal to 400mg or less than or equal to 100.  Do not give insulin based on repeat POC value.  RN may change sliding scale insulin order and POC glucose order to every 6hours if patient is NPO or not on oral diet (tube/enteral feedings, TPN, etc).  Enter as Q6H-SCH  PRN
	glucose oral gel (JE)
		15 gm, Gel, By Mouth, Q15MIN, PRN, low blood sugar
			Comment: For blood glucose is 60-70mg/dL as an alternative to apple juice. Notify provider if given with corresponding POC glucose recheck value
	Dextrose 50%
		25 mL, Injection, IV PUSH, Q15MIN, PRN for low blood sugar, Routine
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
	Dextrose 10% in Water (FH)
		250 mL, Injection, IVPB, Q30MIN, PRN for low blood sugar, infuse over 30 min(s)
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
	glucagon
		1 mg, Injection, IV Push, Q15MIN, PRN for low blood sugar, T;N
			Comment: Give if blood glucose < 70mg/dL AND if dextrose 50% injectable unavailable OR inadequate response to IV dextrose 50%. May give SubQ or IM if patient does not have IV access. Notify provider if given with corresponding POC glucose recheck value.
Patient Care
	Order Lab
		T;N, RN may change schedule of point of care glucose and sliding scale insulin order to every 6 hours if patient is NPO or not on oral diet (tube/enteral feedings, TPN, etc).. Enter POC order as Q6H-SCH, TIMED and medication order as Q6H-SCH PRN.
	Diabetic Snack
		T;N, Give snack (1 complex carb (15g), 1 protein snack (7g) ) anytime insulin is administered after the evening meal is complete and POC glucose is <150mg/dL.
	IV-Maintain
		T;N
			Comment: Patient should have IV site while on hypoglycemia protocol
	Hypoglycemia Treatment Parameters
		T;N, Hypoglycemia protocol initiated for patients with glucose <70mg/dl. Patient should have an IV while in Hypoglycemia protocol.
		T;N, glucose <60 mg/dL treat with Dextrose 50% 25 mL OR glucagon 1mg as per medication orders. Notify provider as per critical result protocol.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy
		T;N, glucose 60-70 mg/dL, administer 4 oz apple juice, 4 oz non-diet soda, or glucose gel (MJE/MFH).  If patient NPO or unable to tolerate oral intake, give Dextrose 50% 25 mL OR glucagon 1mg as per medication orders.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, After initial treatment of any glucose value </= 70 mg/dL, repeat POC glucose in 15 min; if result </= 70mg/dL continue treating as per protocol and rechecking glucose 15 min after treatment until glucose >70mg/dL.
			Comment: Notify provider of all treatments given and corresponding POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, Once glucose is within normal limits, give 1 complex carb and 1 protein source (such as ½ sandwich OR 1 individual container of peanut butter and 3 packs of crackers) or patient meal if patient able to take orals to prevent recurrent hypoglycemia.
			Comment: When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.

Insulin Sliding Scale - Regular
Laboratory
	Glucose POC - RN
		T;N, QIDACHS
	Hemoglobin A1C
		T+1;0400, Routine, spec type = Blood
Medications
	Standard Dose Regular
		2 - 12 units, Solution-Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale, Routine
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 2 units,200 - 249 = 4 units,250 - 299 = 6 units,300 - 349 = 8 units,350 - 399 = 10 units.Over 399 = 12 units, << Sliding Scale Comments >>Notify M.D. and repeat Blood Sugar in 2 hours
	Moderate Dose Regular
		4 - 24 units, Solution-Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale, Routine
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 4 units,200 - 249 = 8 units,250 - 299 = 12 units,300 - 349 = 16 units,350 - 399 = 20 units.Over 399 = 24 units,<< Sliding Scale Comments >> Notify M.D. and repeat Blood Sugar in 2 hours
	High Dose Regular
		5 - 30 units, Solution-Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale, Routine
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 5 units,200 - 249 = 10 units,250 - 299 = 15 units,300 - 349 = 20 units,350 - 399 = 25 units.Over 399 = 30 units,<< Sliding Scale Comments >> Notify M.D. and repeat Blood Sugar in 2 hours
	glucose oral gel (JE)
		15 gm, Gel, By Mouth, Q15MIN, PRN, low blood sugar
			Comment: If blood glucose is 70mg/dL or lower and/or experiencing symptomatic hypoglycemia administer per hypoglycemia protocol.
	Dextrose 50%
		50 mL, Injection, IV Push, Q15MIN, PRN for low blood sugar, Routine
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
	Dextrose 10% in Water (FH)
		250 mL, Injection, IVPB, Q30MIN, PRN for low blood sugar, infuse over 30 min(s)
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
	glucagon
		1 mg, Injection, IV Push, Q15MIN, for low blood sugar, Routine, T;N
			Comment: Give if blood glucose < 70mg/dL AND if dextrose 50% injectable unavailable OR inadequate response to IV dextrose 50%. May give SubQ or IM if patient does not have IV access. Notify provider if given with corresponding POC glucose recheck value
Patient Care
	Order Lab
		T;N, RN may change schedule of point of care glucose to every 6 hours if patient is NP or not on oral diet (tube/enteral feedings, TPN, etc). Enter order as Q6H-SCH and medication order as Q6H-SCH PRN.
	Diabetic Snack
		T;N, Give snack (1 complex carb (15g), 1 protein snack (7g) ) anytime insulin is administered after the evening meal is complete and POC glucose is <150mg/dL.
	IV-Maintain
		T;N
			Comment: Patient should have IV site while on hypoglycemia protocol
	Hypoglycemia Treatment Parameters
		T;N, Hypoglycemia protocol initiated for patients with glucose <70mg/dl.  Check a Glucose-POC level 15min
		T;N, glucose <60 mg/dL treat with Dextrose 50% 25 mL OR glucagon 1mg as per medication orders. Notify provider as per critical result protocol.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy
		T;N, glucose 60-70 mg/dL, administer 4 oz apple juice, 4 oz non-diet soda, or glucose gel.  If patient NPO or unable to tolerate oral intake, give Dextrose 50% 25 mL OR glucagon 1mg as per medication orders.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, After initial treatment of any glucose value </= 70 mg/dL, repeat POC glucose in 15 min; if result </= 70mg/dL continue treating as per protocol and rechecking glucose 15 min after treatment until glucose >70mg/dL.
			Comment: Notify provider of all treatments given and corresponding POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, Once glucose is within normal limits, give 1 complex carb and 1 protein source (such as ½ sandwich OR 1 individual container of peanut butter and 3 packs of crackers) or patient meal if patient able to take orals to prevent recurrent hypoglycemia.
			Comment: When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
Consults/Follow-up
	Consult Diabetes Educator
		Needs Diabetic Assessment

Pain Constipation Nausea Protocol > 65 Geriatric E
Medications
		Select only one medication in each category(NOTE)*
Mild Pain
	acetaminophen
		1,000 mg, Tab, By Mouth, Q8H-Sch, T;N
			Comment: For pain rating 1-3; Consider IV Acetaminophen (Ofirmev) if NPO.
		1,000 mg, Tab, By Mouth, Q8H, PRN pain-mild
			Comment: For pain rating 1-3; Consider IV Acetaminophen (Ofirmev) if NPO.
		1,000 mg, Tab, By Mouth, Q8H-Sch, T+1;N
			Comment: For pain rating 1-3; Consider IV Acetaminophen (Ofirmev) if NPO.
	acetaminophen 10 mg/mL intravenous solution
		1,000 mg, Solution-Injection, IVPB, Q8H, T;N, duration: 3 Dose(s)/Time(s)
			Comment: For pain rating 1-3.
Moderate Pain
	oxyCODONE
		2.5 mg, Tab, By Mouth, Q4H, PRN pain-moderate
			Comment: For pain rating 4-6
	traMADol
		25 mg, Tab, By Mouth, Q6H, PRN pain-moderate
			Comment: For pain rating 4-6; Screen for drug interactions (e.g.SSRI), and adjust dose for CrCl<30ml/min; avoid use if history of seizures.
	Dilaudid Injectable
		0.2 mg, Injection, IV Push, Q4H, PRN pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics.
Severe Pain
	oxyCODONE
		5 mg, Tab, By Mouth, Q4H, PRN pain-severe
			Comment: For pain rating 7-10.
	traMADol
		50 mg, Tab, By Mouth, Q6H, PRN pain-severe
			Comment: For pain rating 7-10; screen for drug interactions (e.g.SSRI), and adjust dose for CrCl<30ml/min; avoid use if history of seizures.
	Dilaudid Injectable
		0.4 mg, Injection, IV Push, Q2H, PRN pain-severe
			Comment: For pain rating 7-10 if NPO or for breakthrough pain if on oral analgesics.
		Opiate Reversal(NOTE)*
	Narcan
		0.2 mg, Injection, IV Push, Q2MIN, PRN see comment
			Comment: If patient has received opiate agents in the past 24 hours and/or if patient becomes somnolent with minimal or no response to stimuli or respiratory rate is 10 or less per minute.  RN may administer naloxone prior to contacting MD.  Notify MD immediately upon administration of naloxone.  May give 0.2mg every 2 min up to 1mg total dose.
PRN Discomfort
	trolamine salicylate 10% topical cream
		1 appl, Cream, TOPICAL, TID, PRN discomfort
			Comment: Apply to affected area.
	menthol-methyl salicylate topical
		1 appl, Cream, TOPICAL, TID, PRN discomfort
			Comment: Apply to affected area.
	lidocaine 4% topical patch
		1 patch, Patch, TransDERMAL, DAILY
	lidocaine Patch Removal
		Patch Removal, Patch, TransDERMAL, QHS
	Medication patch site check
		T;N+720, Q12H
Constipation
	Senokot S 50 mg-8.6 mg oral tablet
		1 TAB, Tab, By Mouth, BID, PRN for constipation
			Comment: Hold for loose stools
	MiraLax oral powder for reconstitution
		17 gm, Packet, By Mouth, BID
			Comment: Hold for loose stools.  Mix in 6oz juice or water.
	Dulcolax
		10 mg, Suppository, RECTALLY, Q12H, PRN constipation
			Comment: If other agents ineffective or if patient NPO.
	Fleet Enema 19 gm-7 gm rectal enema
		1 EA, Enema, RECTALLY, Q12H, PRN constipation
			Comment: If suppository ineffective.
	Enema-Administer
		Tap water, Q1H, see comment
			Comment: If suppository ineffective.
Nausea Vomiting
	ondansetron
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN nausea and/or vomiting
		4 mg, Injection, IV Push, Q6H, PRN nausea and/or vomiting
			Comment: If unable to take by mouth.

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase