Unique Plan Description: Gen Adm Chest Pain Min/No Risk-Heart Score 0-3
Plan Selection Display: Gen Adm Chest Pain Min/No Risk-Heart Score 0-3
PlanType: Medical                                 
Version: 4          
Begin Effective Date: 2020-04-22 13:23:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2022-03-25 09:24:51
Available at all facilities: Yes

Gen Adm Chest Pain Min/No Risk-Heart Score 0-3
Admit/Discharge/Transfer
		HEART Score 0-3: Use this order set for minimal to no risk for Adverse Cardiac Event admitted with Chest Pain (consider on-cardiac etiology)(NOTE)*
	Admit to Observation Status
		T;N
	Admit to Inpatient Status
		T;N, Anticipated LOS 2 midnight or more
		T;N
			Comment: To Inpatient Status
Vital Signs
	Vital Signs
		per floor routine
		q1h x4 then q4h
		Q15MIN
			Comment: until stable
Activity
	Bedrest with Bathroom Privileges
		
	Activity-As Tolerated
		
	Bedrest
		T;N
	Up in Chair
		T;N, TIDWM
	Ambulate
		T;N, In hall, TID
		T;N, In hall, QID
Diet
	Cardiac Diet
		2000 mg (2 gm) Sodium (Low Sodium), Low Cholesterol/Low Saturated Fat
	Renal Diet
		
	Diabetic Diet
		T;N
	NPO
		T;N
	Regular Diet
		T;N
	Sodium Restricted Diet
		T;N
	Clear Liquid Diet
		T;N
Laboratory
Today's Lab
	CBC with Diff
		T;N, Stat, spec type = Blood
	INR - MH/WH/JE
		T;N, Stat, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Stat
	D-Dimer - MH/WH/JE
		T;N, Stat, spec type = Blood
	D-Dimer Level - FH
		T;N, Stat, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Stat, spec type = Blood
	Magnesium Level
		T;N, Stat, spec type = Blood
	Phosphorus
		T;N, Stat, spec type = Blood
	TSH
		T;N, Stat, spec type = Blood
	hs Troponin I - FH
		T;N, Stat, spec type = Blood
	Myoglobin
		T;N, Stat, spec type = Blood
	UA (Culture if Positive)
		T;N, Routine, Routine, spec type = Urine
	Toxicology Screen DAU - MH/WH/JE
		T;N, Stat, Stat, spec type = Urine
	Drug Screen Urine - FH
		T;N, Stat, Stat, spec type = Urine
	Pregnancy Test Urine
		Stat, Stat, spec type = Urine
	Basic Metabolic Panel
		Stat, spec type = Blood
Tomorrow's Lab
	CBC with Diff
		T+1;0400, Routine, spec type = Blood
	Basic Metabolic Panel
		T+1;0400, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T+1;0400, Routine, spec type = Blood
	Magnesium Level
		T+1;0400, Routine, spec type = Blood
	Phosphorus
		T+1;0400, Routine, spec type = Blood
	Lipid Panel
		T+1;0400, Routine, spec type = Blood
Diagnostic Tests

	Echo Stress
		T;N
	Echo w Doppler resting
		T;N
	Echo w Doppler resting w Contrast
		T;N
Radiology
	Chest 1 View
		Stat, Chest Pain
	Chest 2 View
		Routine, Chest Pain
	CTA Chest
		Stat, Dissection of Aorta
		Stat, Thoracic Aneurysm
Cardiology
	ECG
		Stat, Indication: Chest Pain of Uncertain Etiology
		T+1;0600, Timed, Indication: Chest Pain of Uncertain Etiology
		T;N+480, Timed, Indication: Chest Pain of Uncertain Etiology
	Nuclear Stress Lexiscan
		T;N
	Nuclear Stress Treadmill
		T;N
	Nuclear Stress Dobutamine
		T;N
IV Solutions

	Dextrose 5% with 0.45% NaCl
		1,000 mL, IV, 75 ml/hr
		1,000 mL, IV, 125 ml/hr
	Sodium Chloride 0.45%
		1000 mL, IV, 75 ml/hr
	Sodium Chloride 0.45% w/ KCl 20mEq
		1,000 mL, IV, 125 ml/hr
	Sodium Chloride 0.9%
		1,000 mL, IV, 75 ml/hr
		1,000 mL, IV, 125 ml/hr
	Sodium Chloride 0.9% with KCl 20mEq
		1,000 mL, IV, 75 ml/hr
		1,000 mL, IV, 125 ml/hr
	Dextrose 5% with 0.9% NaCl
		1,000 mL, IV, 75 ml/hr
		1,000 mL, IV, 125 ml/hr
Medications
	aspirin
		325 mg, Tablet-Enteric-Coated, By Mouth, Once, NOW
			Comment: if not given in ED
		81 mg, Tablet-Enteric-Coated, By Mouth, DAILY, T+1;0900
	Pepcid
		20 mg, Tab, By Mouth, BID
	Protonix
		40 mg, Tablet-Enteric-Coated, By Mouth, DAILY
PRN
	Nitrostat
		0.4 mg, Tab, SUBLINGUAL, Q5MIN, PRN, chest pain
	morphine  IV
		1 mg, Syringe, IV Push, Q5MIN, PRN, chest pain
		2 mg, Syringe, IV Push, Q5MIN, PRN, chest pain
	aluminum hydroxide/magnesium hydroxide/simethicone 200 mg-200 mg-20 mg/5 mL oral susp
		30 mL, Suspension-Oral, By Mouth, Q4H, PRN, indigestion
	Xanax
		0.25 mg, Tab, By Mouth, Q6H, PRN, anxiety
	Ambien
		5 mg, Tab, By Mouth, QHS, PRN, insomnia
Patient Care

	Resuscitation Status
		Full Code
		No Code
	Notify MD
		HR <60 or >120, sbp <90 or >180, dbp >100, spo2 <90%
		if chest pain or chest pain equivalent, ST segment, HR <45, HR >120, sbp >180, sbp <90, dbp >100, o2 <90%, rhythm change
		if troponin elevated
		if d-dimer positive
	Order ECG
		T;N
			Comment: PRN recurrent chest pain or chest pain equivalent
	Foley Catheter
		Foley, Insert, PRN, unable to void, If foley catheter needed, enter order for foley catheter insert, once, and select the appropriate criteria for insertion and then insert the foley catheter.
	Glucose POC - RN
		QIDACHS
	Cardiac Telemetry Monitoring
		Telemetry Indications: ACS/Arrhythmia/QTc
Therapies
	Smoking Cessation Education
		
	Smoking Cessation Education RT (FH)
		
	Pulse Oximetry Spot Check RT
		Stat, Q4H
	Cardiac Rehab to see: Inpatient
		Indications Stable angina
Consults/Follow-up
	Consult Cardiologist
		Reason for Referral: Chest Pain
	Consult Social Work
		Discharge Planning

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

Peripheral Lock - Access
Medications

	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

VTE Prophylaxis
Medications
	Lovenox
		40 mg, Syringe, SUBCUTANEOUS, DAILY, T;N
			Comment: (CrCl>30) Pharmacy to adjust dose based on pt weight. VTE Prophylaxis
		40 mg, Syringe, SUBCUTANEOUS, DAILY, T;N+480
			Comment: (CrCl>30) Start 8 hours after admission. Pharmacy to adjust dose based on pt weight. VTE Prophylaxis
		40 mg, Syringe, SUBCUTANEOUS, DAILY, T+1;0900
			Comment: (CrCl>30) Pharmacy to adjust dose based on pt weight. VTE Prophylaxis
	HEParin 5000 units/mL SUBCUTANEOUS
		5,000 units, Injection, SUBCUTANEOUS, Q8H-Sch, T;N
			Comment: VTE Prophylaxis
		5,000 units, Injection, SUBCUTANEOUS, Q8H-Sch, T;N+480
			Comment: Start 8 hours after admission. VTE Prophylaxis
		5,000 units, Injection, SUBCUTANEOUS, Q8H-Sch, T+1;0600
			Comment: VTE Prophylaxis
Patient Care
		Sequential Compression Device and Anti Embolism Device orders will not suppress the VTE Advisor(NOTE)*
	Sequential Compression Device
		T;N, Apply, Once
	Anti Embolism Stockings
		T;N, Apply, Once
			Comment: knee high
	VTE Prophylaxis Contraindication
		High Risk of Bleeding
		Procedure Planned
		ASA order meets prophylaxis requirement
		If patient is low risk or further evaluation needed, complete advisor:(NOTE)*
	VTE Advisor
		Medical

DVT VTE Prophylaxis (FH)
Laboratory
	CBC with Diff
		T;N, Routine, spec type = Blood
		T+1;0500, Routine, EVERY OTHER DAY, spec type = Blood
		T+1;0500, Routine, Q24H 3 Day(s), spec type = Blood
		T+1;0500, Routine, Q24H, spec type = Blood
	BMP
		T;N, Routine, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Routine, spec type = Diagnostic Blood
		T+1;0500, Q24H, spec type = Therapeutic Blood
	Partial Thromboplastin Time (PTT) - FH
		T;N, Routine, spec type = Diagnostic Blood
Medications
		See VTE Risk Assessment for patient risk score(NOTE)*
	Lovenox
		40 mg, Syringe, SUBCUTANEOUS, DAILY
			Comment: NOTIFY physician if platelets < 130,000
		30 mg, Syringe, SUBCUTANEOUS, BID
			Comment: NOTIFY physician if platelets < 130,000
		For CrCl < 30 mL/min(NOTE)*
		30 mg, Syringe, SUBCUTANEOUS, DAILY
			Comment: NOTIFY physician if platelets < 130,000. D/C lovenox if INR > 1.8
		For Patients > 150 kg(NOTE)*
		40 mg, Syringe, SUBCUTANEOUS, BID
			Comment: NOTIFY physician if platelets < 130,000
		40 mg, Syringe, SUBCUTANEOUS, DAILY
			Comment: NOTIFY physician if platelets < 130,000
Anticoagulants
		Baseline INR required for Coumadin(NOTE)*
	warfarin
		5 mg, Tab, By Mouth, Once
			Comment: Notify MD and Hold Coumadin if INR > 2.5
		2.5 mg, Tab, By Mouth, Once
			Comment: Notify MD and Hold Coumadin if INR > 2.5
		10 mg, Tab, By Mouth, Once
			Comment: Notify MD and Hold Coumadin if INR > 2.5
		5 mg, Tab, By Mouth, DAILY
			Comment: Notify MD and Hold Coumadin if INR > 2.5
		2.5 mg, Tab, By Mouth, DAILY
			Comment: Notify MD and Hold Coumadin if INR > 2.5
		10 mg, Tab, By Mouth, DAILY
			Comment: Notify MD and Hold Coumadin if INR > 2.5
		ORTHO ONLY(NOTE)*
	Xarelto
		10 mg, Tab, By Mouth, DAILY
	dabigatran
		150 mg, Capsule, By Mouth, BID
			Comment: Check renal function
	Eliquis
		2.5 mg, Tab, By Mouth, BID
			Comment: Hip Replacement: Duration of therapy 35 days  Knee Replacement: 12 days
	HEParin 5000 units/mL SUBCUTANEOUS
		5,000 units, Syringe, SUBCUTANEOUS, TID
		5,000 units, Syringe, SUBCUTANEOUS, BID
Patient Care

	Impulse Foot Pumps
		To be worn at all time while patient is not bearing weight
	Sequential Compression Device
		T;N, Wear, Both legs
			Comment: To be worn at all times while patient is not bearing weight
	Anti Embolism Stockings
		TED hose, knee high, Both legs
		TED hose, knee high, Left leg
		TED hose, knee high, Right leg
		TED hose, thigh high, Both legs
		TED hose, thigh high, Left leg
		TED hose, thigh high, Right leg
	Notify MD
		Contact Physician if INR < 1.8 on Day of Dismissal
Therapies
	Consult Physical Therapy, Evaluate and Treat
		
Consults/Follow-up
	Pharmacy Consult
		D/C Lovenox if INR > 1.8
		D/C Lovenox if INR > 2.0
		Contact MD and Hold Coumadin if INR > 2.5
		Contact MD and Hold Coumadin if INR > 3.0
		Contact MD and Hold Coumadin if INR > 3.5

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, IV Push, Q6H, PRN, 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.

hs Troponin T - MH/WH/JE
Laboratory
	hs Troponin T - MH/WH/JE
		Stat, spec type = Blood
		T;N+120, Timed, spec type = Blood
		T;N+360, Timed, spec type = Blood

hs Troponin I - FH (Stat and 2hr and 6hr)
	hs Troponin I - FH
		T;N, Stat, spec type = Blood
		T;N+120, Timed, spec type = Blood
		T;N+360, Timed, spec type = Blood

Insulin Sliding Scale - NovoLOG
	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, Once, 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.

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