IMPRINT PATIENT’S NAME PLATE or PRINT INFORMATION ABOVE
ACUTE MI –
THROMBOLYTIC NURSING FLOW
Date:
Time of onset of pain:
Time Arrived in ED:
Date
Time
√
( ) N/A
E.D. Physician/Cardiologist:
Pain assessment (0 – 10) (Initial):
Time seen by Cardiologist:
______
Check off appropriate orders.
RN Initials
Prior to Infusion:
EKG
Pain Assessment (0-10)
NeuroVascular Check
Baseline Vital Signs, Cardiac Rhythm, Pulse Ox, O2,
Weight
Establish two (2) IV lines (one (1) 18 gauge to draw
lab work)
Baseline Bloodwork Drawn
Rectal exam for gross blood
1st Bolus Given
__________________________________
(Pain Scale)_________________________
__________________________________
B/P ______ T ______ P ______ R ______
POx_________________ O2 __________
Rhythm__________________ Wt.______
Site #1: _________________
R
L
Site #2: _________________
R
L
Site #3: _________________
R
L
_______
_______
_______
Retavase ten (10) units IV
Other __________________________
Aspirin 81 mg, two (2) chewable tabs PO Stat
Pain assessment 15 minutes after 1st bolus
Infusion started after Bolus
Heparin Bolus Given then drip started
Nitro given
2nd Bolus Given
½ Hour After 2nd Bolus
EKG
Pain Assessment (0-10)
NeuroVascular Check
(Pain Scale)
( ) _______________________________
Heparin Bolus _______ units IV
Heparin drip 25,000units in 250cc
0.45% sodium chloride
Heparin drip _____________________
Nitropaste ______________________”
Nitro SL ________________________
Nitro Drip _______________________
Retavase ten (10) units IV
Other __________________________
__________________________________
(Pain Scale)________________________
__________________________________
Other order:
(THIS AREA TO REPORT LAB RESULTS ONLY)
LAB TEST
Hgb
PT/INR
PTT
TRP-I
Total CK
CKMB (+MB%)
Myoglobin
Magnesium
Lipid Profile
0 Hr
3 Hr
6 Hr
12 Hr
24 Hr
36 Hr
48 Hr
RN Initials
Date/Time
Signature
Initials
Signature
After doctor writes a medication order, send to Pharmacy
Before placing in chart, imprint patient’s Plate as indicated
Initials
msp 8/04; 6/06
IMPRINT PATIENT’S NAME PLATE or PRINT INFORMATION ABOVE
ACUTE MI –
THROMBOLYTIC THERAPY PRETREATMENT EVALUATION
INCLUSION CRITERIA
YES
NO
_____
_____
_____
_____
1.
2.
_____
_____
_____
_____
3.
4.
Chest pain or equivalent symptoms of ischemia >30 minutes duration, <12 hrs.
ST segment elevation of at least 0.1MV with reciprocal ST segment depression
reflecting transmural ischemia.
Both chest pain and ST elevation are not relieved by sublingual Nitroglycerin.
New Left BBB, or BBB with history suggestive of AMI.
ABSOLUTE CONTRAINDICATIONS:
_____
_____
1.
_____
_____
_____
_____
_____
_____
_____
_____
2.
3.
4.
5.
Previous hemorrhagic stroke at any time; other strokes or cerebrovascular events
within 1 year.
Known intracranial neoplasm
Active internal bleeding (except menses)
Suspected aortic dissection
History of arteriovenous malformation, aneurysm
CAUTIONS/RELATIVE CONTRAINDICATIONS:
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Severe uncontrolled hypertension at presentation (BP>180/110)
Lumbar puncture within last 7 days.
Current use of anticoagulants (INR>2-3), known bleeding diathesis
Recent trauma (2-4 weeks), including head trauma
Prolonged (>10 min) and potentially traumatic CPR
Major surgery (<3 weeks prior)
Non-compressible vascular punctures
Recent (2-4 weeks) internal bleeding
Pregnancy/recent childbirth
Active peptic ulcer
History of chronic severe hypertension
Decision
Age ______ Gender __ M __ F
YES
NO
AMI
ST segment elevation
Contraindications to Tx
Stop
Comments: ________________________________
__________________________________________
Physician Signature:
Time Line
Use 24 hour clock time (00:00 equals midnight)
Chest Pain:
Onset Date ____/____/___ Time _____:_____
Door Date ____/____/___ Time _____:_____
Triage Time _____:_____
EKG Done _____:_____
Thrombolytic Start _____:_____
Date:
Time:
After doctor writes a medication order, send to Pharmacy
Before placing in chart, imprint patient’s Plate as indicated
msp 8/04; 6/06
IMPRINT PATIENT’S NAME PLATE or PRINT INFORMATION ABOVE
ACUTE MI –
THROMBOLYTIC PHYSICIAN’S ORDER FORM
ORDERED
DATE TIME
ORDERS
NOTED BY/
TIME DATE
AND
SIGNATURE
Allergies:
Vital Signs & pain assessment (0-10) q 15 minutes during administration of
thrombolytic.
Neuro Vascular check at zero hour, then q 30 minutes during administration of
thrombolytic.
IV: Establish two (2) IV lines (one (1) 18g to draw lab work)
IV Solution:
O2 @ __________ L via __________ & continuous pulse ox.
Test/Studies:
CBC with Differential
Magnesium
Profile 7
U/A
Type & Screen
Initial EKG, then 30 minutes (1/2 hour) after
second bolus
PT/INR
Chest X-ray
PTT
Stool Occult for blood
Lipid Profile
Cardiac Profile ((Troponin 1, Total CK, CKMB (includes MB%, & Myoglobin))
Other Labs/Test:
Medications:
Aspirin 81 mg, two (2) chewable tablets P.O. Stat.
RETAVASE (RETEPLASE RECOMBINANT):
Two (2) - ten (10) unit boluses IV only; each bolus given over two (2) minutes
with the second bolus given thirty (30) minutes after initiation of the first
bolus injection.
HEPARIN:
units IV bolus (60 units/kg; max 4,000 units)
Followed by heparin infusion 25,000 units in 250 cc ________ @ ______
(12 units/kg/hr; max 1,000 unit/hr for
units/hour, starting time:
patients greater than 70 kg)
FONDAPARINUX (ARIXTRA):
2.5mg subcutaneously once daily (Arixtra is contraindicated in patients with
CrCl ≤ 30ml/min or body weight less than 50kg – use heparin)
__________________________________________________________________
Other Orders:
Date:
Time:
Physician’s Signature:
SENT TO PHARMACY – DATE: __________ TIME: __________ INITIAL: __________
After doctor writes a medication order, send to Pharmacy
Before placing in chart, imprint patient’s Plate as indicated
msp 8/04; 6/06
IMPRINT PATIENT’S NAME PLATE or PRINT INFORMATION ABOVE
ACUTE MI –
THROMBOLYTIC PHYSICIAN’S ADMISSION ORDERS
ORDERED
DATE
TIME
ORDERS
PAGE 1 OF 2
ABG’s/IM MEDICATIONS NOT RECOMMENDED FOR 8-12 HOURS. IF
NECESSARY, APPLY PRESSURE UNTIL BLEEDING IS CONTROLLED.
DRAW BLOOD FROM INTRACATHS ONLY.
TIME THROMBOLYTIC THERAPY BEGUN (ZERO HOUR):
Admit to ICU
Attending:
Diagnosis:
Additional Diagnoses:
Condition:
Allergies:
Vital Signs, pulse ox, Neurovascular check and pain assessment as per
Thrombolytic
Nursing Flow Sheet & Thrombolytic policy.
Activity:
Complete bedrest for _____ hours.
Commode after _____ hours.
Diet: Cardiac (2 gm Na, Low Chol)
Other:
Daily Weight
I&O
IV: Intermittent Infusion Device (IID)
IV Solution:
Respiratory Treatments:
O2 @______L/min per nasal cannula
O2 __________mask @________%
Pulse Oximetry
ABG
Call if O2 Sat.< 91%
Other Treatments:
Lab Tests: Check to see if already ordered. (ED 0h – 6h & ICU 12h – 48h)
Lab Test/Time
CBC & diff
Profile 7
Type & Screen
Hgb
PT/INR
PTT
TRP-1
Total CK
CKMB (includes MB%)
Myoglobin
Magnesium
Lipid Profile
0h
X
X
X
X
X
X
X
X
X
X
X
X
3h
6h
12h
24h
36h
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
NOTED BY/
TIME DATE
AND
SIGNATURE
48h
X
X
X
CONTINUED ON PAGE 2
Date:
Time:
Physician’s Signature:
SENT TO PHARMACY – DATE: __________ TIME: __________ INITIAL: __________
After doctor writes a medication order, send to Pharmacy
Before placing in chart, imprint patient’s Plate as indicated
msp 8/04; 6/06
IMPRINT PATIENT’S NAME PLATE or PRINT INFORMATION ABOVE
ACUTE MI –
THROMBOLYTIC PHYSICIAN’S ADMISSION ORDERS
ORDERS
ORDERED
DATE
PAGE 2 OF 2
TIME
NOTED BY/
TIME DATE
AND
SIGNATURE
Test/Studies:
EKG QD x 3
EKG on recurrence of chest pain
PTT daily after 48 hours.
Call physician if PTT is < ___ sec. or > _____ sec
ECHO/Doppler on _______________ (date).
Stool for Occult Blood QD x 3
Other labs:
Medications:
Maintain Heparin infusion 25,000 units in 250 cc __________ @ __________
Nitroglycerin 50mg/250cc D5W @ _____________________________________
Atropine 0.5 mg IV bolus for symptomatic rate below 40/min and notify attending.
ASA ______ mg PO daily
Enteric coated
Pepcid 20 mg q 12 hours
IVP
PO
Mylanta 30 cc q ______ hours prn stomach discomfort
_____________________
____________ mg q HS prn sleep
NTG 0.4 mg SL prn chest pain (may repeat q 5 minutes x 3)
Tylenol 650 mg
PO
Supps. q 4 hours prn pain/temp.
MOM 30 ml PO daily prn for constipation
Anti-arrhythmic:
as per ACLS protocol.
ACE Inhibitor:
If not given, indicate:
Beta Blocker:
If not given, indicate:
Lipid Lowering Therapy:
If not given, indicate:
Pain Medication:
Other medications:
Other Orders:
Give Smoking Cessation Counseling/Education Packet
If smokes or have stopped smoking in the past year
Other Education:
Chest Pain Protocol
Remove IID when Telemetry is D/C’d if not on IV meds
Request Old Charts
Consults: (specify reason for each)
Date:
Time:
Physician’s Signature:
SENT TO PHARMACY – DATE: __________ TIME: __________ INITIAL: __________
After doctor writes a medication order, send to Pharmacy
Before placing in chart, imprint patient’s Plate as indicated
msp 8/04; 6/06