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Post op cardiac surgery orders - ver 15 (2012-07-4) a.dashti no watermark(1)
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Post op cardiac surgery orders - ver 15 (2012-07-4) a.dashti no watermark(1)

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  • 1. Patient Name: Age:ADULT SURGICAL ICU Civil ID:ICU ADMISSION ORDERS File #:ALLERGY:(Specify type of reaction)Admission under Dr. ___________________________Surgical procedure: _______________________________________________________ VITAL SIGNS AND HEMODYNAMIC MONITORINGContinuous monitoring of ECG, Blood Pressure, and SaO2Record vital signs q 15 min x 1h, q 30 min x 2hrs, then q 1 hrCore temperature q1h until T ≥ 36.0, then q4h. Notify MD if T ≥ 38.0 or ≤ 36.0Peripheral pulses q1h X 4, then q4h and PRNIf Swan-Ganz: Continuous monitoring of CO, CI, PA, CVP, SVR, SvO2 : Record parameters q 1hKeep art line and PA line patent with NS. Maintain pressure bag at 300 mmHgNeuro-assessment q1h until awake then q2-4h and PRNINFORM MD IF: Arterial saturation ≤ 90 % Arterial saturation ≤ ___ Heart rate ≤ 60 ≥ 100 /min Heart rate ≤ ___ ≥ ___ Systolic ABP ≤ 90 ≥ 140 mmHg Systolic ABP ≤ ___ ≥ ___ Mean ABP ≤ 60 ≥ 90 mmHg OR Mean ABP ≤ ___ ≥ ___ CVP ≥ 15 mmHg CVP ≤ ___ ≥ ___ CI ≤ 2.0 ≥ 4.5 L/min/m² CI ≤ ___ ≥ ___ SvO2 ≤ 60 ≥ 80 % SvO2 ≤ ___ ≥ ___ PACEMAKER SETTINGSType of wires in situ: ( ) Atrial wires ( ) Ventricular Wires Mode:________Settings: Rate: _____/min Atrial Output:_____/mA Atrial Sensitivity:_____mVVentricular Output:_____/mA Ventricular Sensitivity: _____mVVerify Pacer threshold daily and battery function at start of each shift MEDIASTINAL AND/OR PLEURAL DRAINSApply 20 cmH2O suction to the chest tube drainage unitMonitor mediastinal/pleural drainage q 15 min until drainage ≤50ml/15min then q1hRecord mediastinal/pleural drainage q 1hNotify MD if mediastinal/pleural drainage ≥ 50ml/15mins or ≥200ml/hr VENTILATORY MANAGEMENT Follow Respiratory Therapy Initial Ventilator Management Protocol ORSettings: Mode_______ P. insp_____ Vt______ml FiO2_______ RR______/min PEEP_____PHYSICIAN SIGNATURE: __________________________ DATE: ____________ TIME: __________NOTED BY ASSIGNED NURSE:Ver 15 Page 1 of 5
  • 2. Patient Name: Age: Civil ID:ADULT SURGICAL ICUICU ADMISSION ORDERS File#:ALLERGY:(Specify type of reaction) INVESTIGATIONS ON ARRIVALABG, Lactate, CBC, PT, PTT, ACT, HCT, Troponin, Central venous blood gas when Swan-Ganz unavailableNa, K, Mg, PO4, Cl, Ca, Blood glucose, Bun, CreatinineChest X-ray12-leads ECG FOLLOW UPABG, CBC, Na, K+, Cl, Ca, Mg, PO4, Glucose, Bun, Creatinine q 4h X 2 then PRNTroponin q8h X 3Central venous blood gas q 8h X 3 OR q__ h and PRNLactate q 8h x 3 OR q __ hPT-PTT and ECG PRN DAILY AMABG, Lactate, Na, K, Cl, Ca, PO4, Mg, Glucose, Bun, Creatinine, CBC, HCT, PT, PTT, LFT, Amylase, Troponin, CK/MBChest x-rayWeight daily INTAKE AND OUTPUTKeep patient NPO OR On ________________ dietNG to straight drainageFoley to straight drainageNotify MD if urine output ≤ 40cc/h X 2 consecutive hoursIn and out totals q shift, including urine output and pleural/mediastinal drainage WOUND CARELeave dressings intact for 24 hours, unless otherwise indicated. Reinforce as needed.On POD 1 remove elastic bandages from all sites and apply dressings to sternum and legs as per protocol ACTIVITYPatient to be mobilised on POD 1, unless otherwise indicated : ___________________Continue physiotherapy as per mobilisation protocolPHYSICIAN SIGNATURE: __________________________ DATE: _____________ TIME: ________NOTED BY ASSIGNED NURSE:Ver 15 Page 2 of 5
  • 3. Patient Name: Age: ADULT SURGICAL ICU Civil ID: ADMISSION MEDICATION ORDERS ALLERGY: File #: (Specify type of reaction) MD START INFUSIONS AT : INITIALS max dose call MD: Ultiva (Remifentanyl) ______ mcg/kg/min IV Target pain score _____ 0.20 mcg/kg/min Propofol (Diprivan) _____ml/hr IV or _____ mcg/kg/min IV Target RASS _____ 25 mcg/kg/min Precedex (Dexmedetomidine) ______mcg/kg/hr IV Target RASS _____ 0.7 mcg/kg/hr Adrenaline _____ mcg/Kg/min IV 0.25 mcg/kg/min Dobutamine _____ mcg/kg/min IV 10 mcg/kg/min Primacor (Milrinone) _____mcg/kg/min IV 0.7 mcg/kg/min Simdex (Levosimendan) _____ mcg/kg/min IV 0.2 mcg/kg/min Tridil (Nitroglycerin) _____mcg/kg/min IV 2 mcg/kg/min Titrate to SBP __________ mmHg or MAP ___ mmHg Levophed ______ mcg/kg/min IV 0.25 mcg/kg/min Titrate to SBP __________mmHg or MAP ___ mmHg Vasopressin _____ units/min IV 0.04 units/min Titrate to SBP __________mmHg or MAP ___ mmHg Nipride (Nitroprusside) _____mcg/kg/min IV 2 mcg/kg/min Titrate to SBP ___________mmHg or MAP ___ mmHg Maintenance IV solution: _________________ Rate: _____ ml/h (Total including drips) *See order sheet for additional medications MEDICATIONS: Zinacef (Cefuroxime) 1.5 g IV q 12 hrs x 3 doses post-op OR until drains removed If valve surgery or documented penicillin/cephalosporin allergy or documented MRSA give : Vancomycin ____ g iv q ___ h x 3 doses OR until drains removed ASA □ 160 mg □ 325 mg po 4 hrs post-op if pleural or mediastinal drainage is <100 ml/h x 2 hrs, then QD Lipitor ____mg QD Paracetamol (Perfalgan) 1g iv q6h X 24h then PRN Zantac 50 mg iv q12h while intubated Omeprazole 40 mg po QD when extubated Atrovent 250 mcg/2ml nebulizer q 6h Pulmicort 250 mcg/ml nebulizer BID Clexane (Enoxaparin 0.5 mg/Kg) □ 40 mg sc QD □ 30 mg sc QD (for creatinine clearance less than 30 ml/min) *See order sheet for additional medications PRN MEDICATIONS: Odansetron (Zofran) 4 mg IV q 8 hrs PRN Glycerin sup x1 PR QD PRN Lactulose 30 ml PO/per NGT x1 PRN Fleet enema 1 bottle PR x1 PRN PHYSICIAN SIGNATURE: ___________________________ DATE: _____________ TIME: ________ NOTED BY ASSIGNED NURSE:Ver 15 Page 3 of 5
  • 4. Patient Name: Age: ADULT SURGICAL ICU ADMISSION MEDICATION ORDERS Civil ID: ALLERGY: File #: (Specify type of reaction) ELECTROLYTES REPLACEMENT Do not use this section if serum creatinine greater than 150 mmol/l or urine output is less than 1 ml/kg/hour or patient is on dialysis, and consult MD Serum K+ KCL ≤ 4.0 mmol/L Give 10 mEq in 100 ml iv x 1 over 1 hour via central line 3.3-3.5 mmol/L Give 20 mEq in 100 ml iv x 1 over 1 hour via central line ≤ 3.3 mmol/L Give 20 mEq in 100 ml iv x 1 over 1 hour via central line, then Call MD Repeat serum K+ levels 1h after each dose Do not give sodium phosphate if serum calcium levels are above upper limit of normal. Use potassium or sodium phosphate based on patient’s serum potassium concentration (Phosphorous 1 mmol = 1.8 mEq). Serum phosphate Sodium phosphate ≤ 0.8 mmol/L Give 15 mmol (phosphate) in 100 ml of NS or D5W iv x 1 over 4 hours ≤0.6 mmol/L Give 30 mmol (phosphate) in 100 ml of NS or D5W iv x 1 over 4 hours ≤0.5mmol/L Give 30 mmol (phosphate) in 100 ml iv of NS or D5W x 1 over 4 hours, then Call MD For doses of 0.32 - 0.64 mmol/kg, dilute in 100 ml. For any dose greater than 0.64 mmol/kg, dilute in 250 ml and infuse at a rate not to exceed 7.5 mmol/hr. Repeat serum phosphate levels daily x 3 days If Mg ≤ 1.0 mmol/l give MgSO4 : 1g (2ml of 4 mEq/ml solution) in 100 ml of NS or D5W iv x 1 over 1 hour OR 2g (4ml of 4 mEq/ml solution) in 100 ml of NS or D5W iv x 1 over 2 hours Repeat serum Mg level daily x 3 days PHYSICIAN SIGNATURE: _______________________________ DATE: _____________ TIME: ________ NOTED BY ASSIGNED NURSE:Ver 15 Page 4 of 5
  • 5. Patient Name: Age: ADULT SURGICAL ICU Civil ID: INSULIN SLIDING SCALEALLERGY: File #:(Specify type of reaction) INTRAVENOUS INSULIN SLIDING SCALEAim to keep the glucose between 8-10 mmol/LInsulin infusion: Actrapid HM 50 units in 50ml of D5W for a final dilution 1units/mlIf capillary blood glucose (CBG) ≥ 10.0 mmol/l: Start insulin infusion at: _____ units/h (ml/h)Measure CBG at initiation of infusion and q 1hAdjustment of insulin infusion :If Glucose ≤4.0 mmol/L : Stop insulin infusion and give 20ml of D50W iv push over 2-3 min + INFORM MD STAT.Recheck CBG q 15 min and repeat 20 ml of D50W until CBG is > 8.0mmol/l. Then resume insulin infusion at ½ ofprevious rate.PHYSICIAN SIGNATURE: ______________________________ DATE: ____________ TIME: _______NOTED BY ASSIGNED NURSE: SUBCUTANEOUS INSULIN SLIDING SCALE*Consult Diabetologist for all diabetic patientsSTANDARD □ OR MODIFIED □Verify CHEMSTRIP q 4h : Verify CHEMSTRIP q __ h :<6.0 mmo/l: 0 units ______ mmo/l: ___ units6.1-8.0 mmo/l: 0 units ______ mmo/l: ___ units8.1-10.0 mmol/l: 6 units ______ mmo/l: ___ units10.1-12.0 mmol/l: 8 units ______ mmo/l: ___ units12.1-14.0 mmol/l: 10 units ______ mmo/l: ___ units14.1-16.0 mmol/l: 12 units ______ mmo/l: ___ units16.1-18.0 mmol/l: 14 units ______ mmo/l: ___ units18.1-20 mmol/l: 16 units ______ mmo/l: ___ units>20 call MD ______ call MDPHYSICIAN SIGNATURE: ___________________________ DATE: ___________ TIME: ______NOTED BY ASSIGNED NURSE:Ver 15 Page 5 of 5