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NSTEMI: INITIAL MANAGEMENT ORDER TEMPLATE

(Referenced Version)

This template lists elements, drugs, doses, and strategies that should be highly considered when creating admission order sets based upon recent clinical practice guidelines, medication package inserts, and emerging evidence.

DEMOGRAPHICS

Age ___________ years Weight __________ kg

DIET ORDERS

( NPO

( 2 gm sodium restricted/low cholesterol/low fat

( Diabetic _________________ calorie ADA

( Other (specify) _______________________

ACTIVITY ORDERS

( Bed rest

NURSING1(pg e35)

( Continuous ECG monitoring

( Supplemental O2 to keep arterial saturation > 90%

( Nitroglycerin Protocol: PRN use of 0.4mg q5 min for chest pain

MEDICATION ALLERGIES

( Specify: ________________________________________ Reaction (if known): __________________________

DIAGNOSTIC STUDIES

( 12-lead ECG NOW ( 12-lead ECG FOR RECURRENT CHEST PAIN

( 12-lead ECG IN AM (____/___/___ ___:___ AM)

LABORATORY STUDIES

CARDIAC MARKERS

( Troponin T/ Troponin I: NOW AND EVERY ________ hours X ________ times

OR

( CK AND CK-MB: NOW AND EVERY ________ hours X ________ times

ROUTINE LABS

Chemistry panel: ( NOW ( DAILY IN AM

CBC: ( NOW ( DAILY IN AM

Fasting lipid panel: ( IN AM

HbA1c: ( IN AM

Calculate creatinine clearance (CrCl): _______ml/min

CrCl ml/min = (140- age) X weight (kg)/(serum creatinine X 72) multiply by 0.85 if female

MEDICATIONS FOR ALL PATIENTS

( Aspirin: Loading dose (NOW) 162 mg to 325 mg chewed orally, then maintenance dose (DAILY) of 81 mg to 162 mg orally (or 162 mg to 325 mg DAILY after stent implantation). (If aspirin intolerant, give clopidogrel) 1

Loading dose: _________________________ ___________ mg orally.

Daily dose: _____________________ ___________ mg orally.

( Clopidogrel: Loading dose 300 -600 mg orally, then daily dose of 75 mg orally [i]

(for patients who are aspirin intolerant, or in addition to aspirin in initial conservative strategy or as option with either clopidogrel or IV GP IIb/IIIa inhibitors prior to Cath)[ii]

Loading dose: _________________________ ___________ mg orally.

Daily dose: _____________________ ___________ mg orally

( Statin: Drug: ______________________ _________ mg daily (regardless of LDL)[iii]

( ACE/ARB: (if LVEF100 mmHg)[iv]

Drug: _________________________ ___________ mg _____________ times day

BETA BLOCKERS (Hold if signs of heart failure, evidence of low-output state, high risk for cardiogenic shock* or contraindications to beta blocker therapy**)[v]

( Oral Beta-blocker:

Drug: ____________________ _______ mg _____ times day

( IV Beta-Blockers (Optional; recommended if persistent ischemic symptoms, hypertension, or tachycardia and no signs of hemodynamic instability)[vi] Drug: ___________________ _____ mg IV for ____ doses every ___ minutes

*Risk factors for shock (greater number of risk factors, the greater the risk): age > 70 years, SBP < 120 mmHg, sinus tachycardia with HR > 110 bpm or < 60 mmHg, or increased time since onset of symptoms.

**Contraindications for beta-blockers: PR interval > 0.24 sec, second or third degree AV block, active asthma, or reactive airway disease.

( Stop NSAIDS (except aspirin)

( GI Prophylaxis (with history of GI bleeding)

Drug: _________________________ ___________ mg _____________ times day

RISK STRATIFICATION

( High risk: Refractory angina, hemodynamic or electrical instability, elevated cardiac markers (TnT, TnI), new or presumably new ST segment depression, signs or symptoms of HF or new or worsening mitral regurgitation, high risk from noninvasive testing, reduced EF ................
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