PLACE LABEL HERE
ACUTE MYOCARDIAL INFARCTION
POST TENECTEPLASE (TNKase)
ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
1. Is this a CMS inpatient only procedure?  Yes, admit as inpatient, proceed to # 3  No, proceed to # 2
2. Do you expect that the patient’s condition will require a hospital stay that will cross two midnights (includes the time
spent in outpatient- ED, surgery, OBS) and the patient has medical necessity for an inpatient admission?  Yes,
admit as inpatient, proceed to # 3 No, place in observation
3. If admitted as inpatient, Inpatient Physician Certification:
Diagnosis: ________________________________________________________________________________
Level of Care:  Critical  Intermediate  Acute Care Location/Specialty Unit Preference___________
4.  Telemetry: If patient Medical/Surgical, must complete form # 36084
5.  Isolation:  Contact  Droplet  Airborne For: _________________
6.
Consult:
 Urgent
 Routine, Consult with ______________ concerning _______________
 Cardiopulmonary Rehab, Phase I (if positive Myocardial Infarction)
 Consult Nutritional Services for diet teaching
 Physical Therapy for monitored progressive activity
 Occupational Therapy for stress management
7.
 Phase I Cardiac Rehab
8.
O2 per Protocol (form # 34431)
9.
Smoking Cessation counseling, if patient smokes
10.
Diagnostics:
EKG q AM for 2 days
Repeat Troponin I in 8 hrs post TNKase (tenecteplase)
Fasting lipid profile in AM
11.
INT and Vital signs per unit routine
12.
ST segment monitoring per practice guidelines. Mount strips q 30 min post TNKase (tenecteplase) x 4
13.
No further venipunctures, arterial punctures, IM injections x first 24 hrs post TNKase (tenecteplase)
14.
Stat EKG and notify physician of any recurrent chest pain or ST elevation
Call MRT if suspected acute myocardial infarction, hemodynamic instability or unresolved chest pain despite
intervention
15.
NPO for 6 hrs then clear liquids; advance diet as tolerated to 30% calories from fat
16.
Bedrest with bathroom privileges for 12 hrs, then up ad lib as tolerated
SCHEDULED MEDICATIONS:
17.
Discontinue all NSAID (except aspirin) and COX-2 Inhibitors (i.e., celecoxib)
18.
 Aspirin 160 mg (two x 81 mg chewable) po daily. Give first dose now if not given in ED
If unable to swallow, Aspirin 300 mg suppository per rectum STAT
 Aspirin 81 mg (chewable) po daily. Give first dose now if not given in ED
If unable to swallow, Aspirin 150 mg suppository (1/2 of a 300 mg suppository) per rectum daily
19.
 Plavix (clopidogrel) 300 mg x 1 dose today (for patients < 75 y/o), then 75 mg po q am
 Plavix (clopidogrel) 75 mg po q am
20.
 Nitroglycerin (200 mcg/ml) IV infusion at 10 mcg/min; may titrate up to 100 mcg/min until relief of symptoms.
Maintain SBP > to 100 mm Hg
21.
Anticoagulant:
 Heparin Infusion Protocol, LOW Intensity (form # 28554):
Bolus with 60 units/kg (maximum bolus 4,000 units)
 No Bolus
Begin Heparin infusion at 12 units/kg/hr (maximum initial rate 1,000 units/hr)
 Lovenox (enoxaparin)
 < 75 yo: 1 mg/kg SQ q 12 hr (max 100 mg for first two SQ doses only)
 > 75 yo: 0.75 mg/kg SQ q 12 hr (max 80 mg for first two SQ doses only)
 GFR < 30: 1 mg/kg SQ q 24 hr
Order writer’s initials _______
Copy to pharmacy
*3-18436*
FORM 3-18436
REV. 04/2014
Page 1 of 2
PLACE LABEL HERE
ACUTE MYOCARDIAL INFARCTION
POST TENECTEPLASE (TNKase)
ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
22.
Beta Blocker (for hypertensive patients only) without the following contraindications:

High risk for cardiogenic shock

Inferior MI

2nd or 3rd degree AV block

Bradycardia

Severe COPD or active asthma

Signs of heart failure

Evidence of low output state

 Lopressor (metoprolol) 25 mg po q ____hrs, hold if SBP < 90 or HR < 60
 Lopressor (metoprolol) 50 mg po q ____hrs, hold if SBP < 90 or HR < 60
 Coreg (carvedilol) ______ mg po twice daily, hold if SBP < 90 or HR < 60
23.
Ace Inhibitor/Angiotensin Receptor Blocker:
 Contraindication to Ace Inhibitor/Angiotensin Receptor Blocker:
 Allergy
 Hyperkalemia
 Hypotension
 Other: __________________________
 Prinivil (lisinopril) ______ mg po q am starting in am. Hold if SBP < 90
 Angiotensin receptor blocker: Cozaar (losartan) ________ mg po daily. Hold if SBP < 90
 Other: ___________________________________________________ Hold if SBP < 90
24.
Cholesterol lowering therapy: (Statin for LDL-c > 100mg/dl)
 Contraindication to Statin:  Allergy  Active or chronic liver disease  Other____________
 Lipitor (atorvastatin) ___________ mg po q HS. Baseline Liver Function Tests if not already done
 Crestor (rosuvastatin) __________ mg po q HS. Baseline Liver Function Tests if not already done
 Niaspan (niacin) __________ mg po q HS. Baseline Liver Function Tests if not already done
PRN MEDICATIONS (See policy 520-06 for range orders and pain intensity guidelines)
25.
26.
27.
28.
29.
If patient receiving insulin, initiate Hypoglycemia Treatment Standing Orders (form # 2513)
If patient is in ICU, IMCU or PCU: Insulin SQ Correction Dose in Critical Care Standing Orders (form # 21386)
 Electrolyte Replacement Protocol (form # 21340)
Chest pain: Nitroglycerin 0.4 mg sublingual q 5 min x 3 doses prn (Hold if systolic BP is <100)
Severe chest pain unrelieved with max dose of IV Nitroglycerin or Nitroglycerin sublingual x 3 doses (hold for
excessive sedation):
Morphine 2 mg IV q 5 min prn (up to a max of 10 mg in 2 hrs),
or  DC Morphine. Dilaudid (HYDROmorphone) 0.5-2 mg IV q 15 min prn (max 4 mg in 30 min)
30.

31.
32.
33.
34.
35.
36.
37.
Moderate Pain:
Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn
or 
 DC Norco. Give Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn
Mild Pain, Temp >100.5
Nausea/Vomiting: Zofran (ondansetron) 4 mg IV or po q 6 hrs prn
 If N/V persists, add Reglan (metoclopramide) 10 mg IV or po q 6 hrs prn (5 mg if > 65 y/o)
Sleep: Ambien (zolpidem) 5-10 mg po at HS prn. If 5 mg given, may repeat x 1 dose after 2 hrs
If > 65 year old, begin with 5 mg po at HS, may repeat x 1 dose after 2 hrs
or  DC Ambien. Give: __________________________________________________________________
Indigestion:
Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
Stool Softener: Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
Constipation: Milk of Magnesia (MOM) 30 ml po daily prn
Anxiety:
Ativan (lorazepam) 0.5 - 1 mg po or IV q 8 hrs prn.
or  DC Ativan. Give Xanax (alprazolam) 0.25 - 0.5 mg po q 6 hrs prn.
______________
Date
______________
Time
___________________________________
Physician Signature
___________
PID Number
Copy to pharmacy
FORM 3-18436
REV. 04/2014
Page 2 of 2