PLACE LABEL HERE
CHEST PAIN / CARDIAC SYNCOPE
OBSERVATION 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. Status:  Place in Observation for: _________________________________
2. Level of Care: Acute Care
Location/Specialty Unit Preference 5 South
3.  Telemetry: If patient Medical/Surgical, must complete form # 36084
4.  Isolation:  Contact
5. Consults:
 Droplet
 Airborne
For: _________________
______________________________________________  Notified by physician
______________________________________________  Notified by physician
Cardiology Consult: ______________________________  Notified by physician
6. Diagnostics
 Fasting lipid profile in AM
 6 hr Troponin T at _____ (enter time to be drawn)
 6 hr EKG at _____ (enter time to be drawn) Reason: Chest Pain Read by: ___________________
 D-Dimer STAT
 Echocardiogram  STAT  in AM, Reason: Chest Pain Read by: ____________________
 PA & Lateral CXR STAT Reason: Chest Pain
 CT angiogram of chest STAT Reason: Chest Pain
 Venous Doppler Reason: ___________________
 Right
 Left
 Bilateral
 Upper Extremity
 Lower Extremity
 Other: ____________________________________________________________________
EKG in AM Reason: Chest Pain Read by: ___________________
7. STRESS TESTING:
AHA Selection Methodology
 Exercise Treadmill Test (ETT) is recommended as initial test in patients < 55 years of age with
low to intermediate risk, able to exercise, and has normal or near normal ECG
o Exclusion Criteria: LV hypertrophy with repolarization changes, significant ST or T wave
changes including digoxin effect, biphasic or inverted T waves in anterior leads, LBBB
 Pharmacologic Stress Test is indicated if patient is unable to exercise and/or meets exclusion
criteria for ETT. May be useful to discuss with cardiologist for test of choice.




 Exercise Treadmill Test (ETT) Reason: Chest Pain Read by: _____________  In AM  Now
 DIMPS Reason: Chest Pain Read by: _____________  In AM  Now
 Dobutamine DIMPS Reason: Chest Pain Read by: _____________  In AM  Now
 Lexiscan (regadenoson) DIMPS Reason: Chest Pain Read by: _____________  In AM  Now
(Hold Aminophylline, Sudafed, or medications containing caffeine for Lexiscan DIMPS)
8. Vital signs per unit routine
Order writer’s initials _______
Copy to pharmacy
*3-37193*
FORM 3-37193 REV. 12/2014
Page 1 of 3
PLACE LABEL HERE
CHEST PAIN / CARDIAC SYNCOPE
OBSERVATION ORDERS
Chest Pain 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).
9. Nursing Chest Pain Guidelines:
Notify provider of recurrent chest pain
Notify provider of EKG changes
Notify provider of positive Troponin T or myoglobin
10. Diet:  NPO now for for stress test today
 NPO after midnight for anticipated stress test
 Full liquid breakfast then NPO for anticipated stress test
  Regular
 Cardiac
 Diabetic ______ calories
No caffeine 6 hours before stress test on any diet.
11. Activity:  Bed Rest
 Up ad lib
 Bedside commode
 Up with assistance
 Renal
 Bathroom privileges
12. Maintain INT
SCHEDULED MEDICATION:
13. Nitroglycerin (NTG) 2% ointment:
  ½ inch topically q 6 hrs, remove NTG ointment prior to transport to Cardiology Dept for stress test
or 1 inch topically q 6 hrs, remove NTG ointment prior to transport to Cardiology Dept for stress test
14. Aspirin:
 Aspirin 324 mg (four x 81 mg chewables) po STAT
 Aspirin 325 mg po daily
15. Anticoagulation:
 Lovenox (enoxaparin) 1 mg/kg SQ q 12 hrs (If CrCl ≤ 30, give 1 mg/kg q 24 hrs) Weight____kg
Dose Rounding for 1 mg/kg,
if patient weighs:
< 50 kg
50-69 kg
70-89 kg
90-109 kg
110-129 kg
130-144 kg
145-154 kg
155-169 kg
> 170 kg
Copy to pharmacy
FORM 3-37193 REV. 12/2014
For CrCl > 30, Give
Lovenox (enoxaparin)
40 mg q 12 hrs
60 mg q 12 hrs
80 mg q 12 hrs
100 mg q 12 hrs
120 mg q 12 hrs
140 mg q 12 hrs
150 mg q 12 hrs
160 mg q 12 hrs
180 mg q12 hrs (maximum dose),
notify Clinical Pharmacist
Order writer’s initials _______
Page 2 of 3
PLACE LABEL HERE
CHEST PAIN / CARDIAC SYNCOPE
OBSERVATION 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).
PRN MEDICATIONS See policy 520-06 for range orders and pain intensity guidelines.
16.  Electrolyte Replacement Protocol (form # 21340)
17.
Chest pain:

 Nitroglycerin 0.4 mg sublingual q 5 minutes x 3 doses prn

Severe Pain or Chest pain unrelieved with 3 doses of SL or max IV Nitroglycerin:
 Morphine 2 mg IV q 5 min prn (up to a max of 10 mg in 2 hrs),
DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered.
or  Dilaudid (HYDROmorphone) 0.25-0.5 mg IV q 15 min prn (max 2 mg in 30 min).
If CrCl < 30, dose at 0.25 mg). Hold for excessive sedation. DC if Morphine ordered.
18. Moderate Pain:
 Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered.
or  If patient can not take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po
q 4 hrs prn intead of Norco. DC if Percocet ordered.
or  Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Norco ordered.
and/or  Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (15 mg if CrCl 31-50, > 65 y/o old or < 50
kg) or 10 mg po q 6 hrs prn (max combined duration of IV and po ketorolac is 5 days). DC if CrCl < 30.
19. Mild Pain, Temp >100.5F, HA: 
20. Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
21. Nausea/Vomiting:  Zofran (ondansetron) 4 mg IV or po q 6 hrs prn
 If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)
22. Sleep:
 Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn
23. Indigestion:
 Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
24. Stool Softener:
 Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
25. Constipation:
 Milk of Magnesia (MOM) 30 ml po daily prn
If no BM after 48 hrs  Dulcolax (biscodyl) 10 mg per rectum daily prn
and/or
 Senokot-S (docusate/senna) 2 tablets po at bedtime nightly
26. Cough:
 Robitussin (guaifenesin) 15 ml po q 4 hrs prn
27. Sore Throat:
 Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn
ADDITIONAL ORDERS:
______________________________________________________________________________________
______________________________________________________________________________________
______________
Date
_______________
Time
_________________________________
Physician Signature
___________
PID Number
Copy to pharmacy
FORM 3-37193 REV. 12/2014
Page 3 of 3