UCLA MEDICAL CENTER
DOCTOR’S ADMISSION ORDERS
Patient Addressograph
1. DATE AND TIME ORDERS
2. CHECK ALL APPROPRIATE ORDERS.
PAGE 1 of 2
ACUTE CORONARY SYNDROME ADMISSION ORDERS
ATTENDING PHYSICIAN: ________________________________ PAGER: ________________
HOUSE OFFICER:______________________________________ PAGER: ________________
Diagnosis:  Non-STEMI
DATE:
TIME:
CONDITION
VITAL SIGNS
DIET
ALLERGIES
ACTIVITY
FOLEY
IV’S
I/O and WEIGHT
MONITORING
RESPIRATORY
LABORATORIES
TESTING
 Unstable Angina  Chest Pain  ____________________
ORDER:
Admit to
 CCU  COU/Telemetry  General Medical Floor SERVICE:
 Good  Fair  Guarded
 Per Unit Routine  Other: ____________________________________________
 Call HO for a SBP > 180 SBP < 80 mmHg, HR > 100, HR < 50 RR > 24 or RR < 8.
 NPO (except for meds)
 CCU Diet (4 gram Na, low cholesterol)
 HF Diet (2 gram Na)
 NKDA  Allergy:
 Bed rest  with commode privileges
 Out of bed with assistance
 Ambulation.
 If patient is unable to void, place Foley catheter.
 Heplock with 3cc normal saline flush q 12 hours
 ____ NS with ______ meq KCL/L @ _____ cc/hr x _____ hrs
 Strict recording of Ins and Outs with running totals of urine output to be recorded
 Daily weights (chart results)
 Cardiac montoring
 Pulse oximetry
 Oxygen ____ L via nasal cannula (for CP, SOB, SaO2 < 93%)
Now
 CBC with differential and platelets
 Electrolytes, BUN, Creatinine, Glucose  Mg  PO4  Ca
 CPK total, MB NOW and Q8 hours x 3, first draw @ _____. (follow cardiac enzyme protocol)
 Cardiac troponin I NOW and 6 hours, first draw @ ______.
 PT/ INR and  PTT (if indicated)
 BNP (if indicated)
 Cardiovascular lipid panel (nonfasting)
 HbA1c (if indicated)
 Liver function tests (if indicated) ______________________________________________
 Others:__________________________________________________________________
In AM
 Electrolytes  BUN  Cr  Glucose  Mg  PO4  Ca
 CBC  platelets  PT/INR  PTT
 Others: __________________________________________________________________
 EKG on admission, with CP, and QAM x 2. Please mark chest leads
 Chest X-ray (PA and lateral) (if indicated)
 Echocardiogram (if indicated)
 Stress Testing _______________________ (if indicated) Schedule after ______ (time)
 Others: __________________________________________________________________
MD Signature: ___________________________________
Patient Addressograph
UCLA MEDICAL CENTER
DOCTOR’S ADMISSION ORDERS
1. DATE AND TIME ORDERS
2. CHECK ALL APPROPRIATE ORDERS.
PAGE 2 of 2
ACS ADMISSION ORDERS (cont)
MEDICATIONS
(all bolded Class I
Indications)
Aspirin
 Aspirin 325 mg PO NOW chewed (unless given in EMC)
 Enteric coated Aspirin 325 mg PO QAM
 Enteric coated Aspirin 81 mg PO QAM
 Other ______________________________
Clopidogrel
 Clopidogrel 300 mg PO NOW (unless given in EMC)
 Clopidogrel 75 mg PO QD
Beta Blocker
 Metoprolol 5 mg IVP over 2 minutes, repeat Q 5 minutes X2
(hold for SBP < 90, symptomatic bradycardia, severe reactive airway disease, decompensated HF)
 Metoprolol 25 mg PO q6 hours X 48 hours, then 50 mg PO BID (hold SBP < 90, HR <50)
 Carvedilol 6.25 mg PO bid X 48 hours, then 12.5 mg PO BID (hold SBP < 90, HR <50)
 Other: _______________________________________________
ACE Inhibitor
 ________________ ___ mg PO Q ____ (hold SBP < 90)
Statin
 ________________ ____ mg PO QHS (irrespective of LDL, see LDL to goal guide)
 Other lipid lowering agent _______________ ____ mg PO QD (if indicated)
Omega-3 Fatty Acid
 Fish Oil Capsule 1000 mg PO QD
Heparin
 Standard Heparin Protocol (see attached order)
 Heparin bolus _____ unit IVP then Heparin 25,000 units/250 D5W IV @ ____ units/hour
 Enoxaparin ________________ mg SQ ______
Nitroglycerin
 Nitroglycerine 0.4 mg SL q5 mins prn chest pain; MR x 2
 Nitroglycerine 100 mg/250 ml D5W IV @ 20 mcg/min, titrate to relief of CP, keeping SBP > 100
Prn Medications
 Acetaminophen 650 mg PO Q 4H prn pain, HA or fever T > 38.5.
 Morphine Sulfate __________ mg IVP Q 2H prn severe pain.
 Diazepam (Valium) 2 mg IVP Q 4H prn for back pain or anxiety.
 Mylanta II 15 ml PO Q6 hrs prn dyspepsia or GI upset.
 Docusate (Colace) 100 mg PO BID
 Serax 15 mg PO Q hs prn insomnia. May repeat x 1 prn.
PROTOCOLS
Other Medications
 _____________________________________________________________________
 _____________________________________________________________________
 _____________________________________________________________________
 _____________________________________________________________________
 _____________________________________________________________________
 Cardiac Risk Factor Modification Teaching and Documentation
 AMI/ACS Education and Documentation
Smoking Status  current  former  nonsmoker  unknown
 Smoking Cessation Counseling and Patient Education Materials
 Cardiac Rehabilitation Assessment and Referral
 Nutrition Consultation and Counseling
MD Signature: ___________________________________