PLACE LABEL HERE
DEEP VEIN THROMBOSIS (DVT) and
PULMONARY EMBOLISM (PE)
TREATMENT 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 with: Nurse:  Instruct patient about subcutaneous self injections
Coumadin (warfarin) teaching if patient on warfarin
Social Services consult: Outpatient anticoagulation therapy and monitoring
7.
Diagnostics, if not done in ED:
EKG, Reason: suspected DVT/PE, Read by: __________________
 PA/lat CXR, Reason: suspected DVT/PE
 Portable CXR, Reason: suspected DVT/PE
 ECHO Reason: suspected DVT/PE, Read by: __________________
 TTE
 TEE
8.
Labs, if not done in ED:
On admission: CBC, CMP, PT/PTT, UA
 BNP  Troponin
CBC q 3 days while receiving Heparin or Lovenox (enoxaparin)
PT/INR now (baseline), then daily while receiving Coumadin (warfarin)
9.
Vital signs:  q 8 hrs  q ______ hrs
10.
Intake and output:  q 8 hrs  q ______ hrs
11.
 O2 per Protocol (form # 34431)
12.
Diet:
 NPO  Regular  Cardiac  Diabetic ______ calorie
 Renal Other: ___________
13.
Activity:  Bedrest
 Bathroom privileges  Out of bed to chair
 Up ad lib
 Other: ___________
14.
Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)
15.
Oral Nutrition Supplement Standing Order (form # 31417), initiate if patient meets criteria
SCHEDULED MEDICATIONS
16.
IVF: ______________________________________________________________________________
17.
Pulmonary Embolism:
 No contraindications to Tissue Plasminogen Activator (Activase), listed on back of this order.
 Tissue Plasminogen Activator (Activase) 100 mg IV over 2 hrs. Thrombolytic therapy is a consideration in
patients with syncope, hypoxemia/respiratory failure, or hemodynamic instability.
 Avoid IM injections and arterial punctures if possible.
 Every 1 hr neurochecks x 24 hrs post Activase administration
 Hold anticoagulant therapy if Tissue Plasminogen Activator (Activase) is to be given
 Check PTT after Tissue Plasminogen Activator (Activase) has infused and q 4 hrs thereafter
 Start Heparin Infusion when PTT is < 76
 Heparin Infusion Protocol: HIGH Intensity, NO initial Bolus (form # 28554)
Order writer’s Initials _______
*4-1181*
2
FORM 4-1181 REV. 11/2015
WHITE: Medical Record
CANARY: Pharmacy
Page 1 of
PLACE LABEL HERE
DEEP VEIN THROMBOSIS (DVT) and
PULMONARY EMBOLISM (PE)
TREATMENT ORDERS
OR See next page for Anticoagulation order options
Order writer’s Initials _______
*4-1181*
2
FORM 4-1181 REV. 11/2015
WHITE: Medical Record
CANARY: Pharmacy
Page 2 of
DEEP VEIN THROMBOSIS (DVT) and
PULMONARY EMBOLISM (PE)
TREATMENT ORDERS
Reference Page
CONTRAINDICATION TO THROMBOLYTICS
*Physician to use professional judgment
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Age less than 18 years.*
Active internal bleeding.
Known bleeding abnormalities, including but not limited to:

Platelet count less than 100,000

Administration of heparin within 48 hours and has an
elevated PTT

Current/recent use of oral anticoagulants, INR greater
than 1.5
Major surgery within 14 days.
Intracranial surgery, serious head trauma, or recent
previous stroke within 3 months.
Recent arterial puncture at a noncompressible site.*
Uncontrolled hypertension at time of treatment (greater
than 185mm Hg systolic and/or greater than 110 mmHg
diastolic).
History of intracranial hemorrhage or known AVM,
aneurysm, or intracranial neoplasm.*
Patients at risk for left heart thrombus, acute pericarditis,
or subacute bacterial endocarditis.*
Diabetic hemorrhagic retinopathy or other hemorrhagic
ophthalmic conditions.*
Pregnancy*
FORM 4-1181 REV. 11/2015
REFERENCE PAGE
PLACE LABEL HERE
DEEP VEIN THROMBOSIS (DVT) and
PULMONARY EMBOLISM (PE)
TREATMENT 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).
18. Anticoagulant therapy: Patient weight __________ kg
 Lovenox (enoxaparin), round dose to nearest syringe size, max 180 mg.
 1 mg/kg SQ q 12 hrs, CrCl < 30, 1 mg/kg q 24 hrs
 1.5 mg/kg SQ q 24 hrs, CrCl < 30, 1 mg/kg q 24 hrs
or  Heparin infusion Protocol, High intensity, (form # 28554)
 No initial bolus
and  Coumadin (warfarin): _____ mg po daily, beginning on ____
Requires 5 day overlap with parenteral anticoagulation and INR > 2.0.
19. Anticoagualtion using only oral agents (do not use with parenteral anticoagulation)
 Eliquis (apixaban) 10 mg po bid x 7 days, then 5 mg po BID. DC Eliquis if CrCl < 30 ml/min and contact
physician for new order.
DO NOT use concurrently with other anticoagulants, DC Coumadin (warfarin), Lovenox, Heparin if ordered.
or  Xarelto (rivaroxaban) 15 mg po BID. DC Xarelto if CrCl < 30 ml/min and contact physician for new order.
DO NOT use concurrently with other anticoagulants, DC Coumadin (warfarin), Lovenox, Heparin if ordered.
PRN MEDICATIONS (See policy 520-06 for range orders and pain intensity guidelines)
20.  Electrolyte Replacement Protocol (form # 21340)
21. Mild Pain, Temp >100.5F, HA:  Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
22. Moderate Pain:
 Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Percocet ordered.
or  If patient cannot take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po q 4 hrs
prn instead 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.
23. Severe Pain (Begin when Epidural or PCA has been discontinued)
 Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered.
or  Dilaudid (HYDROmorphone) 0.25-0.5 mg IV q 3 hrs prn. If CrCl < 30, dose at 0.25 mg. Hold for
excessive sedation. DC if Morphine ordered.
24. 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)
25. Sleep:
 Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn
26. Indigestion:
 Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
27. Stool Softener:
 Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
28. 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
29. Cough:
 Robitussin (guaifenesin) 15 ml po q 4 hrs prn
30. Sore Throat:
 Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn
________________
Date
FORM 4-1181 REV. 11/2015
_______________
Time
_________________________________
Physician Signature
WHITE: Medical Record
CANARY: Pharmacy
___________
PID Number
Page 2 of 2