PLACE LABEL HERE
CARDIOVASCULAR SURGERY
CVC ACUTE PHASE
POST-OP 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).
ALLERGIES: _____________________________________________________________________________________
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: _________________
ADMISSION:
6. Stat ECG unless pacer dependent; obtain ECG once pacer is off, then stat ECG for any ST/rhythm changes prn
7. Stat portable CXR and repeat in AM and daily if intubated or chest tube in place
8. STAT labs on admission and in AM of POD 1;RN to draw:
CBC
PT/INR
PTT
Chem 7
Mg+
Ionized Ca++
AM of POD 2: CBC and Chem 7
9. H & H and K+ 2 hrs after admission, then q 4 hrs x 2, then prn
10. ABG’s
STAT Cardiovascular ABG on admission to CVICU
PRN Cardiovascular ABG if respiratory distress or hemodynamically unstable
ABG in AM if on positive pressure ventilation (includes CPAP and BiPAP)
CONSULTS:
11. Cardiologist: ________________________________________________________________________
12. Other: _____________________________________________________________________________
VITAL SIGNS:
13. Continuous ECG with ST segment, hemodynamic and ABP monitoring. Notify physician with any change in the
baseline cardiac rhythm. Wedge PA catheter with anesthesia; follow PAD.
14. VS q 15 mins for the first 2 hrs or if actively titrating vasoactive drugs until stable, then q 30 mins x 2 hrs, then hourly.
15. CO/CI on admission and q 1 hr x 4, then q 4 hrs and prn
16. Maintain temperature > 96.8°F. Temperatures below 96.8°F: apply warm blankets and/or forced air warming device.
17. Obtain blood, sputum, and urine cultures for Temp >101°F
18. Notify physician for:
SBP less than 90 mm Hg or greater than 160 mm Hg
MAP less than 60 mm Hg or greater than 95 mm Hg
Cardiac index less than 2
HR less than _____ or greater than _____
New onset atrial fib or atrial flutter
Change in neurological status
Hgb less than 8
ST or ischemic changes on the ECG
Temperature greater than 101F
Order writer’s initials ___________
Copy to pharmacy
*3-40025*
6
FORM 3-40025 REV. 09/2015
Page 1 of
PLACE LABEL HERE
CARDIOVASCULAR SURGERY
CVC ACUTE PHASE
POST-OP 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).
19. Neurological checks hourly until awake, then q 2 hrs X 24 hrs and prn
Order writer’s initials ___________
Copy to pharmacy
*3-40025*
6
FORM 3-40025 REV. 09/2015
Page 2 of
PLACE LABEL HERE
CARDIOVASCULAR SURGERY
CVC ACUTE PHASE
POST-OP 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).
ADDITIONAL ORDERS:
20. Foley to gravity drainage for strict I&O. Notify physician if urine output is <30 ml/hr x 2 consecutive hrs.
DC POD #1 unless otherwise specified by CV service. If continued, reason: _____________________________
21. Hourly intake and output (including CT drainage)
22. Daily weights by 0600 and record in kg
23. NGT/OGT to low intermittent suction. Discontinue NGT/OGT upon extubation.
24. Chest tubes:
Chest tubes to (-) 20 cm suction
Do not ambulate off suction without an order
Notify physician if chest tube output is 200 ml/hr or greater, and obtain stat portable CXR, Hgb/Hct, PT/PTT,
platelets and fibrinogen
Maintain occlusive CT dressing
25. Maintain Intra-aortic Balloon pump settings, if applicable
Institute routine Intra-aortic Balloon Pump Orders (form # 40040)
26. Temporary Pacemaker
Adjust MA/sensitivity prn and document
 Assess underlying rhythm every shift and prn
Insulate and secure epicardial wires per routine
Initiate epicardial pacing if HR < 50 and prn
MODE:  Atrial
 Ventricular or  AV Sequential to temporary pacer at ______ bpm
Atrial MA ______
Ventricular MA _______
 Demand
 Asynchronous
Place VVI demand mode at 50 BPM if no bradycardia or heart block
27. Tamponade precautions following epicardial pacer wire removal:
Bedrest x 1 hr; VS q 15 min x 4 then q 30 min x 2
28. OSA Screen: If patient screens positive for suspected sleep apnea or has reported sleep apnea, initiate Sleep Apnea
Orders (form # 21266)
29. DVT Prophylaxis:
Knee high antiembolic hose on unaffected leg day of surgery; on affected leg after dressings removed
Sequential compression device (SCD) x 24 hrs and patient out of bed
30. Medical-Surgical Restraint Order (form # 17609) on chart for intubated patients
DIET:
31. NPO while intubated. Once extubated, start ice chips, then Diabetic Clear liquid Diet.
32. Advance to full diet starting 24 hrs after admission to CVICU,if tolerated
ACTIVITY:
33.
34.
35.
36.
37.
38.
 Keep flat x 2 hrs
Turn side to side q2h while in bed
Bedrest with HOB at least 30 degrees; once extubated, dangle on bedside as tolerated within 2 hrs of extubation
Up in chair AM POD #1; may transfer to step-down unit in recliner
Splint chest with activity
 Discontinue femoral arterial/venous lines in _____ hrs post-op if CT drainage < 100 ml/hr and CI > 2.2
Apply manual pressure x 20 minutes then sandbag for 4 hrs
Copy to pharmacy
FORM 3-40025 REV. 09/2015
Order writer’s initials ___________
Page 3 of 6
PLACE LABEL HERE
CARDIOVASCULAR SURGERY
CVC ACUTE PHASE
POST-OP 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).
DRESSINGS:
39. Keep original sternal dressing intact (reinforce if needed) for the first 48 hrs
40. If bleeding from sternal or leg incision(s), apply manual pressure to site until bleeding stops. If unsuccessful, notify
physician.
41. ACE wrap to endoscopic vein harvest (EVH) surgical site x 48 hrs post-op, then remove and place antiembolic
stockings
42. Radial artery harvest site care: keep affected arm elevated
No BP or venipuncture in affected arm
Maintain ACE wrap x 48 hrs post-operatively
Circulation, motor and sensory checks on admission and q 4 hr
43. Paint incisions daily with betadine. May use CHG if Allergic. Start 48 hours post-op
44. Change Chest tube and pacing wire dressings daily. Start 48 hours post-op
45. Change sternal and leg incision dressing daily if applicable. Start 48 hours post-op
RESPIRATORY:
46. Oxygenation: Initial ventilator settings per anesthesia, or:  Mode: ________ Rate: ________ VT: 8-10 ml/kg
FiO2: ________ PEEP: ________ PS: ________
47. Cardiac surgery respiratory weaning protocol when patient awake and stable (policy # 7504-10-04-05)
 Do not extubate. State reason ______________________________________________________
48. Cough and deep breath and incentive spirometry q 1 hrs post extubation while awake
49. If progressed to BIPAP, stat ABG and CXR; notify Physician of results
50. Oxygen per Protocol (Form #34431)
IV FLUIDS:
51.
52.
53.
54.
55.
NS at 20 ml/hr IV
Arterial and PA pressure lines to pressure transducer system. Use 0.9% NS - NO HEPARIN in flush bags.
NS 500 ml for CO injectate
Flush unused central line ports with NS 10 ml q 8 hrs
Flush unused peripheral INTs with NS 10 ml q 8 hrs
ELECTROLYTE REPLACEMENT (recheck level 2 hours after infusion completed, repeat if needed):
56. Potassium: Maintain serum K+ level between 4.0 – 5.0 mmol/L; Call physician for K+ < 3.2 or > 5.0
Hold K+ replacement if UOP is < 30 ml/hr or Cr is > 2
Serum K+ < 4.2, give KCl 20 mEq in 100 ml pre-mix IV over 1 hr in central line
Serum K+ < 3.9, give KCl 20 mEq in 100 ml pre-mix IV over 1 hr x 2 doses in central line
57. If Mg++ < 2, give Magnesium sulfate 2 grams/50 ml D5W pre-mix IV prn over 1 hr in central line
If ionized Ca++ is < 1.1, give CaCl 1 gm in 50 ml NS IV piggyback in central line over 10 minutes
VOLUME:
58. NS 0.9% 1000 ml bolus IV for PAD < 8 or CI < 2.2, maximum 2 L
59. Albumin 5%, 250 ml IV for PAD < 8 or CI < 2.2, may repeat x 1 dose, maximum 500 ml
60.  PRBCs 1 unit for Hgb < ____. Repeat Hgb in 2 hrs and call physician if less than target number
 Other: _______________________________________________________________________
Copy to pharmacy
FORM 3-40025 REV. 09/2015
Order writer’s initials ___________
Page 4 of 6
PLACE LABEL HERE
CARDIOVASCULAR SURGERY
CVC ACUTE PHASE
POST-OP 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).
INFUSIONS: (PLEASE NOTIFY PHYSICIAN PRIOR TO INITIATING)
61. Diprivan (propofol) 1% at 5-50 mcg/kg/min for ventilation >24 hrs.
Titrate 5-10 mcg/kg/min q 10 min for RASS: 0 to -2
62. Precedex (dexmedetomidine) 1 mg/250 ml NS at 0.2-1 mcg/kg/hr for ventilation > 24 hrs.
Titrate 0.1mcg/kg/hr for RASS: 0 to -2
63. Nitroprusside 50 mg/250 ml D5W: 0.1 mcg/kg/min starting dose or _____ mcg/kg/min to max 4 mcg/kg/min.
Titrate 0.1-1mcg/kg/min q 5 min to maintain MAP < 90 or ____________________
64. Nitroglycerin 50 mg/250 ml D5W: 5 mcg/min starting dose or _____ mcg/min to max 100 mcg/min
Titrate 5-20 mcg/min q5min to keep PAS < 45 or ____________________
65. Cardene (nicardipene) 40 mg/200 ml premix: 5 mg/hr starting dose or ____ mg/hr to max 15 mg/hr
Titrate 2.5 mg/hr q15 min to maintain MAP < 90 or ____________________
66. EPInephrine 4 mg/250 ml NS: 1 mcg/min or ____ mcg/min starting dose to max 10 mcg/min
Titrate 1 mcg/min q1 min to maintain CI of 2.2 or ____________________
67. Levophed (norepinephrine) 4 mg/250 ml NS: 2 mcg/min or ____ mcg/min starting dose to max 30 mcg/min
Titrate 2-10 mcg/min q 2 min to MAP > 65 mm Hg or ___________________
68. Pitressin (vasopressin) 50 units/500 ml NS: 0.02 units/min or ____ units/min starting dose to max 0.04 units/min
Titrate 0.01 units/min q 15 min to MAP > 65 or ____________________
69. Cardizem (diltiazem) 100 mg/100 ml NS: 5 mg/hr for radial artery graft or 5-15 mg/hr starting or ______ mg/hr to max
15 mg/hr. Titrate 5 mg/hr q 15 min for HR > 120 or ____________
70. DOBUTamine 500 mg/250 ml D5W: 2 mcg/kg/min or ____ mcg/kg/min starting dose.
Do no titrate without physicain order
71. Milrinone 20 mg/100 ml NS: 0.25 mcg/kg/min or ____ mcg/kg/min starting dose.
Do no titrate without physician order
72. Amiodarone protocol (form # 17044), initiate if started in Operating Room
73. If Nitrates or Calcium Channel Blockers used for radial artery graft, titrate by physician order only
74. Other: _______________________________________________________________________
BLOOD GLUCOSE (BG) MANAGEMENT:
75. Blood glucose q 1 hr x 6. For BG > 150mg/dL, or if patient started on insulin infusion in OR, Initiate ENDOTOOL Insulin
Infusion Standing Orders (form # 38635).
76. If remains off ENDOTOOL, use sliding scale formula: Humalog (insulin lispro) (BG-100)/30 q 4 hrs. Check BG q 4 hrs
77. If ENDOTOOL started, transition to SQ insulin using ENDOTOOL generated orders. If patient is diabetic or HgB a1C ≥
6.5, maintain ENDOTOOL until 24 hrs after admission to CVICU.
Copy to pharmacy
FORM 3-40025 REV. 09/2015
Order writer’s initials ___________
Page 5 of 6
PLACE LABEL HERE
CARDIOVASCULAR SURGERY
CVC ACUTE PHASE
POST-OP 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).
SCHEDULED MEDICATIONS:
Do Not Start or Change Any Anti-Coagulant Without Cardiovascular Approval
78. Post-Op Antibiotics:
Ancef(cefazolin) was given pre-op (dose was given at ______), continue with:
 Patient weight < 90 kg, give Ancef (cefazolin) 1 gm IV q 8 hours x 5 doses
 Patient weight ≥ 90 kg, give Ancef (cefazolin) 2 gm IV q 8 hours x 5 doses
ORVancomycin IV was given pre-op (dose was given at ______), continue with:
 Patient weight < 90 kg, give Vancomycin 1 gm IV q 12 hrs x 3 doses
 Patient weight ≥ 90 kg, give Vancomycin 1.5 gm IV q 12 hrs x 3 doses
79. Bactroban (mupirocin) 2% ointment to bilateral nares twice daily x 5 days (DC if nasal culture negative)
80. Stress Ulcer Prophylaxis:
 Pepcid (famotidine) 20 mg IV q 12 hours; change to po when tolerating orals
OR  Protonix (pantoprazole) 40 mg IV daily; change to po when tolerating orals
81. Aspirin (enteric coated) 81 mg po daily; begin at 0900 on POD #1. Hold if platelets < 100,000.
OR  DC Aspirin. Aspirin contraindicated due to: _____________________________________________
82. Lopressor (metoprolol) 12.5 mg or ______ mg po or NG tube q 12 hr daily. Start first dose at 0900 on POD #1.
Hold if SBP < 100, HR < 60, or receiving inotropic drugs
OR  DC Lopressor (metoprolol).Lopressor (metoprolol) contraindicated because:
83. Peridex (chlorhexidene) oral rinse BID while intubate
PRN MEDICATIONS See policy 520-06 for range orders and pain intensity guidelines. Administer drugs in order listed.
84. Sedation/Agitation when RASS score is > +2: Versed (midazolam) 0.5-2 mg IV q 1 hr prn while intubated
85. Hypertension: Hydralazine 10 mg IV q 4 hrs prn SBP > 150,
If hydralazine is ineffective after 2 doses, give Labetolol 10 mg IV q 5 min prn SBP > 150 and HR >
60 x 3 doses and recheck SBP. If SBP still > 150, call physician.
86. Respiratory/wheezing:
Proventil (albuterol) 2.5 mg q 4 hrs prn with Atrovent (ipratropium) 0.5 mg aerosol q qid prn
If patient HR > 100 bpm , DC Proventil and administer Xopenex (levalbuterol) 1.25 mg aerosol q 4 hr prn
87. Shivering: Demerol (meperidine) 12.5 mg IV q 5 minutes prn up to 25 mg
88. Base Excess (BE) less than (-)5: Sodium Bicarbonate 50 ml IV x 1 dose; may repeat x 1 if BE not improved
89. CV Care Unit Electrolyte Replacement Protocol (form # 40046)
90. Chest pain: Nitroglycerin 0.4 mg sublingual q 5 minutes x 3 doses prn and notify physician.
91. Mild Pain, Temp >100.5F, HA: Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
92. Moderate Pain:
Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn.
 DC Percocet. Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn.
93. Severe Pain for CVICU:
Morphine sulfate 2-5 mg IV q 1 hr prn. DC if CrCl < 30, see below order.
 If morphine ineffective after 2 doses or CrCl < 30, DC morphine; give Dilaudid (HYDROmorphone) 0.25-2 mg IV
q 2 hrs prn (if CrCl < 30 start at 0.25 mg)
94. Nausea/Vomiting: Zofran (ondansetron) 4 mg IV q 6 hrs prn
If N/V persists, add Reglan (metoproclamide) 10 mg IV q 6 hrs prn (5 mg if > 65 yo or CrCl < 30)
95. Sore Throat:  Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn
Copy to pharmacy
FORM 3-40025 REV. 09/2015
Page 6 of 7
PLACE LABEL HERE
CARDIOVASCULAR SURGERY
CVC ACUTE PHASE
POST-OP 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).
ADDITIONAL ORDERS:
96. Fax copy of Cardiovascular Post-Operative Note to 678-312-3529
____________
Date
____________
Time
_________________________________
Physician Signature
___________
PID Number
Copy to pharmacy
FORM 3-40025 REV. 09/2015
Page 7 of 7