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.
2.
Diagnosis & Status: Admit as Inpatient __________________________________________(reason for admission)
Unit: CVC
ADMISSION:
3. Stat ECG unless pacer dependent; obtain ECG once pacer is off, then stat ECG for any ST/rhythm changes prn
4. Stat portable CXR and repeat in AM and daily if intubated or chest tube in place
5. STAT labs on admission and in AM of POD 1; RN to draw:
CBC
PT/INR
PTT
Chem 7
Mg+
Ionized Ca++
ABGs
AM of POD 2: CBC and Chem 7
6. H & H and K+ 2 hrs after admission, then q 4 hrs x 2, then prn
7. ABGs prn
CONSULTS:
8. Cardiologist: ________________________________________________________________________
9. Other: _____________________________________________________________________________
VITAL SIGNS:
10. 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.
11. VS q 15 minutes for the first 2 hrs or if actively titrating vasoactive drugs until stable, then q 30 minutes x 2 hrs, then
hourly.
12. CO/CI on admission and q 1 hr x 4, then q 4 hrs and prn
13. Maintain temperature > 96.8°F. Temperatures below 96.8°F: apply warm blankets and/or forced air warming device.
14. Obtain blood, sputum, and urine cultures for Temp >101°F
15. 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
16. Neurological checks hourly until awake, then q 2 hrs X 24 hrs and prn
ADDITIONAL ORDERS:
17. 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: _____________________________
18. Hourly intake and output (including CT drainage)
Send copy to pharmacy
*3-40025*
Order writer’s Initials___________
FORM 3-40025 REV. 06/2012
Page 1 of 5
PLACE LABEL HERE
CARDIOVASCULAR SURGERY
CVC ACUTE PHASE
POST-OP ORDERS
19. Daily weights by 0600 and record in kg
Send copy to pharmacy
*3-40025*
Order writer’s Initials___________
FORM 3-40025 REV. 06/2012
Page 2 of 5
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 Continued:
20. NGT/OGT to low intermittent suction. Discontinue NGT/OGT upon extubation.
21. 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
22. Maintain Intra-aortic Balloon pump settings, if applicable
Institute routine Intra-aortic Balloon Pump Orders (form # 40040)
23. 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
24. Tamponade precautions per GMC protocol following epicardial pacer wire removal
Bedrest x 1 hr; VS q 15 min x 4 then q 30 min x 2
25. OSA Screen: If patient screens positive for suspected sleep apnea or has reported sleep apnea, initiate Sleep
Apnea Orders (form # 21266)
26. 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
27. Medical-Surgical Restraint Order (form # 17609) on chart for intubated patients
DIET:
28. NPO while intubated. Once extubated, start ice chips, then clear liquids, then advance as tolerated.
ACTIVITY:
29.  Keep flat x 2 hrs
30. Bedrest with HOB at least 30 degrees; once extubated, dangle on bedside as tolerated within 2 hrs of extubation
31. Up in chair AM POD #1; may transfer to step-down unit in recliner
32. Splint chest with activity; place Heart Hugger
33.  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
DRESSINGS:
34. Keep original sternal dressing intact (reinforce if needed) for the first 48 hrs
35. If bleeding from sternal or leg incision(s), apply manual pressure to site until bleeding stops. If unsuccessful, notify
physician.
36. ACE wrap to endoscopic vein harvest (EVH) surgical site x 48 hrs post-op, then remove and place antiembolic
stockings
37. 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 hrs
Send copy to pharmacy
FORM 3-40025 REV. 06/2012
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).
RESPIRATORY:
38. Oxygenation: Initial ventilator settings per anesthesia, or:  Mode: ________ Rate: ________ VT: 8-10 ml/kg
FiO2: ________ PEEP: ________ PS: ________
39. Cardiac surgery respiratory weaning protocol when patient awake and stable (policy # 7504-10-04-05)
 Do not extubate. State reason ______________________________________________________
40. Cough and deep breath and incentive spirometry q 1 hrs post extubation while awake
41. RT eval and treat Protocol (# 7504-10-03-01) if incentive spirometry is ineffective
42. If progressed to BIPAP, stat ABG and CXR; notify Physician of results
43. Oxygen per Respiratory Care Protocol (policy #7504-10-01-03)
 Adjust O2 to maintain SpO2 >90% or 88% in COPD. Call physician for O2 usage >4 L/min or >40%.
 Reassess daily, wean O2 to maintain SpO2 >90% or 88% in COPD. Wean to room air if SpO2 is acceptable and
patient has no known exclusions per 7504-10-01-03. May restart O2 as needed.
IV FLUIDS:
44. D5 ½ NS at 20 ml/hr IV
45. Arterial and PA pressure lines to pressure transducer system. Use 0.9% NS - NO HEPARIN in flush bags.
46. NS 500 ml for CO injectate
47. Flush unused Swan Ganz ports with NS 10 ml q 8 hrs
48. Flush unused peripheral INTs with NS 10 ml q 8 hrs
ELECTROLYTE REPLACEMENT (recheck level 2 hours after infusion completed, repeat if needed):
49. 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
50. If Mg++ < 2, give Magnesium sulfate 2 grams/50 ml D5W pre-mix IV prn over 1 hr in central line
51. If ionized Ca++ is < 1.1, give CaCl 1 gm in 50 ml NS IV piggyback in central line over 10 minutes
VOLUME:
52. NS 0.9% 500 ml bolus IV for PAD < 8 or CI < 2.2, maximum 2 L
53. Albumin 5%, 250 ml IV for PAD < 8 or CI < 2.2, may repeat x 1 dose, maximum 500 ml
54. PRBCs 1 unit for Hgb < ____. Repeat Hgb in 2 hrs and call physician if less than target number
55.  Other: ______________________________________________________________________
INFUSIONS: PLEASE NOTIFY PHYSICIAN PRIOR TO INITIATING
56. 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
57. Precedex (dexmedetomidine) 1 mg/250ml NS at 0.2-1 mcg/kg/hr for ventilation >24 hrs.Titrate for RASS: 0 to -2
58. Nitroprusside 50 mg/250 ml D5W: 0.1 mcg/kg/min starting dose or _____ mcg/kg/min to max 4 mcg/kg/min.
Titrate to maintain MAP < 90 or ____________________
59. Nitroglycerin 50 mg/250 ml D5W: 5 mcg/min starting dose or _____ mcg/min to max 100 mcg/min
Titrate to keep PAS < 45 or ____________________
60. Cardene (nicardipene) 20 mg/200 ml premix: 5 mg/hr starting dose or ____ mg/hr to max 15 mg/hr
Titrate to maintain MAP < 90 or ____________________
61. EPInephrine 4 mg/250 ml NS: 1 mcg/min or ____ mcg/min starting dose to max 10 mcg/min
Titrate to maintain CI of 2.2 or ____________________
62. Levophed (norepinephrine) 4 mg/250 ml NS: 2 mcg/min or ____ mcg/min starting dose to max 30 mcg/min
Titrate to MAP > 65 mm Hg or ___________________
63. Pitressin (vasopressin) 50 units/500 ml NS: 0.02 units/min or ____ units/min starting dose to max 0.04 units/min
Titrate to MAP > 65 or ____________________
64. Cardizem (diltiazem) 100 mg/100 ml NS: 5 mg/hr for radial artery graft or HR > 120 or _______________________
65. DOBUTamine 500 mg/250 ml D5W: 2 mcg/kg/min or ____ mcg/kg/min starting dose. Titrate by Physician order only
66. Milrinone 20 mg/100 ml NS: 0.25 mcg/kg/min or ____ mcg/kg/min starting dose. Titrate by Physician order only
67.  Other: _______________________________________________________________________
Send copy to pharmacy
FORM 3-40025 REV. 06/2012
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).
68. BLOOD GLUCOSE (BG) MANAGEMENT:
 Blood glucose q 1 hr x 2. For BG > 150 implement Insulin Infusion Initiation Table (below)
 If BG values are < 150 continue BG q 2 hr. For BG > 150 implement Insulin Infusion Table (below)
 Once insulin infusion is initiated, continue infusion using Insulin Infusion Critical Care Orders (form # 27495)
If insulin infusion is started in OR, continue infusion using Insulin Infusion Critical Care Orders (form # 27495)
 If patient is receiving insulin, initiate Hypoglycemia Treatment Protocol (form # 2513)
Consult Hospitalist ____________________________________________________________________________
INSULIN INFUSION INITIATION TABLE (Insulin infusion: 100 units/100 ml NS = 1 unit/ml concentration)
A*= Non-diabetic/No EPInephrine infusion
Accu-Chek
Weight 
Diabetes/
Epinephrine
151-200
201-250
251-300
301-350,
call physician
351-400,
call physician
>400,
call physician
Insulin IVP Bolus
(Regular insulin)
B*= Diabetic OR EPInephrine infusion
C* = Diabetic AND EPInephrine infusion
Initial IV insulin rate (units/hr), based on body weight in kilograms
< 60 kg
60-90 kg
> 90 kg
A*
B*
C*
A*
B*
C*
A*
B*
C*
5 units IVP x 1 dose
5 units IVP x 1 dose
2
2
2
3
2
4
2
3
3
4
4
6
2
4
4
6
6
8
10 units IVP x 1 dose
2
3
4
3
4
6
4
6
8
10 units IVP x 1 dose
3
5
6
4
6
8
6
8
10
10 units IVP x 1 dose
4
6
8
5
7
10
6
9
12
10 units IVP x 1 dose
5
7
10
6
9
12
7
10
14
SCHEDULED MEDICATIONS:
Do Not Start or Change Any Anti-Coagulant Without Cardiovascular Approval
69. Antibiotics:
Pre-op dose Ancef (cefazolin) 2 grams IV; Pre-op dose given at ______, then
 Patient weight < 85 kg, give 1 gm IV q 8 hours x 5 doses
 Patient weight > 85 kg, give 2 gm IV q 8 hours x 5 doses
OR  If allergic to penicillin and cephalosporin, give Vancomycin (dose below) IV; Pre-op dose given at ___, then
 Patient weight < 85 kg, give 1 gm IV q 12 hrs x 3 doses
 Patient weight > 85 kg, give 1.5 gm IV q 12 hrs x 3 doses
70. Bactroban (mupirocin) 2% ointment to bilateral nares twice daily x 5 days (DC if nasal culture negative)
71. 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
72. 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: _____________________________________________
73. Lopressor (metoprolol) 12.5 mg or ______ mg orally 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: _______________________
74. Peridex (chlorhexidene) oral rinse BID while intubated
Send copy to pharmacy
FORM 3-40025 REV. 06/2012
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).
PRN MEDICATIONS (If > one drug is ordered for the same indication, clinical assessment will be used per policy 520-06)
Administer drugs in order listed.
75. Sedation/Agitation:
Versed (midazolam) 0.5-2 mg IV q 1 hr prn while intubated
76. Severe Pain:
Morphine sulfate 2-5 mg IV q 1 hr prn
Dilaudid (HYDROmorphone) 1-2 mg IV q 2 hrs prn if allergic to morphine or morphine ineffective
Percocet (oxyCODONE/acetaminophen) 5/325 1-2 tablets or 10/325 mg 1 tab po q 4 hrs prn once taking po
77. Headache/Temp > 100.5F:
Tylenol (acetaminophen) 650 mg po or per rectum q 4 hrs prn
78. Nausea/Vomiting:
Zofran (ondansetron) 4 mg IV q 6 hrs prn
Reglan (metoproclamide) 10 mg IV q 6 hrs prn (5 mg if > 65 years old or Cr Cl <30 per Rx) if ondansetron is
ineffective
Phenergan (promethazine) 12.5-25 mg po or per rectum q 4 hrs prn if metoproclamide is ineffective
79. Hypertension:
Hydralazine 10-20 mg IV q 4 hrs prn SBP > 150
Labetolol 10 mg IV q 5 minutes prn SBP > 150 and HR > 60 if hydralazine is ineffective after 2 doses
80. Respiratory/wheezing:
Proventil (albuterol) 2.5 mg NS q 4 hrs prn with Atrovent (ipratropium) 0.5 mg aerosol q qid prn
If patient tachycardic, DC Proventil and administer Xopenex (levalbuterol) 1.25 mg aerosol q 4 hr prn
Other: _________________________________________________________________________________
81. Itching or allergic reaction: Benadryl (diphenhydramine) 12.5-25 mg IV q 6 hrs prn
82. Shivering: Demerol (meperidine) 12.5 mg IV q 5 minutes prn up to 25 mg
83. Base Excess (BE) less than (-) 5:
Sodium Bicarbonate 50 ml IV x 1 dose; may repeat x 1 if BE not improved
ADDITIONAL ORDERS:
84. Fax copy of Cardiovascular Post-Operative Note to 678-312-3529
_________________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
____________
Date
___________________
Time
_________________________________
Physician Signature
___________
PID Number
Send copy to pharmacy
FORM 3-40025 REV. 06/2012
Page 6 of 6