<p> PLACE LABEL HERE LEFT ATRIAL APPENDAGE OCCLUSION (WATCHMAN) PRE-PROCEDURE ORDERS</p><p>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 Care  Intermediate Care  Acute Care Specialty/Unit Preference: ______4.  Telemetry: Med/Surg Complete form # 36084 5.  Isolation:  Contact  Airborne  Droplet For: ______6. Procedure scheduled Date: ______Estimated time: ______</p><p>Procedure:  Left Atrial Appendage Occlusion Device</p><p>7. Diagnostics, if not done within the last 72 hours:</p><p>12 Lead EKG </p><p>CBC w diff, Chem 7, Serum Magnesium, PT/INR, PTT</p><p>Serum HCG for females 12-60 years old, if pregnancy test not already done</p><p>8.  Bedside blood glucose monitoring:  q 4 h x2  q 6 h x2 (Notify physician if BG is > 180 mg/dl)</p><p>9. Notify physician: if K+ ≤ 3.7 or ≥ 5.2, INR > 1.5, creatinine > 1.5, or INR < 2.0 for Afib ablation and on warfarin</p><p>10. Clip hair on left and right groin areas </p><p>11. Cleanse groin area with soap and water</p><p>12. Obtain patient height and weigh patient</p><p>13. Vital Signs as routine</p><p>14. Initiate Oxygen for Adults Initiation and Weaning Protocol (form # 34431)</p><p>15.  Insert Foley catheter prior to procedure</p><p>16. Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)</p><p>17. Diet:  NPO except medcations </p><p> NPO after midnight, except for medications</p><p> Regular  ____ gm Sodium  Cardiac  ______calorie diabetic diet</p><p> NPO after clear liquid breakfast and medications</p><p>18. Activity:  Up ad lib  Bed rest with BRP Copy to pharmacy</p><p>*1-43030* FORM 1-43030 INITIATED 06/2017 Page 1 of 1 PLACE LABEL HERE LEFT ATRIAL APPENDAGE OCCLUSION (WATCHMAN) PRE-PROCEDURE ORDERS</p><p>19. IV Access: Insert and maintain INT in left arm, if possible. (Minimum size 20 gauge) </p><p>20. Education: Provide patient with LAAO device information if not provided previously. SCHEDULED MEDICATIONS: 21. Procedure IVF start time:______ NS at ______ml/hr  1/2 NS at ______ml/hr LR at 75ml/hr 22. If history of contrast reaction, give below medications as prophylaxis 60 minutes prior to procedure: Benadryl (diphenhydramine) 25 mg IV x 1 dose Solu-Medrol (methylprednisolone) 125 mg IV x 1 dose Pepcid (famotidine) 20 mg IV x 1 dose 23. Ancef (cefazolin) 2 gm (or 3 gm if weight is >120 kg) IV x 1 dose to be administered by anesthesia 24. If allergic to Penicillin and Cephalosporin or history of or current MRSA colonization/positive nasal screen: If <90 kg: Vancomycin 1 gm IVPB infused over 60 minutes prior to incision If >90 kg: Vancomycin 1.5 gm IVPB infused over 90 minutes prior to incision</p><p>______Date Time Physician Signature PID Number</p><p>Copy to pharmacy</p><p>*1-43030* FORM 1-43030 INITIATED 06/2017 Page 1 of 1</p>