<p> PLACE LABEL HERE DEEP VEIN THROMBOSIS (DVT) and PULMONARY EMBOLISM (PE) TREATMENT 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).</p><p>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) </p><p>OR See next page for Anticoagulation order options Order writer’s Initials ______</p><p>*4-1181* FORM 4-1181 REV. 07/2017 WHITE: Medical Record CANARY: Pharmacy Page 1 of 2 DEEP VEIN THROMBOSIS (DVT) and PULMONARY EMBOLISM (PE) TREATMENT ORDERS Reference Page</p><p>CONTRAINDICATION TO THROMBOLYTICS *Physician to use professional judgment</p><p>1. Age less than 18 years.* 2. Active internal bleeding. 3. 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 4. Major surgery within 14 days. 5. Intracranial surgery, serious head trauma, or recent previous stroke within 3 months. 6. Recent arterial puncture at a noncompressible site.* 7. Uncontrolled hypertension at time of treatment (greater than 185mm Hg systolic and/or greater than 110 mmHg diastolic). 8. History of intracranial hemorrhage or known AVM, aneurysm, or intracranial neoplasm.* 9. Patients at risk for left heart thrombus, acute pericarditis, or subacute bacterial endocarditis.* 10. Diabetic hemorrhagic retinopathy or other hemorrhagic ophthalmic conditions.* 11. Pregnancy*</p><p>FORM 4-1181 REV. 07/2017 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).</p><p>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 # 39814)  No initial bolus and  Coumadin (warfarin): _____ mg po daily, beginning on ____ Requires 5 day overlap with parenteral anticoagulation and INR > 2.0.</p><p>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.</p><p>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:  Melatonin 5 mg po q HS prn or  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</p><p>______Date Time Physician Signature PID Number</p><p>FORM 4-1181 REV. 07/2017 WHITE: Medical Record CANARY: Pharmacy Page 2 of 2</p>