2. Diagnosis: Unstable Angina
3 Condition:
4. Vital Signs: q1h. Call physician if pulse >90,<60; BP>150/90, <90/60;R>25, <12; T >38.5/C.
5. Activity: Bed rest with bedside commode.
7. Nursing:
Guaiac stools. If patient has chest pain,obtain 12-lead ECG and call physician.
8. Diet: Cardiac diet, 1-2 gm sodium, low fat, low cholesterol diet.
No caffeine or temperature extremes.
9. IV Fluids: D5W at TKO
10. Special Medications:
-Oxygen 2-4 L/min by NC.-Aspirin 325 mg PO, chew and swallow, then aspirin EC 162 mg PO qd OR
-Clopidogrel (Plavix) 75 mg PO qd (if allergic to aspirin).
-Nitroglycerine infusion 10 mcg/min infusion
(50 mg in 250-500 mL D5W, 100-200 mcg/mL).
Titrate to control symptoms in 5-10 mcg/min steps, up to 200-300 mcg/min;
maintain systolic BP >90 OR
-Nitroglycerine SL, 0.4 mg (0.15-0.6 mg) SL q5min until pain free (up to 3 tabs) OR
-Nitroglycerin spray (0.4 mg/aerosol spray)1-2 sprays under the tongue q 5min; MR x 2.
-Heparin 60 U/kg IV push, then 12 U/kg/hr by continuous IV infusion
for 48 hours to maintain aPTT of 50-70 seconds. Check aPTTq6h x 4, then qd.
Repeat aPTT 6 hours after each heparin dosage change.
Glycoprotein IIb/IIIa Blockers:
-Eptifibatide (Integrilin) 180mcg/kg IVP, then 2 mcg/kg/min for 72 hours OR
-Tirofiban (Aggrastat) 0.4 mcg/kg/min for 30 min,
then 0.1 mcg/kg/min for 48-108 hours.
Glycoprotein IIb/IIIa blockers for Use With Angioplasty:
-Abciximab (ReoPro) 0.25 mg/kg IVP, then 0.125mcg/kg/min IV infusion
for 12 hours OR
-Eptifibatide (Integrilin) 180 mcg/kg IVP, then 2mcg/kg/min for 20-24 hours.
Angiotensin Converting Enzyme Inhibitor:
-Lisinopril (Zestril, Prinivil) 2.5-5 mg PO qd; titrate to10-20 mg qd.
Long-acting Nitrates:
-Nitroglycerin patch 0.2 mg/hr qd. Allow for nitrate-free period to prevent tachyphylaxis.
-Isosorbide dinitrate (Isordil) 10-60 mg PO tid [5,10,20,30,40 mg] OR
-Isosorbide mononitrate (Imdur) 30-60 mg PO qd.Beta-Blockers:
Contraindicated in cardiogenic shock.
-Metoprolol (Lopressor) 5 mg IV q2-5min x 3 doses;then 25 mg PO q6h for 48h,
then 100 mg PO q12h;keep HR <60/min, hold if systolic BP <100 mmHg OR
-Atenolol (Tenormin), 5 mg IV, repeated in 5 minutes,
followed by 50-100 mg PO qd OR
-Esmolol (Brevibloc) 500 mcg/kg IV over 1 min, then50 mcg/kg/min IV infusion,
titrated to heart rate >60 bpm (max 300 mcg/kg/min).
Statins:
-Atorvastatin (Lipitor) 10 mg PO qhs OR
-Pravastatin (Pravachol) 40 mg PO qhs OR
-Simvastatin (Zocor) 20 mg PO qhs OR
-Lovastatin (Mevacor) 20 mg PO qhs OR
-Fluvastatin (Lescol)10-20 mg PO qhs.
11. Symptomatic Medications:
-Morphine sulfate 2-4 mg IV push prn chest pain.-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn headache.
-Lorazepam (Ativan) 1-2 mg PO tid-qid prn anxiety.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
-Docusate (Colace) 100 mg PO bid.
-Dimenhydrinate (Dramamine) 25-50 mg IV over 2-5min q4-6h
or 50 mg PO q4-6h prn nausea.
-Famotidine (Pepcid) 20 mg IV/PO bid.
12. Extras: ECG stat and in 12h and in AM, portable CXR,
impedance cardiography, echocardiogram.Cardiology consult.
13. Labs: SMA7 and 12, magnesium. Cardiac enzymes:
CPK-MB, troponin T, myoglobin STAT and q6h for 24h. CBC, INR/PTT, UA.
