Download SCA Prevention: HF Admission Orders

Heart Failure Admission Orders
1. Include Date and Time on orders
2. Check all appropriate orders
Intern: ______________________ Resident: ____________________ Attending: _____________________
Pager: ______________________ Pager: ______________________ Pager: ________________________
General
Date
Time
Admit to:
 CCU
 Telemetry ________  General Med ________ SERVICE:
Diagnosis:
HF Etiology:
Reason(s) for
Admission
 New-onset HF  HF exacerbation  Refractory HF  Arrhythmia
 Noncompliance–meds  Noncompliance–diet  Volume overload
 Other__________________
LVEF
_________%
Stage and Class
ACC/AHA Stage:  C  D
Condition
 Good
 Fair
Allergies
 NKDA
 Allergy:
 Overdiuresis
Date obtained: ____________
NYHA class (Prior to admission):  I  II  III  IV
 Guarded
Nursing
Vital Signs
 Per unit routine  Q _____
 Call House Officer if: SBP > _____ mmHg or SBP < _____ mmHg; HR >_____ or HR < _____;
RR > _____ or RR < _____; T > _____
Activity
 Bed rest
 Out of bed to chair with assistance (BID, TID)
 Physical therapy consultation
Diet
 2 gram Na diet with 2000 mL (2 quarts) PO fluid restriction
 2 gram Na diet with 1500 mL PO fluid restriction
 2 gram Na, carbohydrate-controlled, low-cholesterol diet with _____ mL PO fluid restriction
 Other: ______________________________________________________
IV Fluids
 HEPLOCK with 3 mL normal saline flush Q12 hours (document on flow sheet 0800H and 2000H)
 Other: ______________________________________________________
I/O and Weight
 Strict recording of Ins and Outs
Foley
 If patient is unable to void, place Foley catheter
Monitoring
 Electrocardiographic monitor
Oxygen
 O2 _____ L/min nasal cannula for chest pain, shortness of breath, SaO2 < 93%
 Bed rest with commode privileges
 Ambulate in hall with assistance (BID, TID)
 Cardiac rehabilitation consultation
 Daily AM weights; record in chart
 Pulse oximetry:
 continuous
 Q _____
Laboratory
On Admission
(ACC/AHA Class I
Recommendations
Indicated in Bold, if
new HF diagnosis)
In AM
 CBC with differential and platelets
 Electrolytes  BUN  Creatinine  Glucose  Mg  Ca  PO4  Uric Acid
 HbA1c
 CPK total and MB NOW and Q8 hours x 3
 Cardiac troponin I NOW and 6 hours
 PT/INR (if patient receiving warfarin)  PTT (if patient treated with heparin/LMWH)
 BNP (if indicated)
 Liver function tests:  AST  ALT  Alk Phos  Total Bili  __________
 Cardiovascular lipid panel (fasting)
 Digoxin level (if patient receiving digoxin)
 Thyroid function test:  TSH ___________________________________________
 Urinalysis
 Others:__________________________________________________________________
 Electrolytes  BUN  Creatinine  Glucose  Mg  Ca  PO4  Uric Acid
 CBC with differential and platelets
 PT/INR (if patient receiving warfarin)
 PTT (if patient treated with heparin/LMWH)
 BNP (if indicated)
 Others: __________________________________________________________________
Medication
Intravenous
IV Diuretics:
 Furosemide _______ mg IVP x 1 and/or by  continuous IV infusion at _______ mg/hour
 Other ___________________________________________
IV Vasoactive Medications:
 ________________________________________________
 ________________________________________________
IV Electrolyte Replacement:
 Potassium chloride _____ mEq IVPB over _____ hours x 1 _____ via central line or
____ via peripheral line
 Magnesium sulfate _____ g over _____ hours x 1
Oral
 ACE Inhibitor: _______________ _____ mg PO ___ (hold for SBP < 80 mmHg or ____,
notify MD)
Contraindication/reason not used:___________________________
 ARB: _______________ _____ mg PO ___ (hold for SBP <80 mmHg, or ____, notify MD)
Contraindication/reason not used:___________________________
 Beta-blocker _______________ _____ mg PO ___ (hold for SBP < 80 mmHg or ____
or HR < 45 or ____, notify MD) (Use 1 of 3 proven to reduce mortality: bisoprolol, carvedilol,
or sustained-release metoprolol succinate; should not be newly initiated for HF until patient is
stable and no longer significantly volume overloaded; if treated prior to admit, continue current
dose unless shock)
Contraindication/reason not used:___________________________
 Aldosterone Antagonist: _______________ _____ mg PO QD (Start spironolactone 6.25 or
12.5 mg or eplerenone 12.5 mg or 25 mg; contraindicated if hyperkalemia or CrCl ≤ 30 mL/min;
initiate very low doses; closely monitor renal function and K+)
Contraindication/reason not used:___________________________
 Diuretic: ___________________ mg PO _____ (if congestion)
 Hydralazine _____ mg PO _____ (hold for SBP < 80 mmHg)
 Nitrate _______________ _____ mg PO _____ (hold for SBP < 80 mmHg)
 Fixed-dose hydralazine/nitrate (BiDil®) _____ PO TID (hold for SBP < 80 mmHg)
 Digoxin _____ mg PO _____ (keep level < 1.0 ng/mL)
 Enteric Coated Aspirin _____ mg PO daily (if CAD, CVD, PVD, diabetes)
 Clopidogrel 75 mg PO daily (if indicated)
 Statin: _______________ _____ mg PO QD or QHS (if CAD, CVD, PVD, diabetes)
 Warfarin _____ mg PO _____ (if history of paroxysmal or permanent A-fib, LV thrombus, or
mechanical heart valve)
 Potassium chloride _____ mEq tab PO _____
 Potassium chloride _____ mEq/L elixir PO ____
 _____________________________________  _________________________________
 _____________________________________  _________________________________
 _____________________________________  _________________________________
 _____________________________________  _________________________________
(ACC/AHA Class I
Recommendations
in Bold)
DVT
Prophylaxis
 Enoxaparin 40 mg SQ daily  Enoxaparin 30 mg SQ daily (if creatinine clearance < 30 mL/min)
 Fondaparinux 2.5 mg SQ daily
 Heparin 5000 units SQ TID
 IV Heparin Protocol
 Intermittent compression stockings  Elastic Stockings (thigh-high)
PRN
Medications
 Acetaminophen (Tylenol®) 650 mg PO Q4 hours, PRN pain or headache
 Mylanta II 15 mL PO Q6 hours, PRN dyspepsia or GI upset
 Docusate (Colace®) 100mg PO BID, PRN.
 ____________________________________________
 ____________________________________________
(ACC/AHA Class I
Recommendations
Indicated in Bold)
 EKG
 Chest X-ray (PA and lateral)
 Echocardiogram – if not performed in prior 12 months or if prior EF cannot be documented
 EP device interrogation (ICD, CRT, pacemaker) Brand:____________________
 Other __________________________
Tests
Vaccinations
Pneumococcal
Vaccine
INDICATED FOR ALL HEART FAILURE PATIENTS (Adult)
CONTRAINDICATIONS: Previous SEVERE reaction to vaccine
 INDICATED: Administer 0.5 mL IM x 1 dose on day of admission
 NOT INDICATED:  previously vaccinated, Date _______  Other reason: ________________
 Patient refusal
Influenza
Vaccine
INDICATED FOR ALL HEART FAILURE PATIENTS (October thru February)
CONTRAINDICATIONS: Allergy to eggs; previous SEVERE reaction to vaccine; history of
Guillain-Barre Syndrome
 INDICATED: Administer 0.5 mL IM x 1 dose on day of admission
 NOT INDICATED:  previously vaccinated, Date _______  Other reason: ________________
 Patient refusal
Protocols
(ACC/AHA Class I
Recommendations
Indicated in Bold)
 Provide and Document HF Instructions: (1) diet and fluid restriction, (2) activity, (3) medications,
(4) daily weight, (5) worsening symptoms, and (6) follow-up
 Smoking Status:  current or past 1 year  former  nonsmoker  unknown
 Smoking Cessation Counseling and Patient Education Materials
Consults
 General cardiology
 EP consult for sudden cardiac arrest risk assessment/device assessment
 Nephrology
 Endocrinology
 Medical social worker
 Smoking cessation
 Nutrition services
 Physical therapy
 Cardiac rehabilitation
 Other: _________________________________________
MD Signature: ____________________ Pager: _______________
Date/Time: _____________________________________________
Adapted, with permission, by the SCA Prevention Medical Advisory Team, from the UCLA Medical Center.
This is a general algorithm to assist in the management of patients.
This clinical tool is not intended to replace individual medical judgment or individual patient needs.
Please refer to the manufacturers’ prescribing information and/or instructions for use for the indications, contraindications,
warnings, and precautions associated with the medications and devices referenced in these materials.
Sponsored by Medtronic, Inc.
April 2007
UC200705409 EN