PLACE LABEL HERE

ACUTE EXACERBATION

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) / ASTHMA

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).

  1. 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 # 2No, place in observation

2. If admitted as inpatient, Inpatient Physician Certification:

Diagnosis: ______

Level of Care:  Critical  Intermediate  Acute Care Location/Specialty Unit Preference______

3. Telemetry: If patient Medical/Surgical, must complete form # 36084

4. Isolation:  Contact  Droplet  Airborne For: ______

  1. Diagnosticson Admission:

CBC Chem 7 CMP  Magnesium level  Phosphorus

 Albumin level Theophylline levelPT/INR PTT

Quantativative hCG, for any menustrating female ≥ 12 years of age

 Sputum collection per Respiratory Care protocol (03-02-20) for culture and gram stain

ABG on:  Room air OR  Current Oxygen Settings

 EKG 12 lead: Reason: ______Group to Read: ______

Chest X-ray, PA/lateral, Reason: COPD Exacerbation

 Portable CXR: Reason: COPD Exacerbation

 CT Chest  without  with contrast Reason: ______

 CTA Chest Reason: ______

Diagnostics in AM:

 CBC  Chem 7  CMP  Magnesium level  Phosphorus  Albumin level

 Theophylline level PT/INR PTT

 CRP  alpha 1 antitrypsin level

ABG on:  Room air OR  Current Oxygen Settings

 CXR: PA/lateral, Reason: COPD Exacerbation

 Portable CXR, Reason: COPD Exacerbation

 EKG 12 lead: Reason: ______Group to Read: ______

6.Initiate Sleep Apnea Orders (form # 21266), if OSA screen is positive for suspected or reported sleep apnea

7.Vital Signsper unit routine OR q ______hrs

8.INT

9.Finger stick blood glucose:  ac & hs OR  q 6 hrs (patient NPO) for 48 hrs 72 hrs until discontinued

 Notify physician if BG is > 180 x 2 in 24 hrs

10.Diet: NPO  Regular  Cardiac Diabetic ______calories  Renal  No Added Salt

Other:______

11.Activity: Bedrest Bathroom privileges Up ad lib  Fall Precautions

Other:______

12.Initiate PT/OT order set (form #32655) if patient has a substantial decrease from base line function
(that is unlikely to resolve within 48 hrs), or needs placement and disposition.

13.Oral Nutrition Supplement Standing Order (form # 31417), initiate if patient meets criteria

14. Dietitian to Assess and Manage: Reason: ______

15. Diabetes Education consult:  Steroid induced hyperglycemia  Other:______

Copy to pharmacyOrder writer’s initials ______

*3-16573* FORM 3-16573 REV. 03/2017 Page 1 of 3

PLACE LABEL HERE

ACUTE EXACERBATION

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) / ASTHMA

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).

16.  Foley catheter

17. Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)

18.O2 per Protocol (form # 34431)

19.Pulmonary Rehabilitation Evaluation

20.Smoking cessation program, if patient is a smoker

MEDICATIONS

21.Scheduled Aerosol (Neb= Nebulizer) Treatment Options

 Albuterol 2.5 mg / ipratropium 0.5 mg (Duoneb)neb q 4 hrs  while awake  around the clock

 Albuterol 2.5 mg neb q 4 hrs  while awake  around the clock

 Atrovent (ipratropium) 0.5 mg neb q 4 hrs  while awake  around the clock

 Pulmicort (budesonide) neb  0.25 mg  0.5 mg BID

 Brovana (arformoterol) 15 mcg neb BID

22. PRN Aerosol (Neb= Nebulizer) Treatment Options (May Order in Addition to Scheduled Aerosol Treatments):

 Albuterol 2.5 mg / ipratropium 0.5 mg (Duoneb)neb q 4 hrswheezing

 Albuterol 2.5 mg neb q 4 hrs prn wheezing

 Atrovent (ipratropium) 0.5 mg neb q 4 hrs wheezing

23. IVF ______IV at ______ml/hr

24.Antibiotics (if indicated):

 Avelox (moxifloxacin) 400 mg  po or  IV daily(not recommended if patient has received any fluoroquinolone in the past 30 days)

 Rocephin (ceftriaxone) 1 gm IV q 24 hrs

 Zithromax (azithromycin) 500 mg  po or  IV x 1 dose, then 250 mg q 24 hrs

 Ceftin (cefuroxime) 500 mg po q 12 hrs

Doxycycline 100 mg po BID

Bactrim DS (trimethoprim/sulfamethoxazole) 1 tablet po BID

Amoxicillin 500 mg po TID

25.Steroids: Solu-Medrol (methylprednisolone) ______mg IV q ______hrs (consider oral steroid if ≤ 60 mg/day)

or Prednisone ______mg po q ______hrs

26. Nicotine patch 14 mg apply daily or  Nicotine patch 21 mg apply daily

27.VTE prophylaxis, Initiate Venous Thromboembolism (VTE) Prophylaxis Orders (form # 33058)

Heparin 5,000 units SQ q 8 hrs (q 12 hrs if wt < 50 kg OR age > 75)

orLovenox (enoxaparin) 40 mg SQ daily at 1700 (30 mg if CrCl < 30 ml/min)

Mechanical devices Sequential Compression Devices (SCDs)

Copy to pharmacyOrder writer’s initials ______

FORM 3-16573 REV. 03/2017 Page 1 of 3

PLACE LABEL HERE

ACUTE EXACERBATION

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) / ASTHMA

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 (See policy 520-06 for range orders and pain intensity guidelines)

28.Electrolyte Replacement Protocol (form # 21340)

29.Mild Pain, Temp>100.5F, HA: Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn

30.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)

31.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

32.Indigestion:  Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn

33.Stool Softener:  Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement

34.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

35.Cough:  Robitussin (guaifenesin) 15 ml po q 4 hrs prn

36.Sore Throat:  Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn

ADDITIONAL ORDERS:

______

______

______

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-16573 REV. 03/2017 Page 1 of 3