Heart Failure Orders

PLACE LABEL HERE

HEART FAILURE

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. Diagnosis: Acute  Diastolic  Left Ventricular

Chronic  Systolic Heart Failure Due to Hypertension

Acute on Chronic  Diastolic & Systolic Other: ______

3. 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 EP Physician ______ Already called  Call back #:______

Reason:  EF ≤35% with a QRS duration of 120 ms or above for CRT-D or CRT-P  ICD (EF≤35%)

Reasons for not consulting EP Physician:  Already in place prior to arrival  Other:______

Consult:______Already called Call back #:______Reason: ______

Other consults:  Physical therapy consult

Occupational therapy consult; for exercise recommendations and energy conservation

Nutrition consult for education, if appropriate

7. Coordinated CareConsult: Home Health referral for CHF Program and Telehealth

8. Transition coordinator referral for post discharge follow-up

9. Schedule follow up appointment with the cardiologist within 7 days of discharge

10. Diagnostics:

BNP on admission CBC, Chem 7Chem 7 in AM

TSH on admission PT/INR on admission Troponin

Magnesium on admission Other: ______

CXR on admission Reason: Heart Failure

EKG on admission Reason: Heart FailureGroup to Read: ______

EKG prn for chest pain unrelieved by Nitroglycerin sublingual x 3, rhythm or ST changes

ECHO with Doppler, Reason: Heart Failure, Read by:______

DC ECHO with Doppler, not indicated due to known EF ____% (MUST DOCUMENT)

Draw ABGs if 3 liters or more O2 needed to maintain saturation greater than 90%

11. Sleep Apnea Orders (form #21266), IFOSA screenis positive for suspected orreported sleep apnea

12. O2 per Protocol (form # 34431)

13. Vital signs q 4 hrs (per unit routine in critical care areas)

14. Orthostatic vital signs: Once before discharge q AM Other:______

15. Strict intake and output

16.  Foley catheter

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

18. Weigh on admission and daily thereafter

19. Activity (advance as tolerated):  Bedrest BRP  Up ad lib Ambulate in room

 Dangle Chair May shower Ambulate in hall

20. Smoking Cessation Counseling/Advice if patient smokes or smoked in the past year

21. PT/OT Protocol (form #32655) IF patient has a substantial decrease from base line function (that is unlikely to resolve within 48 hours), or needs placement and disposition

22. Diet:  Cardiac  Renal  Diabetic  ______ml/24 hr fluid restriction Other:______

23. Oral Nutrition Supplement Protocol (form # 31417), initiate if patient meets criteria

24. INT

Copy to pharmacy Order writer’s initials______

*3-14930*FORM 3-14930 REV. 06/2018 Page 1 of 5

PLACE LABEL HERE

HEART FAILURE

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).

25. Loop diuretic:

 Lasix (furosemide) ______mg IV q______

Bumex (bumetanide) ______mg IV q ______OR

Lasix (furosemide) Bolus (max 160 mg): 1mg/kg IV  1.5 mg/kg IVfollowed byIV infusion:

Lasix (furosemide) 20 mg/hr IV infusion (for decompensated acuteCHF/Pulmonary edema)

ICUonlywith titration:  Potassium level q 6 hrs while on Lasix (furosemide) infusion

26. Vasodilator:

 Nitroglycerin10 mcg/min IV, and

ICU: titrateup to 100 mcg/min for chest pain

CardiacTelemetry, PCU/ IMCU: titrate up to 50 mcg/min for chest pain

Medical Telemetry(GMC-D): titrate up to 20mcg/min for chest pain

Natrecor (nesiritide), physician to complete separate order (form # 19962)

27. Inotrope:

 Dobutrex (doBUTAmine)

ICU: see Titration Protocol, form # 33883, max 40 mcg/kg/min

IMCU, PCU, 5N, 6S:______mcg/kg/min IV (max 10 mcg/kg/min, no titration)

Medical Telemetry (GMC-D): ______mcg/kg/min IV (max 5 mcg/kg/min, no titration)

 DOPAmine

ICU: see Titration Protocol, form # 33883, max 50 mcg/kg/min

IMCU, PCU, 5N, 6S, Medical Telemetry (GMC-D) ______mcg/kg/min IV (max 5 mcg/kg/min, no titration)

 Primacor (milrinone)

ICU: see Titration Protocol, form # 33883, max 0.75 mcg/kg/min

IMCU, PCU, 5N, 6S, Medical Telemetry (GMC-D) ______(max 0.75 mcg/kg/min, no titration)

28. Beta Blocker:

Coreg (carvedilol) ______mg po twice daily. Hold for SBP < 90 or HR < 60

 Toprol XL (metoprolol succinate) ______mg po daily. Hold for SBP < 90 or HR < 60

Zebeta (bisoprolol) ______mg po daily. Hold for SBP < 90 or HR < 60

Contraindication to Beta Blocker:

Allergy COPD Hypotension Bradycardia  2nd or 3rd degree heart block Other: ______

29. Angiotensin Converting Enzyme Inhibitor (ACEI):_____EF%, if EF< 40%, must have ACEI/ ARB or

ARNI unless contraindicated

None needed, EF > 40%

Contraindication to ACEI:

Allergy Hyperkalemia Hypotension  Worsening renal function Other: ______

OR

Vasotec (enalapril) 1.25 mg IV q 6 hrs (Hold if systolic BP < 90)

Prinivil (lisinopril) ____ mg po daily (Hold if systolic BP < 90)

Other: ______(Hold if systolic BP < 90)

I have confirmed that an ACEI/ Angiotensin Receptor Blocker (ARB) or Angiotensin-Receptor/ Neprilysin Inhibitor (ARNI) is a current medication order.

OR

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).

30. Angiotensin Receptor Blocker (ARB):___EF%, if EF< 40%, must have ACE/ ARB or ARNI unless

contraindicated

None needed, EF > 40%

Contraindication to Angiotensin Receptor Blocker:

Allergy Hyperkalemia Hypotension  Worsening renal function Other: ______

OR

 Cozaar (losartan) ____ mg po daily (Hold if systolic BP < 90)

Other: ______(Hold if systolic BP < 90)

I have confirmed that an ARB/ACEI or ARNI is a current mediction order.

OR

31. Angiotensin- Receptor /Neprilysin Inhibitor (ARNI): ___EF%,ifEF< 40%, must have ACE / ARB or ARNI unless contraindicated

None needed, EF > 40%

Contraindication to Angiotensin Receptor/ Neprilysin Inhibitor:

Allergy Hyperkalemia Hypotension  Worsening renal function Other: ______

OR

 Entresto (sacubitril/valsartan) 24/26 mg 49/51 mg 97/103 mgpo twice daily (Hold if systolic BP < 90)

Concomitant use of an ACE inhibitor is contraindicated; allow a 36-hour washout period when switching from or to an ACE inhibitor.

If washout period required start Entresto on Date:______Time:______

I have confirmed that an ARNI or ACEI/ARB is a current medication order.

32. Aldosterone Antagonist (Indicated if EF< or = 35% unless contraindicated)

Aldactone (spironolactone) _____ mg po daily or ______Hold for K+ > 5.0

 Other:______

Contraindication to Aldosterone Antagonist:

Allergy Impaired renal function Hypotension  Hyperkalemia Other: ______

33. Hydralazine and Isosorbide Dinitrate for African American Patients with EF <40%:

 BiDil (Isosorbide Dinitrate 20 mg & Hydralazine 37.5 mg), 1 tablet po tid

 Other:______

Contraindication to Hydralazine and Isosorbide Dinitrate:

Allergy/Sensitivity Hypotension Other: ______

34. Aspirin 325 mg po x 1 dose if aspirin not already ordered.

35. Anticoagulation:

Coumadin (warfarin) ______mg po daily

Pradaxa (dabigatran) 150 mg po bid, if CrCl 11-30, use 75 mg po bid

Eliquis (apixaban) 5 mg po bid, if CrCl 15-50 and 2 of the following: Age > 80, Weight ≤ 60 kg, SCr ≥ 1.5, use 2.5 mg po bid

Xarelto (rivaroxaban) 20 mg po q day, if CrCl 15-50, use 15 mg po q day.

Other: ______

OR Contraindication to anticoagulant

Active bleeding/High risk for bleeding CVA Planned Surgery Pt/family refusal Other: ______

Heparin Infusion Protocol, LOW Intensity (form# 39815)

Lovenox (enoxaparin) 1 mg/kg SQ q 12 hrs (refer to Lovenox Dosing Rounding Chart below)

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).

Dose Rounding for 1 mg/kg,
if patient weighs: / Give
Lovenox (enoxaparin)
< 50 kg / 40 mg q 12 hrs
50-69 kg / 60 mg q 12 hrs
70-89 kg / 80 mg q 12 hrs
90-109 kg / 100 mg q 12 hrs
110-129 kg / 120 mg q 12 hrs
130-144 kg / 140 mg q 12 hrs
145-154 kg / 150 mg q 12 hrs
155-169 kg / 160 mg q 12 hrs
170 kg / 180 mg q12 hrs (maximum dose)

36. 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: SCDs

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

37. Chest pain: Nitroglycerin 0.4 mg sublingual q 5 min x 3 doses prn

38. Electrolyte Replacement Protocol (form # 21340)

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

40. Moderate Pain:

Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 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.

41.Severe Pain or Chest pain unrelieved with 3 doses of SL or max IV Nitroglycerin

Morphine 2 mg IV q 5 min prn (up to a max of 10 mg in 2 hrs), Hold for excessive sedation.

DC if CrCl < 30. DC if Dilaudid ordered.

or  Dilaudid (HYDROmorphone) 0.25-0.5 mg IV q 15 min prn (max 2 mg in 30 min).

If CrCl < 30, dose at 0.25 mg). Hold for excessive sedation. DC if Morphine ordered.

42. 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)

43. Sleep: Melantonin 5 mg po q HS prn

orAmbien (zolpidem)5 mg (female or males ≥ 65 y/o) or 5-10mg (male < 65 y/o) po at HS prn

Copy to pharmacy Order writer’s initials______

FORM 3-14930 REV. 06/2018 Page 1 of 5

PLACE LABEL HERE

HEART FAILURE

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 (continued)

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

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

46. 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

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

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

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-14930 REV. 06/2018 Page 1 of 5