Admit Heart Failure Plan - Begin Immediately

Admit Heart Failure Plan - Begin Immediately Diagnosis Weight PHYSICIAN S Allergies Admit/Discharge/Transfer Patient Status Requested Location: CICU, Pt Status: Observation (LOS < 2 midnights) Requested Location: Floor, Pt Status: Observation (LOS < 2 midnights) Patient Condition Acuity Level Floor Status Acuity Level Critical Acuity Level Intermediate Continuous Telemetry (Intermediate Care) Intermittent Telemetry Communication Code Status Code Status: Full Code Code Status: DNR/AND (Allow Natural Death) Code Status: Care Limitation Notify Provider/Primary Team of Pt Admit In AM Upon Arrival to Unit Now Order Taken by Signature: Page: 1 Admit Heart Failure Plan Version: 5 Effective on: 04/27/16 Page 1 of 13

PHYSICIAN S Patient Care Vital Signs Per Unit Standards Daily Weight Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest Bedrest Bathroom Privileges Bedrest Up to Bedside Commode Only Ambulate Patient Ambulate in Room Ambulate in Hallway Strict Intake and Output (Strict I & O) Per Unit Standards Fluid Restriction Amount to Restrict: 1000 ml per 24 hours Amount to Restrict: 1200 ml per 24 hours Communication Notify Nurse (DO NOT USE FOR MEDS) Provide the patient with the UMC Congestive Heart Failure Discharge Instruction Sheet and have the patient watch the Heart Failure education on TV channel 56 for English or 58 for Spanish Dietary Oral Diet 2 g Sodium Diet AHA Diet Regular Diet ADA Diet 1800 Calories, AHA 1600 Calories, AHA 1800 Calories 1600 Calories NPO Diet NPO NPO, Except Meds T;2359, NPO After Midnight T;2359, NPO After Midnight, Except Meds IV Solutions 1/2 NS IV, 75 ml/hr IV, 125 ml/hr IV, 150 ml/hr IV, 200 ml/hr D5 1/2 NS IV, 75 ml/hr IV, 125 ml/hr IV, 150 ml/hr IV, 200 ml/hr Order Taken by Signature: Page: 2 Admit Heart Failure Plan Version: 5 Effective on: 04/27/16 Page 2 of 13

PHYSICIAN S D5NS IV, 75 ml/hr IV, 125 ml/hr IV, 175 ml/hr IV, 200 ml/hr NS (Normal Saline) IV, 75 ml/hr IV, 125 ml/hr IV, 150 ml/hr IV, 200 ml/hr Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. digoxin 125 mcg, PO, tab, Daily 250 mcg, PO, tab, Daily 500 mcg, IVPush, inj, ONE TIME Loading Dose 500 mcg, PO, tab, ONE TIME Loading Dose potassium chloride 20 meq, PO, tab sa, Daily 40 meq, PO, tab sa, Daily magnesium chloride 535 mg, PO, tab, Daily, [elemental magnesium 64 mg] magnesium sulfate 1 g, IVPB, ivpb, ONE TIME, Infuse over 30 min 2 g, IVPB, ivpb, ONE TIME, Infuse over 60 min 1 g, IVPB, ivpb, as needed, PRN other, Infuse over 30 min For low magnesium level 2 g, IVPB, ivpb, as needed, PRN other, Infuse over 30 min For low magnesium level spironolactone 25 mg, PO, tab, Daily isosorbide mononitrate 20 mg, PO, tab, Daily Diuretics furosemide 40 mg, IVPush, inj, BID 40 mg, IVPush, inj, TID 40 mg, IVPush, inj, Daily 40 mg, PO, tab, Daily 40 mg, PO, tab, BID bumetanide 0.25 mg, PO, tab, BID 0.5 mg, PO, tab, BID 1 mg, PO, tab, BID metolazone 5 mg, PO, Daily 2.5 mg, PO, Daily Ace Inhibitors If Ejection Fraction less than 40%, give Ace Inhibitor or ARB per Core Measures. If Ace Inhibitor or ARB not given, choose the Contraindications Order below and Complete Order Taken by Signature: Page: 3 Admit Heart Failure Plan Version: 5 Effective on: 04/27/16 Page 3 of 13

PHYSICIAN S Contraindications ACEI or ARB Allergy to Both Allergy to One-Must Try the Other Angioedema Caused by an ACE or ARB Hyperkalemia Hypotension Moderate or Severe Aortic Stenosis Renal Artery Stenosis Worsening Renal Function Other (specify below in other reason) candesartan 4 mg, PO, tab, Daily 8 mg, PO, tab, Daily 16 mg, PO, tab, Daily 32 mg, PO, tab, Daily valsartan 40 mg, PO, tab, BID Beta Blockers Must be given per Core Measures. If not given, choose the Contraindications Order below and Complete Contraindications Beta Blocker Allergy or Sensitivity Bradycardia or Heart Block Chronic Lung Disease -- Asthma Severe Hypotension Other (specify below in other reason) atenolol 12.5 mg, PO, tab, Daily 12.5 mg, PO, tab, BID 25 mg, PO, tab, Daily 25 mg, PO, tab, BID 50 mg, PO, tab, Daily 50 mg, PO, tab, BID 100 mg, PO, tab, Daily 100 mg, PO, tab, BID metoprolol (metoprolol succinate extended release) 12.5 mg, PO, tab sa, Daily 25 mg, PO, tab sa, Daily 50 mg, PO, tab sa, Daily 100 mg, PO, tab sa, Daily carvedilol 3.125 mg, PO, tab, BID Administer with breakfast and dinner. 6.25 mg, PO, tab, BID Administer with breakfast and dinner. 12.5 mg, PO, tab, BID Administer with breakfast and dinner. 25 mg, PO, tab, BID Administer with breakfast and dinner. Anti Platelets Must be given within 24 hours of arrival per Core Measures. If not given, choose the Contraindications Order below and Complete Order Taken by Signature: Page: 5 Admit Heart Failure Plan Version: 5 Effective on: 04/27/16 Page 5 of 13

PHYSICIAN S Contraindications Aspirin Allergy Coumadin or Pradaxa Already Prescribed History of GI Bleed Positive Occult Blood in Stool Other (specify below in other reason) aspirin 81 mg, PO, tab chew, Daily 325 mg, PO, tab, Daily clopidogrel 300 mg, PO, tab, ONE TIME 600 mg, PO, tab, ONE TIME clopidogrel 75 mg, PO, tab, Daily, Daily Maintenance Dose Statins atorvastatin 10 mg, PO, tab, Nightly 20 mg, PO, tab, Nightly 40 mg, PO, tab, Nightly 80 mg, PO, tab, Nightly rosuvastatin 5 mg, PO, tab, Nightly 10 mg, PO, tab, Nightly 20 mg, PO, tab, Nightly 40 mg, PO, tab, Nightly simvastatin 5 mg, PO, tab, Nightly 10 mg, PO, tab, Nightly 20 mg, PO, tab, Nightly 40 mg, PO, tab, Nightly 80 mg, PO, tab, Nightly Laboratory CBC with Differential Prothrombin Time with INR PTT Comprehensive Metabolic Panel Basic Metabolic Panel Magnesium Level Phosphorus Level CK Routine, T;N Routine, T;N, q8h for 2 times Order Taken by Signature: Page: 6 Admit Heart Failure Plan Version: 5 Effective on: 04/27/16 Page 6 of 13

PHYSICIAN S Troponin T Routine, T;N Routine, T;N, q8h for 2 times Brain Natriuretic Peptide (probnp) Lipid with Cardiac Risk and LDL Direct Digoxin Level TSH Urinalysis Diagnostic Tests DX Chest Portable Routine, CHF (congestive heart failure) Routine, CHF (congestive heart failure), In AM for 2 days DX Chest PA & Lateral Routine, CHF (congestive heart failure) EKG-12 Lead T;N, Routine, Congestive Heart Failure (428.0) Routine, Congestive Heart Failure (428.0), Every AM for 2 days, Perform EKG PRN for Chest Pain appropriately Chest MUST be marked Respiratory Respiratory Care Plan Guidelines Oxygen Therapy Via: Nasal cannula, Keep sats greater than: 91% IS Instruct Consults/Referrals Consult Cardiac Rehab Cardiac Rehab for Inpatient Phase I evaluation and treatment. Arrange Outpatient Cardiac Rehab Phase II evaluation and treatment. Consult MD Service: Cardiology Consult Palliative Care Reason: Other : Hospice services Consult Dietitian for Diet Education Social Services for Assessment and Eval Social Services for Home Health Care Other Home Care Service, Further Heart Failure education for medications, diet and symptom managment Social Services for Hospice...Additional Orders Order Taken by Signature: Page: 7 Admit Heart Failure Plan Version: 5 Effective on: 04/27/16 Page 7 of 13

PHYSICIAN S Order Taken by Signature: Page: 8 Admit Heart Failure Plan Version: 5 Effective on: 04/27/16 Page 8 of 13

- Discomfort Med Plan PHYSICIAN S Patient Care Perform Bladder Scan Scan PRN, If more than 250, Then: Call MD, Perform as needed for patients complaining of urinary discomfort and/or bladder distention present OR 6 hrs post Foley removal and patient has not voided. Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. phenol topical (Cepastat) 1 lozenge, PO, lozenge, q4h, PRN sore throat Do not exceed 6 lozenges in 24 hours dextromethorphan-guaifenesin (dextromethorphan-guaifenesin 20 mg-200 mg/10 ml oral liquid) 10 ml, PO, liq, q4h, PRN cough dexamethasone-diphenhydramin-nystatin-ns (Fred s Brew) 15 ml, swish & spit, liq, q2h, PRN mucositis While awake lidocaine topical (Lidocaine Viscous 2% mucous membrane solution) 15 ml, swish & spit, liq, q4h, PRN mucositis Analgesics acetaminophen 500 mg, PO, tab, q6h, PRN pain-mild (scale 1-3) *****IF acetaminophen ineffective/contraindicated, USE ibuprofen if ordered:***** 1,000 mg, PO, tab, q4h, PRN pain-mild (scale 1-3) *****IF acetaminophen ineffective/contraindicated, USE ibuprofen if ordered:***** acetaminophen 650 mg, rectally, supp, q4h, PRN pain-mild (scale 1-3) *****If acetaminophen ineffective/contraindicated, USE ibuprofen if ordered:***** ibuprofen 400 mg, PO, tab, q6h, PRN pain-mild (scale 1-3) ***Do not exceed 3,200 mg of ibuprofen from all sources in 24 hours*** Give with food. Use if acetaminophen ineffective or contraindicated. HYDROcodone-acetaminophen (HYDROcodone-acetaminophen 5 mg-325 mg oral tablet) 1 tab, PO, tab, q4h, PRN pain-moderate (scale 4-7) *****IF HYDROcodone-acetaminophen ineffective/contraindicated or NPO, USE ketorolac if ordered***** 2 tab, PO, tab, q4h, PRN pain-moderate (scale 4-7) *****IF HYDROcodone-acetaminophen ineffective/contraindicated or NPO, USE ketorolac if ordered***** Order Taken by Signature: Page: 9 Admit Heart Failure Plan Version: 5 Effective on: 04/27/16 Page 9 of 13

- Discomfort Med Plan PHYSICIAN S acetaminophen-codeine (acetaminophen-codeine #3) 1 tab, PO, q4h, PRN pain-moderate (scale 4-7) *****IF acetaminophen-codeine #3 ineffective/contraindicated or NPO, USE ketorolac if ordered***** 2 tab, PO, q4h, PRN pain-moderate (scale 4-7) *****IF acetaminophen-codeine #3 ineffective/contraindicated or NPO, USE ketorolac if ordered***** ketorolac 15 mg, IVPush, inj, q6h, PRN pain-moderate (scale 4-7), x 48 hr ***May give IM if no IV access*** Use if HYDROcodone-acetaminophen ineffective or contraindicated. 30 mg, IVPush, inj, q6h, PRN pain-moderate (scale 4-7), x 48 hr ***May give IM if no IV access*** Use if HYDROcodone-acetaminophen ineffective or contraindicated. morphine 2 mg, IVPush, inj, q4h, PRN pain-severe (scale 8-10) ***Slow IV Push*** *****IF morphine is ineffective/contraindicated, USE HYDROmorphone if ordered***** 4 mg, IVPush, inj, q4h, PRN pain-severe (scale 8-10) ***Slow IV Push*** *****IF morphine is ineffective/contraindicated, USE HYDROmorphone if ordered***** HYDROmorphone 1 mg, IVPush, inj, q4h, PRN pain-severe (scale 8-10) ***Slow IV Push*** Use if morphine ineffective or contraindicated. Antiemetics promethazine 25 mg, PO, tab, q4h, PRN nausea/vomiting *****IF promethazine is ineffective/contraindicated or patient is NPO, USE ondansetron if ordered***** ondansetron 4 mg, IVPush, soln, q8h, PRN nausea/vomiting Use if promethazine ineffective or contraindicated. Gastrointestinal Agents docusate 100 mg, PO, cap, Nightly, PRN constipation *****IF docusate is contraindicated or ineffective after 12 hours, USE bisacodyl if ordered***** bisacodyl 10 mg, rectally, supp, Daily, PRN constipation *****IF bisacodyl is contraindicated or ineffective after 6 hours, USE Fleet Enema if ordered***** Order Taken by Signature: Page: 10 Admit Heart Failure Plan Version: 5 Effective on: 04/27/16 Page 10 of 13

- Discomfort Med Plan PHYSICIAN S sodium biphosphate-sodium phosphate (Fleet Enema) 132 ml, rectally, enema, Daily, PRN constipation loperamide 4 mg, PO, cap, ONE TIME, PRN diarrhea Initial dose after first loose stool 4 mg, PO, liq, ONE TIME, PRN diarrhea Initial dose after first loose stool loperamide 2 mg, PO, cap, as needed, PRN diarrhea 2 mg after each loose stool, up to 16 mg per day 2 mg, PO, liq, as needed, PRN diarrhea 2 mg after each loose stool, up to 16 mg per day Antacids Al hydroxide-mg hydroxide-simethicone (aluminum hydroxide-magnesium hydroxide-simethicone 200 mg-200 mg-20 mg/5 ml oral suspension) 30 ml, PO, susp, q4h, PRN indigestion Administer 1 hour before meals and nightly. simethicone 80 mg, PO, tab chew, q4h, PRN gas 160 mg, PO, tab chew, q4h, PRN gas Sedatives ALPRAZolam 0.25 mg, PO, tab, TID, PRN anxiety *****IF ALPRAZolam is ineffective/contraindicated or patient is NPO, USE LORazepam if ordered***** LORazepam 1 mg, IVPush, inj, q6h, PRN anxiety 0.5 mg, IVPush, inj, q6h, PRN anxiety zolpidem 5 mg, PO, tab, Nightly, PRN insomnia may repeat x1 in one hour if ineffective Antihistamines diphenhydramine 25 mg, PO, cap, q4h, PRN itching *****IF diphenhydramine PO is ineffective or patient is NPO, USE diphenhydramine inj if ordered***** diphenhydramine 25 mg, IVPush, inj, q4h, PRN itching Use if oral dose is ineffective or patient is NPO Anti-pyretics Order Taken by Signature: Page: 11 Admit Heart Failure Plan Version: 5 Effective on: 04/27/16 Page 11 of 13

- Discomfort Med Plan PHYSICIAN S acetaminophen 500 mg, PO, tab, q4h, PRN fever *****IF acetaminophen is ineffective/contraindicated, USE ibuprofen if ordered***** 1,000 mg, PO, tab, q4h, PRN fever *****IF acetaminophen is ineffective/contraindicated, USE ibuprofen if ordered***** ibuprofen 200 mg, PO, tab, q4h, PRN fever Do not exceed 3,200 mg in 24 hours. Give with food. Use if acetaminophen is ineffective or contraindicated. 400 mg, PO, tab, q4h, PRN fever Do not exceed 3,200 mg in 24 hours. Give with food. Use if acetaminophen is ineffective or contraindicated. Anorectal Preparations witch hazel-glycerin topical (witch hazel-glycerin 50% topical pad) 1 app, topical, pad, as needed, PRN hemorrhoid care Wipe affected area *****IF witch hazel-glycerin or phenylephrine ointment ineffective/contraindicated, USE hydrocortisone-pramoxine foam if ordered***** phenylephrine topical (phenylephrine 0.25%-3% rectal ointment) 1 app, rectally, oint, q6h, PRN hemorrhoid care Apply to affected area *****IF witch hazel-glycerin or phenylephrine ointment ineffective/contraindicated, USE hydrocortisone-pramoxine foam if ordered***** hydrocortisone-pramoxine topical (hydrocortisone-pramoxine 1%-1% rectal foam) 1 app, rectally, foam, q8h, PRN hemorrhoid care apply to affected area Order Taken by Signature: Page: 12 Admit Heart Failure Plan Version: 5 Effective on: 04/27/16 Page 12 of 13

- VTE Prophylaxis Plan PHYSICIAN S Patient Care VTE Guidelines See Reference Text for Guidelines ***If VTE Pharmacologic Prophylaxis not given, choose the Contraindications for VTE below and complete reason contraindi cated*** Contraindications VTE Active/high risk for bleeding Treatment not indicated Patient or caregiver refused Other anticoagulant ordered Anticipated procedure within 24 hours Intolerance to all VTE chemoprophylaxis Apply Elastic Stockings Apply to: Bilateral Lower Extremities, Length: Knee High Apply to: Left Lower Extremity (LLE), Length: Knee High Apply to: Right Lower Extremity (RLE), Length: Knee High Apply to: Bilateral Lower Extremities, Length: Thigh High Apply to: Left Lower Extremity (LLE), Length: Thigh High Apply to: Right Lower Extremity (RLE), Length: Thigh High Apply Sequential Compression Device Apply to Bilateral Lower Extremities Apply to Left Lower Extremity (LLE) Apply to Right Lower Extremity (RLE) Apply Pedal Pump Apply to Bilateral Feet Apply to Left Foot Apply to Right Foot Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. ***Recommended Trauma Dose = 30 mg, subcut, q12h*** ***Recommended Dose for Morbidly Obese Patients = 40 mg, subcut, q12h*** enoxaparin 40 mg, subcut, syringe, q24h 30 mg, subcut, syringe, q12h 30 mg, subcut, syringe, q24h, For CrCl less than 30 ml/min 40 mg, subcut, syringe, q12h, For BMI greater than 39 heparin 5,000 units, subcut, inj, q12h 5,000 units, subcut, inj, q8h fondaparinux 2.5 mg, subcut, syringe, q24h rivaroxaban 10 mg, PO, tab, In PM 20 mg, PO, tab, In PM warfarin 5 mg, PO, tab, QPM aspirin 81 mg, PO, tab chew, Daily 325 mg, PO, tab, Daily Order Taken by Signature: Page: 13 Admit Heart Failure Plan Version: 5 Effective on: 04/27/16 Page 13 of 13