CHF Admission iForm

@@patient.name@@ (MRN @@patient.medical_record_number@@) - UNIT @@patient.unit@@
Please scroll down to see the complete orderset

INR:


Admission Status

Admission Status: Inpatient Bed Observation Bed
Attending:
Cardiologist:
Level of Care: Telemetry: may leave unit w/o tele Telemetry: may not leave unit w/o tele Medical / Surgical Unit ICU
Code Status: Full Code DNR

CHF Quality Indicators

Quality Indicators are required and are marked in blue boxes below.
  1. ACE Inhibitor or ARB should be prescribed at discharge for patients with systolic dysfunction and no contraindiation
  2. Provide discharge instruction for heart failures.
  3. Smoking cessation counseling at discharge.
  4. LV systolic function evaluation should be performed if LVEF is unknown

Nursing Orders

Required CHF Nursing Orders
Smoking Cessation Education (if indicated)
Discharge Instructions: Heart Failure
Vital Signs Per Shift
Insert Peripheral IV and Saline Lock
Weigh Patient on Admission and Daily
O2 via nasal cannula, maintain saturation >92%
Insert Urinary Catheter to Straight Drainage
Remove Urinary Catheter (if inserted in ED)
Strict Intake and Output

Diet Orders

1. Consistency
Regular / Normal
Clear Liquid
Full Liquid
Soft
NPO
2. Modifier
Diabetic 1800kcal
Low Fat
Low Cholesterol
Caffeine Free
Caffeine Restricted
3. Electrolyte and Fluid
2g Sodium (Low Salt)
3g Sodium (No Added Salt)
2g Potassium
3g Potassium
Fluid Restriction 1000mL
Fluid Restriction 1200mL
4. Other Restrictions
Kosher
Gluten Free
Lactose Free

Activity Orders

Activity
Out of Bed as Tolerated
Out of Bed with Assistance
Out of Bed to Chair with Assistance
Head of Bed
Elevate Head of Bed 30 to 45 degrees

CHF Medications

ACE Inhibitor and ARB
Name
Dose
Frequency
No ACE-I or ARB because:
Beta Blocker
Name
Dose
Frequency
No beta blocker because:
Diuretics
Name
Dose
Frequency
Spironolactone [Aldactone] 25 mg po daily
Spironolactone [Aldactone] 12.5 mg po daily
Metolazone [Zaroxolyn] 5 mg po daily
Other CHF Meds
Digoxin [Lanoxin] load 0.5 mg IV x1, then 0.25 mg IV q6h x2
Digoxin [Lanoxin] 0.125 mg IV daily at 2pm
Digoxin [Lanoxin] 0.25 mg po daily at 2pm
Digoxin [Lanoxin] 0.125 mg po daily at 2pm
Nitroglycerin SL [Nitrostat] 0.4 mg SL q5min prn
Nitroglycerin 2% oint [Nitrol] topical once STAT
Morphine Sulfate IV q2h prn
Antiplatelets
Aspirin 81 mg po daily
Aspirin 325 mg po daily
Clopidogrel [Plavix] 75 mg po daily
Statins
Atorvastatin [Lipitor] po at bedtime
Simvastatin [Zocor] mg po at bedtime
VTE Prophylaxis
Pharmacologic Prophylaxis
Lovenox 40mg subcut daily (for GFR≥30ml/min)
Lovenox 30mg subcut daily (for GFR<30ml/min)
Heparin 5000units subcut q12hr
None:
Already on pharmacologic prophylaxis
Mechanical Prophylaxis
Sequential Compression Device (SCD) to bilateral legs
None:
Already on mechanical prophylaxis

Common Medications [click to show]


Insulin Management [click to show]


Labs / Microbiology

Stat Labs
Acute Care Panel (ACP)
CBC with differential
Liver Function Test (LFT)
PTT
PT / INR
Cardiac Enzymes (at 0, 6, 12, 24hrs)
BNP
Digoxin Level
AM Labs
Acute Care Panel (ACP)
CBC with differential
Liver Function Test (LFT)
PTT
PT / INR
Lipid Panel
Vitamin B12 & Folate
Ferritin & Iron Panel
TSH and reflex free T4
Hemoglobin a1c
AM Labs (Recurring)
Acute Care Panel (ACP) x3 days
PT / INR x3 days
Microbiology
Blood Cultures x2
Urinalysis
Urine Culture

Radiology

Chest XR
Chest XR Portable, Today
Chest XR Portable, in AM
Chest XR PA and Lateral, Today
Chest XR PA and Lateral, in AM
EKG
EKG 12 Lead, Today
EKG 12 Lead, in AM
EKG 12 Lead, Daily in AM
Echocardiogram
Echocardiogram (TTE):
Cardiologist to read:
Comment to tech:
Reason for not ordering echo:
 

Interdisciplinary Consult

PT/OT Eval and Treat
Social Work Consult
Wound/Ostomy Care Consult
Diabetes Education Consult
Nutrition Consult
End of CHF iForm