UCLA MEDICAL CENTER
DOCTOR’S ADMISSION ORDERS
Patient Addressograph
HEART FAILURE ADMISSION ORDERS
1. DATE AND TIME ORDERS
2. CHECK ALL APPROPRIATE ORDERS.
PAGE 1 of 2
INTERN: __________________ PAGER: ________ RESIDENT: _________________ PAGER: ______
ATTENDING PHYSICIAN: __________________ PAGER: _________
Etiology: _____________ NHYA Class: _____________ LVEF (if known): _____________________
DATE:
TIME:
Diagnosis:
CONDITION
VITAL SIGNS
ALLERGIES
ACTIVITY
DIET
IV’S
I/O and WEIGHT
FOLEY
MONITORING
RESPIRATORY
LABORATORY
TESTS
ORDER:
Admit to
 CCU
 Telemetry ____  General Med ____ SERVICE:
 Good  Fair  Guarded
 Per Unit Routine  Other: ____________________________________________
 Call HO for a SBP > 150 SBP < 80 mmHg, HR > 100, HR < 50 RR > 24 or RR < 8.
 NKDA  Allergy:
 Bed rest
 Bed rest with commode privileges
 Out of bed with assistance
 Ambulation
 Physical Therapy Consultation
 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 Diet with _____ cc PO fluid restriction
 Other: _________________________________________________________
 Heplock with 3ml normal saline flush q 12 hours (document on flow sheet 0800H and 2000H)
 Other: ___________________________________
 Strict recording of Ins and Outs
 Daily weights
 If patient is unable to void, place Foley catheter.
 Cardiac monitoring
 Pulse oximetry
PLEASE COMPLETE RESPIRATORY THERAPY FORM
Now
 CBC with differential and platelets
 Electrolytes, BUN, Creatinine, Glucose  Mg  Ca  PO4  Uric Acid
 CPK total and MB NOW and Q8 hours x 3
 Cardiac troponin NOW and 6 hours
 PT/INR and  PTT
 BNP (if indicated)
 Liver function tests (if indicated) ______________________________________________
 Cardiovascular lipid panel (nonfasting)
 Digoxin level (if patient receiving digoxin)
 Thyroid Function Tests _____________________________________________________
 Others:__________________________________________________________________
In AM
 Electrolytes, BUN, Creatinine  Glucose  Mg  Ca  PO4  Uric Acid
 CBC with differential and platelets  PT/INR  PTT
 BNP (if indicated)
 Others: _________________________________________________________________
 EKG–PLEASE COMPLETE REQUISITION
 Chest X-ray (PA and lateral) PLEASE COMPLETE REQUISITION
 Echocardiogram – if not performed in prior 12 months or prior EF cannot be documented
PLEASE COMPLETE REQUISITION
MD Signature: ___________________________________
UCLA MEDICAL CENTER
DOCTOR’S ADMISSION ORDERS
Patient Addressograph
HEART FAILURE ADMISSION ORDERS (cont)
MEDICATIONS
(Class I Indicated
in Bold)
1. DATE AND TIME ORDERS
2. CHECK ALL APPROPRIATE ORDERS.
PAGE 2 of 2
IV Medications
Diuretics


Furosemide ______ mg IVP x 1 and/or by  continuous IV infusion at _______ mg/hr
Other ________________________________________ (Consider using diuretic protocol)
Intravenous Vasodilators/Natriuretic Peptides

Nesiritide _______mcg (2 mcg/Kg) IV bolus x1 and then continuous IV infusion at
0.01mcg/kg/min (hold for SBP < 80) (only adult monitored bed, follow monitoring protocol)
Potassium Chloride
 Potassium Chloride ___ mEq IVPB in _____ D5W IVPB over ___ hrs X 1
 Potassium Chloride ___ mEq tabs PO x 1
 Potassium Chloride ___ mEq elixir PO x1
 Magnesium Sulfate ___ mEq in ______ D5W over_________hrs X 1
Oral Medications
 ACE Inhibitor: ____________ ___ mg PO ______ (hold for SBP < 80, notify HO)
 Beta Blocker: ____________ ___ mg PO ______ (hold for SBP < 80 or HR < 45, notify HO)
(should not be newly initiated for HF until patient is stable and no longer significantly volume
overloaded, continue current dose unless shock) (start with low HF doses for initiation)
 Spironolactone: ______ mg PO qd. (use with caution if Cr > 2.5, contraindicated if
hyperkalemia; use very low doses, closely monitor renal function and K+)
 Digoxin ___________________mg PO ____ (keep level < 1.1 ng/ml)
 Nitrate _______________ ____ mg PO ______ (hold for SBP < 80)
 Enteric Coated Aspirin ____ mg PO QD (if CAD, CVD, PVD, Diabetes)
 Clopidogrel 75 mg PO QD (if indicated)
 Statin: ________________ ____ mg PO ______ (if CAD, CVD, PVD, Diabetes)
 Warfarin _______mg PO _____ (if paroxysmal or chronic afib, LV thrombus, or heart valve)
 Docusate (Colace) 100mg PO BID
 _____________________________________  _________________________________
 _____________________________________  _________________________________
 _____________________________________  _________________________________
 _____________________________________  _________________________________
 _____________________________________  _________________________________
 _____________________________________  _________________________________
DVT Prophylaxis or Anticoagulation
 Heparin 5000 units SQ bid  IV Heparin Protocol
 Enoxaparin 40 mg SQ qd (reserve for pts at increased risk of bleeding, caution in renal failure)
 Intermittent compression stockings  Elastic Stockings (thigh high)
PROTOCOLS
PRN Medications
 Acetaminophen 650 mg PO Q 4H prn pain, HA or fever T > 38.5.
 Lorazepam (Ativan) ____ mg PO Q8 prn for anxiety.
 Mylanta II 15 ml PO Q6 hrs prn dyspepsia or GI upset.
 Temazepam 15 mg PO Q hs prn insomnia. May repeat x 1 prn.
 _____________________________________________________________________
 Provide and Document HF Instructions for 1) diet, fluid restriction, 2) activity, 3) medications,
4) daily weight, 5) worsening symptoms, and 6) follow-up.
 Provide and Document “HF Patient Education”: print out from web and give to patient/family
 Nutrition Consultation and Counseling
Smoking Status  current or past 1 year  former  nonsmoker  unknown
 Smoking Cessation Counseling and Patient Education Materials
 Cardiac Rehabilitation Assessment and Referral
MD Signature: _______________________Pager ___________
Date/Time:______________________________________