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: _________________
5. Diagnostics on 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.
7.
8.
9.
10.
11.
12.
13.
Initiate Sleep Apnea Orders (form # 21266), if OSA screen is positive for suspected or reported sleep apnea
Vital Signs per unit routine OR  q _______ hrs
INT
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
Diet:
 NPO  Regular  Cardiac  Diabetic ________ calories
 Renal  No Added Salt
 Other: ________________________________
Activity:
 Bedrest  Bathroom privileges  Up ad lib  Fall Precautions
 
 Other: _________________________________
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.
Oral Nutrition Supplement Standing Order (form # 31417), initiate if patient meets criteria
Order writer’s initials _______
Copy to pharmacy
*3-16573*
3
FORM 3-16573 REV. 05/2015
Page 1 of
PLACE LABEL HERE
ACUTE EXACERBATION
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) / ASTHMA
ORDERS
14.  Dietitian to Assess and Manage: Reason: ___________________________________
15.  Diabetes Education consult:  Steroid induced hyperglycemia  Other:_________________________
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)
RESPIRATORY CARE
18.  O2 per Protocol (form # 34431)
19. Pulmonary Rehabilitation Evaluation
20. Smoking cessation program, if patient is a smoker
MEDICATIONS
21. Aerosol treatment:  Albuterol 2.5 mg q 4 hrs while awake and prn wheezing
 Albuterol 2.5 mg q 4 hrs around the clock and prn wheezing
 Atrovent (ipratropium) 0.5 mg q 4 hrs while awake. Do not order with Spiriva (tiotropium).
 Atrovent (ipratropium) 0.5 mg q 4 hrs around the clock. Do not order with Spiriva (tiotropium).
 Brovana (arformoterol) 15 mcg q 12 hrs

 Pulmicort (budesonide) 0.5 mg q 12 hrs

 Other: ______________________________________________________________
22. Metered Dose Inhalers (MDI):
 Combivent (albuterol/ipratropium): _______ puffs q ______ hrs
 Advair (salmeterol/fluticasone) HFA 2 puffs q 12 hrs:  45/21
 115/21  230/21
 Spiriva (tiotropium) 1 capsule inhalation q 24 hrs. D/C if Atrovent (iptatropium) or Combivent
(albuterol/ipratropium) is ordered.
 Flovent (fluticasone) q 12 hrs:  220 mcg ____ puffs  110 mcg ____ puffs  44 mcg ___ puffs

 Other: _____________________________________________________________
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
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)
Copy to pharmacy
FORM 3-16573 REV. 05/2015
Order writer’s initials _______
Page 2 of 3
PLACE LABEL HERE
ACUTE EXACERBATION
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) / ASTHMA
ORDERS
Mechanical devices  Sequential Compression Devices (SCDs)
Copy to pharmacy
FORM 3-16573 REV. 05/2015
Order writer’s initials _______
Page 2 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).
28. Stress ulcer prophylaxis:
 Oral: Pepcid (famotidine) 20 mg po bid daily

 IV: Pepcid (famotidine) 20 mg IV bid daily
or Proton Pump Inhibitor:  Oral: Prilosec (omeprazole) 40 mg po daily

 IV:
Protonix (pantoprazole) 40 mg IV daily
PRN MEDICATIONS (See policy 520-06 for range orders and pain intensity guidelines)
29.  Electrolyte Replacement Protocol (form # 21340)
30. Mild Pain, Temp >100.5F, HA:  Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
31. 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)
32. Sleep:
 Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn
33. Indigestion:
 Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
34. Stool Softener:
 Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
 Milk of Magnesia (MOM) 30 ml po daily prn
35. Constipation:
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
36. Cough:
 Robitussin (guaifenesin) 15 ml po q 4 hrs prn
37. Sore Throat:
 Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn
ADDITIONAL ORDERS:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
______________
Date
______________
Time
_________________________________
Physician Signature
___________
PID Number
Copy to pharmacy
FORM 3-16573 REV. 05/2015
Page 3 of 3