GREY BRUCE HEALTH NETWORK
ADDRESSOGRAPH
Page 1 of 4
SITE: _____________________
Allergies: □ NKA or: ________________________
Weight (kg) _______________
Processed
Chronic Obstructive Pulmonary Disease (COPD)
Order Set
Open Box indicates optional order, activated when checked .
 Checked box indicates mandatory order unless crossed out.
Admit to _________________: Dr. __________________
to consult or
assume MRP
Diagnosis: COPD:
with pneumonia __________________________________
Isolation:
Contact
Droplet
Airborne re: ____________
ARO Droplet/Contact
Comorbidities: a) ____________ b) _______________ c) _______________
________
________
________
________
________ Code Status:
________
Full Resuscitation
No CPR
Defibrillation only
No Defibrillation
No Intubation
Do Not Resuscitate
________ Family Physician: Same as MRP, or __________________________________
Clinical Pathway:  Cerner Order for COPD Pathway
Kardex
________
________
________
________
________
________
________
Consults
________
________
________
________
CCAC
Clinical Nutrition
Physiotherapy
Social Work
Discharge Planning
Occupational Therapy
Palliative Care Nurse
Pharmacy
Speech/Language Pathology
Respiratory Therapy (to teach regarding puffer use)
________
________
________
Regular Diet
________
Activity as Tolerated
___________________ Reason: __________________________
Diet
Regular Diet, NPO after 2400 hrs
May take meds with sips if NPO
NPO
Energy Controlled Diet ________kcal
Other Diet: ______________________________
Healthy Heart Diet
Activity
________
________
________
________
________
________
________
________
Ambulate within 8h and TID
Vital Signs
VS + O2 sats q4h x 24h, qid x24h then bid when stable
VS + O2 sats q4h
________
VS + O2 sats qshift
________
________
________
O2 to keep O2 sats greater than 92%
COPD Patient: O2 to keep O2 sats 88% - 92%
02 ________L/minute via NP
02 ________________________
VS + O2 sats q ________h
Respiratory
________
________
Patient Care
________ Direct Care:
________ Tubes/Drains:
 Height and Weight on admission
 Daily Weight
 Chart fluid intake and output x 24 h then reassess
Foley Catheter
NG tube suction
NG tube straight drain
Physician’s Signature __________________________Date ___________Time __________
C/1/GBHN/Med/-/COPD/MD/07-07/v1/-
Copyright © 2007 Grey Bruce Health Network
NOTE: this is a CONTROLLED document as are all files on this server. Any documents appearing in paper form are not
controlled and should ALWAYS be checked against the server file versions (electronic version) prior to use.
________
________
GREY BRUCE HEALTH NETWORK
ADDRESSOGRAPH
Page 2 of 4
SITE: _____________________
Allergies: □ NKA or: ________________________
Weight (kg) _______________
Chronic Obstructive Pulmonary Disease (COPD)
Order Set
Processed
________ POC:
POC Capillary Glucose QID x 2 days
POC Capillary Glucose daily
Kardex
________
Laboratory
(Order details blood and routine unless otherwise noted)
On admission (if not already done in ER):
________  CBC
APTT
INR
________
 Lytes, Creatinine, Glucose
ABG
CPK, Troponin
Calcium, Magnesium
________
ALT, ALP, Bili
AST
Culture Sputum
________
Culture Blood x 2 STAT
Urinalysis
Culture Urine
________ Additional Labs: ________________________________________________
Day 1 (first morning post admission):
________
CBC,
APTT
INR
________
Lytes, Creatinine
CPK, Troponin
Calcium, Magnesium
________
ALT, ALP, Bili
AST
________ Additional AM Labs: _____________________________________________
________
________
Additional Lab Tests:
CBC in AM on day two of admission
Lytes, Creatinine, Glucose in AM on day two of admission
Culture Blood x 2 if temp greater than or equal to 385 °C
________
________
________
________
________
________
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ABG if O2 sats less than 90%
________ Additional follow up labs: __________________________________________
________
Diagnostic Tests
________
________
________
________
________
 CXR PA and Lateral (next morning if after hours)
 ECG with chest pain and notify MD
ECG on admission
________
ECG Day 1
CT Scan ____________ Re: ____________________________________
Ultrasound __________Re: ____________________________________
2D echo Re: _______________________________
Doppler US to R/O DVT
_______________________________________________________
________
________
________
________
IV Solutions
________ Bolus IV: __________________________________________________
After Bolus IV finished:
NS
With 20 mmol KCl per L of IV fluid
________ IV Fluid:
2/3 1/3
________
Other ________________
With 40 mmol KCl per L of IV fluid
________
Rate ___________________ mL/h
 Decrease IV to TKVO when drinking well. Discontinue IV if Pt not on any IV medications.
Saline Lock
Physician’s Signature __________________________Date ___________Time __________
C/1/GBHN/Med/-/COPD/MD/07-07/v1/-
Copyright © 2007 Grey Bruce Health Network
NOTE: this is a CONTROLLED document as are all files on this server. Any documents appearing in paper form are not
controlled and should ALWAYS be checked against the server file versions (electronic version) prior to use.
________
________
________
________
GREY BRUCE HEALTH NETWORK
ADDRESSOGRAPH
Page 3 of 4
SITE: _____________________
Allergies: □ NKA or: ________________________
Weight (kg) _______________
Chronic Obstructive Pulmonary Disease (COPD)
Order Set
Processed
Kardex
Medications
Antibiotic Therapy: **Antibiotics are indicated when exacerbations of COPD are accompanied
by two of the following signs: increased dyspnea, increased sputum or increased sputum purulence**
________
**If the patient has been on antibiotic therapy in the last 3 months (regardless of clinical success), the
therapy chosen should be a regimen based on a different mechanism of action.**
Moxifloxacin 400 mg IV x 1 dose STAT, then
Moxifloxacin 400 mg PO daily x 10 days
________
________
**HDH Only**
Levofloxacin 500 mg IV x 1 dose STAT, then
Levofloxacin 500 mg PO daily x 10 days
________
________
________ Anticholinergic bronchodilators:
________
________
________
________
Azithromycin 500 mg PO on admission, then
Azithromycin 250 mg PO daily x 4 days
Ipratropium 40 mcg inhaled QID OR
Tiotropium 18 mcg inhaled once daily
________
________
5 mg inhaled Q4H
2.5 mg inhaled Q1H PRN
________
________
Short-acting β-agonist (SABA):
salBUTAMol
2.5 mg inhaled Q4H
200 mcg inhaled Q4H
________ Long-acting β-agonist (LABA):
________ Inhaled steroid:
200 mcg inhaled Q6H
5 mg inhaled Q1H PRN
salMETERol 50 mcg INH BID
Fluticasone 500 mcg inhaled BID
________
________
________ Other Bronchodilators: ___________________________________________________
________
________
________
Monitor response to treatment with peak expiratory flow bid
________ Steroid Therapy:
________
________
________
________
________
methylPREDNISolone 125 mg IV Q6H X 3 days then
predniSONE 50 mg PO daily X 10 days, discontinue with no taper
PRN Medication: **max Acetaminophen from all sources 4000 mg/24h**
Acetaminophen 650 mg
PO or
NG or
Rectally q4h PRN
Aluminum hydroxide/magnesium hydroxide oral suspension 30 mL PO q4h PRN
dimenhyDRINATE 25-50 mg
IV or
NG or
PO q4h PRN
Bowel Care Clinical Protocol
Adult Potassium Oral Dosing Clinical Protocol
________ Smoking Cessation:
________ Sedation:
________
Nicotine transdermal patch _____mg/day
Lorazepam 1 mg
PO or
sublingual qhs PRN, OR
Zopiclone 3.75-7.5 mg PO QHS PRN
Physician’s Signature __________________________Date ___________Time __________
C/1/GBHN/Med/-/COPD/MD/07-07/v1/-
Copyright © 2007 Grey Bruce Health Network
NOTE: this is a CONTROLLED document as are all files on this server. Any documents appearing in paper form are not
controlled and should ALWAYS be checked against the server file versions (electronic version) prior to use.
________
________
________
________
________
________
________
________
________
GREY BRUCE HEALTH NETWORK
ADDRESSOGRAPH
ADDRESSOGRAPH
Page 4 of 4
SITE: _____________________
Allergies: □ NKA or: ________________________
Weight (kg) _______________
Processed
Chronic Obstructive Pulmonary Disease (COPD)
Order Set
Kardex
Diabetes Management Protocols
________
 Hypoglycemia Clinical Protocol greater than or equal to 16 years
Adult Subcutaneous Insulin Order Set
________
DVT Prophylaxis Protocol
________
________
________
________
If Creatinine clearance is greater than 30 mL/min, consider (check with pharmacy to determine
calculated Creatinine clearance – Height, Weight and serum creatinine are required for this
calculation):
Enoxaparin 40 mg subcutaneous once daily.
Dalteparin 5000 units subcutaneous once daily (HDH only).
If Enoxaparin/Dalteparin ordered, then
 CBC, APTT, INR, Creatinine prior to initiating therapy if not already ordered
 CBC day 1, 3, 7, and 14 to monitor platelet count
 CBC weekly for patients on therapy greater than 14 days
If Creatinine clearance is less than 30 mL/min OR serum Creatinine greater than 150mmol/L,
consider:
Heparin 5000 units subcutaneous q12h. If Heparin ordered, then
 CBC, APTT, INR, Creatinine prior to initiating therapy if not already ordered
 CBC, day 1, 3, 7, and 14 to monitor platelet count
 CBC weekly for patients on therapy greater than 14 days
Anti-emboli Stockings:
Knee high
Thigh High
 Reassess DVT prophylaxis therapy when patient is ambulating and on day of discharge
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Physician’s Signature __________________________Date ___________Time __________
C/1/GBHN/Med/-/COPD/MD/07-07/v1/-
Copyright © 2007 Grey Bruce Health Network
NOTE: this is a CONTROLLED document as are all files on this server. Any documents appearing in paper form are not
controlled and should ALWAYS be checked against the server file versions (electronic version) prior to use.
________
________
________
________