Unique Plan Description: Heart Failure
Plan Selection Display: Heart Failure
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2020-04-20 15:08:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2023-04-18 09:25:59
Available at all facilities: Yes

Heart Failure
Vital Signs
	Vital Signs
		T;N, Routine
	BP and Pulse
		T;N, Once
		T;N, DAILY
Activity
	Activity-As Tolerated
		with assistance
	Up in Chair
		T;N, TIDWM
	Ambulate
		T;N, QID
	Oral Care
		BID
	Elevate head of bed
		T;N
			Comment: for meals
Diet
	Sodium Restricted Diet
		T;N, 2000 mg (2 gm) Sodium (Low Sodium)
	Fluid Restriction
		2000ml/per day
Diagnostic Tests
	Echo w Doppler resting
		Indication: Congestive heart failure
Medications
Diuretic
		Diuretic-Select only one of the following groupings(NOTE)*
		Select the following if home diuretic equal to furosemide 20mg daily(NOTE)*
	Lasix Injection
		40 mg, IV Push, Once
			Comment: administer over 2-3 minutes
		40 mg, IV Push, Once, T;N+360
			Comment: give if urine output 500-1000ml 6hr after first diuretic dose; administer over 2-3 min
		80 mg, IV Push, Once, T;N+360
			Comment: give if urine output <500 6hr after first diuretic dose; administer over 3-5 min
	Notify MD
		Urine Output <500ml 6 hr after initial diuretic dose
		Select the following if home diuretic equal to furosemide 40mg daily, torsemide 20mg daily(NOTE)*
	Lasix Injection
		100 mg, IV Push, Once
			Comment: administer over 2-3 minutes
		100 mg, IV Push, Once, T;N+360
			Comment: give if urine output 500-1000ml 6hr after first diuretic dose; administer over 3-5 min
		200 mg, IVPB, Once, T;N+360
			Comment: give if urine output <500 6hr after first diuretic dose; administer over 60 min
	Notify MD
		Urine Output <500ml 6 hr after initial diuretic dose
		Select the following if home diuretic  to furosemide >/=80mg daily, torsemide >/=40mg daily(NOTE)*
	Lasix Injection
		200 mg, IVPB, Once
			Comment: administer over 60 minutes
		200 mg, IVPB, Once, T;N+360
			Comment: give if urine output <1000 6hr after first diuretic dose; administer over 60 min
	Notify MD
		Urine Output <500ml 6 hr after initial diuretic dose
		Select the following if home diuretic equal to bumetanide 1mg daily(NOTE)*
	bumetanide
		2.5 mg, Injection, IV Push, Once
			Comment: administer over 3 minutes
		2.5 mg, Injection, IV Push, Once, T;N+360
			Comment: give if urine output 500-1000ml 6hr after first diuretic dose; administer over 3 min
		5 mg, Injection, IV Push, Once, T;N+360
			Comment: give if urine output < 500ml 6hr after first diuretic dose; administer over 5 min
	Notify MD
		Urine Output <500ml 6 hr after initial diuretic dose
Miscellaneous
	Entresto 24 mg-26 mg oral tablet
		1 TAB, Tab, By Mouth, BID
	Entresto 49 mg-51 mg oral tablet
		1 TAB, Tab, By Mouth, BID
	Entresto 97 mg-103 mg oral tablet
		1 TAB, Tab, By Mouth, BID
	nitroglycerin 50 mg/D5W 250 mL Premix IV
		50 mg, EVERY BAG, 5 mcg/min
		250 mL, IV, Routine, Start: T;N, Maintain Parameter Goal: SBP> 90, Increment Increase: 5 mcg/min, Increment Decrease: 5 mcg/min, Increment Freq: 5 min(s), Max Dose: 200 mcg/min
			Comment: If no response at 20mcg/min, may increase by 10mcg/min every 5 min.  If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached.  IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that maintained Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation.
	nitroglycerin
		0.4 mg, Tab, SUBLINGUAL, Q5MIN, PRN chest pain, duration: 3 Dose(s)/Time(s)
	nitroglycerin 2% topical ointment
		1 in, Packet, TOPICAL, Q6H
	DOBUTamine 1000mg/D5W 250mL
		1,000 mg, EVERY BAG, 2.5 mcg/kg/min
		250 mL, IV, Routine, Start: T;N, Increment Increase: 1 mcg/kg/min, Increment Decrease: 1 mcg/kg/min, Increment Freq: 10 min(s), Max Dose: 40 mcg/kg/min
			Comment: Concentration: 4000mcg/mL. .Notify MD if > 20mcg/kg/min.  If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached.  IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that maintained Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation.
	DOBUTamine 500 mg/D5W 250 mL
		250 mL, IV, Routine, Start: T;N, Increment Increase: 1 mcg/kg/min, Increment Decrease: 1 mcg/kg/min, Increment Freq: 10 min(s), Max Dose: 40 mcg/kg/min
			Comment: Concentration: 2000mcg/mL. .Notify MD if > 20mcg/kg/min.  If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached.  IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that maintained Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation.
		500 mg, EVERY BAG, 2.5 mcg/kg/min
	hydrALAZINE
		10 mg, Tab, By Mouth, TID
		10 mg, Tab, By Mouth, QID
		25 mg, Tab, By Mouth, TID
		25 mg, Tab, By Mouth, QID
		50 mg, Tab, By Mouth, TID
		50 mg, Tab, By Mouth, QID
	isosorbide dinitrate
		5 mg, Tab, By Mouth, TID
		5 mg, Tab, By Mouth, QID
		10 mg, Tab, By Mouth, TID
		10 mg, Tab, By Mouth, QID
		20 mg, Tab, By Mouth, TID
		20 mg, Tab, By Mouth, QID
		30 mg, Tab, By Mouth, TID
		30 mg, Tab, By Mouth, QID
		40 mg, Tab, By Mouth, TID
		Digoxin not indicated for Primary HF treament per ACC/AHA guidelines(NOTE)*
	digoxin
		0.125 mg, Tab, By Mouth, DAILY
		0.25 mg, Tab, By Mouth, DAILY
ACE
		Class A Level of Evidence if EF < 40%(NOTE)*
	Lotensin
		5 mg, Tab, By Mouth, DAILY
		5 mg, Tab, By Mouth, BID
		10 mg, Tab, By Mouth, DAILY
		10 mg, Tab, By Mouth, BID
		20 mg, Tab, By Mouth, DAILY
	Vasotec
		2.5 mg, Tab, By Mouth, BID
		5 mg, Tab, By Mouth, BID
		10 mg, Tab, By Mouth, BID
		20 mg, Tab, By Mouth, BID
	lisinopril
		2.5 mg, Tab, By Mouth, DAILY
		5 mg, Tab, By Mouth, DAILY
		10 mg, Tab, By Mouth, DAILY
		20 mg, Tab, By Mouth, DAILY
		30 mg, Tab, By Mouth, DAILY
		40 mg, Tab, By Mouth, DAILY
ARB
		Class A Level of Evidence if EF < 40%(NOTE)*
	Diovan
		40 mg, Tab, By Mouth, BID
		40 mg, Tab, By Mouth, DAILY
		80 mg, Tab, By Mouth, BID
		80 mg, Tab, By Mouth, DAILY
		160 mg, Tab, By Mouth, BID
		160 mg, Tab, By Mouth, DAILY
		320 mg, Tab, By Mouth, DAILY
	Cozaar
		12.5 mg, Tab, By Mouth, DAILY
		25 mg, Tab, By Mouth, DAILY
		50 mg, Tab, By Mouth, DAILY
		100 mg, Tab, By Mouth, DAILY
	valsartan
		80 mg, Tab, By Mouth, QHS
		160 mg, Tab, By Mouth, QHS
		320 mg, Tab, By Mouth, QHS
Beta Blocker
		Class A Level of Evidence if EF < 40%(NOTE)*
		For patients who are not already taking a beta blocker, UpToDate suggests that they NOT be initiated at the time of presentation with an episode of ADHF (Grade 2B). Beta blockers are generally started later than ACE inhibitors or ARBs, when the patient is(NOTE)*
	Toprol-XL
		12.5 mg, Tablet-Extended-Release, By Mouth, DAILY
		25 mg, Tablet-Extended-Release, By Mouth, DAILY
		50 mg, Tablet-Extended-Release, By Mouth, DAILY
		100 mg, Tablet-Extended-Release, By Mouth, DAILY
		200 mg, Tablet-Extended-Release, By Mouth, DAILY
	Coreg
		3.125 mg, Tab, By Mouth, BIDWM
		6.25 mg, Tab, By Mouth, BIDWM
		12.5 mg, Tab, By Mouth, BIDWM
		25 mg, Tab, By Mouth, BIDWM
	bisoprolol
		1.25 mg, Tab, By Mouth, DAILY
		2.5 mg, Tab, By Mouth, DAILY
		5 mg, Tab, By Mouth, DAILY
		10 mg, Tab, By Mouth, DAILY
Aldosterone Antagonist
	Aldactone
		12.5 mg, Tab, By Mouth, DAILY
		25 mg, Tab, By Mouth, DAILY
	Inspra
		12.5 mg, Tab, By Mouth, DAILY
		25 mg, Tab, By Mouth, DAILY
Potassium Supplement
	potassium chloride Oral
		20 mEq, Tablet-Extended-Release, By Mouth, Once
		20 mEq, Tablet-Extended-Release, By Mouth, Q6H, duration: 2 Dose(s)/Time(s)
		40 mEq, Tablet-Extended-Release, By Mouth, Once
		40 mEq, Tablet-Extended-Release, By Mouth, Q6H, duration: 2 Dose(s)/Time(s)
Patient Care

	Intake and Output
		Q6H-Sch, 24, hr
	Notify MD
		if any of the following: no improvement in dyspnea c/o dyspnea at rest pt cannot lay flat secondary to dyspnea.
		Urine Output <500ml in first 6 hours of admission
	Foley Catheter
		Insert, PRN, unable to void, If foley catheter needed, enter order for foley catheter insert, once, and select the appropriate criteria for insertion and then insert the foley catheter.
	Patient Education
		Instructions: Provide the "Heart Failure Zone Log" Calendar"
	VTE Advisor
		Medical
	Cardiac Telemetry Monitoring
		Telemetry Indications: Acute Decompensated HF
	Notify Health Care Provider
		T;N
Therapies
	Smoking Cessation Education
		
	Smoking Cessation Education RT (FH)
		
	Oxygen Therapy
		T;N, Titrate/wean to keep: > or = to 90%
	Pulse Oximetry Spot Check RT
		T;N, BID
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
Consults/Follow-up
	Consult Cardiologist
		Reason for Referral: CHF, Refer to/Consult with: Heart Consultants, No Provider Notified
	Meds2Beds
		T;N
			Comment: From Heart Failure Plan
	Consult Social Work
		Discharge Planning
			Comment: Regarding: assess for patient resources including medication barriers, food insecurities, and transportation to appointments
	Consult Dietitian
		Regarding: Nutrition Assessment
	Consult Cardiac Rehab: Inpatient
		Indications Heart Failure
	Consult Cardiac Rehab: Outpatient
		Indications Heart Failure
	Consult Palliative Care
		Reason for Referral: Regarding Advance Directive query for complex health management, Refer to/Consult with: Palliative care team, No Provider Notified
	Consult Care Navigator
		Education
	Consult APRN
		T;N, Consult Heart Failure Clinic APRN Call Heart Consultants at 402-391-5055 to schedule an appointment in the next 3-5 days.
		T;N, Consult Heart Failure NMH APRN 402-354-3938
	Consult Physical Therapy, Evaluate and Treat
		T;N, Reason to See: Evaluate and Treat

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase