Admission Orders for Asthma Patient Paper

Admission Orders for Asthma Patient Paper

Admission Orders Template

Primary Diagnosis: a 65-year-old female patient with atrial fibrillation shown on 12-lead EKG. Patient has a history of chronic hypertension.  Patient also has asthma. The patient is overweight with a BMI of 26.4. Patient is to be admitted to the cardiac telemetry unit for close monitoring of patient’s heart rate, rhythm, as well as other vital signs.

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Status/Condition: Stable condition

Code Status: Full code

Allergies: No known food or drug allergies

Admit to Unit: Admit to inpatient cardiac telemetry unit.

Activity Level:  Bedrest until heart rate is controlled. Ambulate as tolerated

Diet: Light diet. Heart healthy diet. Minimum or no added sodium. Nurse can advise on a full cardiac diet as tolerated by the patient.

IV Fluids: 100 ml/hour Normal Saline to hydrate the patient and maintain IV access. Administer 1 liter after which a reevaluation is done to determine if patient needs more IV fluids.

  • Critical Drips: Metoprolol IV bolus 2.5mg to 5mg bolus infused over 2 minutes. Recheck heart rate after 15 minutes and if >100 bpm, repeat bolus up to a total of 15mg at 5-minute intervals. Convert to Metoprolol PO if the patient converts to sinus rhythm (Low et al., 2019)

Respiratory: Continuous pulse oximetry monitoring. Keep oxygen level above 92% (Matuskowitz et al., 2018). May start 2L oxygen on nasal cannula and titrate for comfort. If patient becomes short of breath, start patient on supplemental oxygen without respiratory therapy consult to keep oxygen saturation above 90%.

Medications:

  1. Hold patient’s home medication—Losartan 50mg PO daily, Albuterol QID PRN shortness of breath (no other
    medications until heart rate is controlled, then meds will be added for rhythm control)
  2. Lisinopril 10 mg PO daily (Home dose is 20 mg daily) A trial of 10 mg daily while in the hospital with the addition of Metoprolol Tartrate
  3. Metoprolol tartrate 12.5 mg PO twice daily (Heart rate control, can titrate to a higher dose if necessary)
  4. Heparin 5000 units SQ every 12 hours for DVT Prophylaxis
  5. Aspirin 81 mg PO daily for Anticoagulation (Díez-Villanueva & Alfonso, 2019)
  6. Tylenol 650 mg PO every 6 hours as needed for fever or Mild Pain
  7. Metoprolol Tartrate 2.5 mg IV push as needed for sustained A-fib HR >140. Please notify medical provider if this is administered. (JAMA, 2019)

Nursing Orders:

  1. Monitor vitals every 4 hours: blood pressure, oxygen saturation, temperature, respiratory rate for the first 12 hours then if stable vital signs can be assessed 1 time per shift.
  2. Continuous heart rate/rhythm monitoring. Monitor for bradycardia. Please obtain a stat EKG and contact medical provider for further intervention if the A-fib with a sustained rate of >140.
  3. Encourage frequent position changes while lying in bed to prevent skin breakdown.
  4. Observe strict intake and output.
  5. Ambulate as tolerated.

Follow-Up Lab Tests:

Diagnostic testing:

  1. Initial labs tests completed in the ED: CBC, Thyroid function, Complete Metabolic Panel
  2. Additional Initial labs to be collected and assessed initially: B-type Natriuretic peptide, Creatine kinase, Cardiac Troponin, D-dimer, Urinalysis, Urine Drug Screen.
  3. First morning of hospital stay fasting lipid profile.
  4. 2D Echo may be ordered if heart failure is suspected of if the patient doesn’t respond to IV medications2 view chest X-Ray, Consider CT, CTA, MRI if D-dimer comes back with a positive result. ABG if O2 applied & demand
    exceeds 4L/min via nasal canula

Consults:

  • Cardiology consult: For evaluation of new-onset atrial fibrillation. This will be considered if patient doesn’t convert to normal sinus rhythm after 24 hours and rate cannot be controlled (Amin et al., 2016).
  • Cardiology consult also for discussion of possible anticoagulation medications and to establishoutpatient follow up post hospital discharge.
  • Nutrition consult: To recommend a heart healthy diet to follow once the patient is discharged from the hospital.
  • Consult discharge planning: To begin working on a discharge plan and to assess the patient’s at home resources. This is to ensure that she has adequate supportto enable safe home discharge.

Patient Education and Health Promotion:

  • Discuss with patient their current Alcohol/Drug use history and educate on how these can trigger atrial fibrillation.
  • Educate patient on any new medications that patient may be discharged home with.
  • Educate the patient on cardiac diet.

Discharge Planning and Required Follow-Up Care:

  • patient is only discharged once the heart rate has remained in normal sinus for 24 hours and all the other vitals have been stable for 24 hours
  • patient can be discharged home as long as she has a good support system and sufficient home support
    the patient’s discharge instructions should be discussed with patient and patient’s family. The family should understand the discharge instructions and if similar symptoms reoccur or are worse, they should seek immediate medical attention or call emergency medical services.
  • Medication reconciliation should be completed with patient/family and all new medications discussed. Necessary prescriptions should be sent to patient’s pharmacy.
  • Patient should seek post hospital follow up with Primary Care Provider or follow up with Cardiology

References for Admission Orders for Asthma Patient Paper

Amin, A., Houmsse, A., Ishola, A., Tyler, J., & Houmsse, M. (2016). The current approach of atrial fibrillation management. Avicenna Journal of Medicine, 6(1), 8-16.

Díez-Villanueva, P., & Alfonso, F. (2019). Atrial fibrillation in the elderly. Journal of Geriatric Cardiology: JGC16(1), 49–53. https://doi.org/10.11909/j.issn.1671-5411.2019.01.005

JAMA. (2019). Drugs for atrial fibrillation. JAMA, 322(18), 1819. doi:10.1001/jama.2019.15892

Low, B., Shah, M., Nassour, V., & Fox, K. (2019). Acute management of atrial fibrillation with rapid ventricular response. British Journal of Hospital Medicine, 80(6). doi: 10.12968/hmed.2019.80.6.c82

Matuskowitz, A. J., Abukhdeir, H., Weant, K., Calhoun, C., Domanque, B., & Caporossi, J. (2018). Evidence-based management of atrial fibrillation in the emergency department. Relias Media, 1-37.