1. Admit to:
2. Diagnosis: Congestive Heart Failure3. Condition:
4. Vital Signs: q1h. Call physician if P >120; BP >150/-100 <80/60;T>38.5°C;R >25, <10.
5. Activity: Bed rest with bedside commode.
6. Nursing: Daily weights, measure inputs and outputs.
Head-of-bed at 45 degrees,legs elevated.
7. Diet: 1-2 gm salt, cardiac diet.
8. IV Fluids: Heparin lock with flush q shift.
9. Special Medications:
-Oxygen 2-4 L/min by NC.Diuretics:
-Furosemide (Lasix) 10-160 mg IV qd-bid or 20-80 mg PO qAM-bid
[20,40,80 mg] or 10-40 mg/hr IV infusion OR
-Torsemide (Demadex) 10-40 mg IV or PO qd; max200 mg/day
[5, 10, 20, 100 mg] OR
-Bumetanide (Bumex) 0.5-1 mg IV q2-3h until response;
then 0.5-1.0 mg IV q8-24h (max 10 mg/d);or 0.5-2.0 mg PO qAM.
-Metolazone (Zaroxolyn) 2.5-10 mg PO qd, max 20mg/d;
30 min before loop diuretic [2.5,5,10 mg].
ACE Inhibitors:
-Quinapril (Accupril) 5-10 mg PO qd x 1 dose,
then 20-80 mg PO qd in 1 to 2 divided doses [5,10,20,40 mg]OR
-Lisinopril (Zestril, Prinivil) 5-40 mg PO qd [5,10,20,40mg] OR
-Benazepril (Lotensin) 10-20 mg PO qd-bid, max 80mg/d [5,10,20,40 mg] OR
-Fosinopril (Monopril) 10-40 mg PO qd, max 80 mg/d[10,20 mg] OR
-Ramipril (Altace) 2.5-10 mg PO qd, max 20 mg/d[1.25,2.5,5,10 mg].
-Captopril (Capoten) 6.25-50 mg PO q8h [12.5,25,50,100 mg] OR
-Enalapril (Vasotec) 1.25-5 mg slow IV push q6h or 2.5-20 mg PO bid[5,10,20 mg] OR
-Moexipril (Univasc) 7.5 mg PO qd x 1 dose, then 7.5-15 mg PO qd-bid[7.5, 15 mg tabs] OR
-Trandolapril (Mavik) 1 mg qd x 1 dose, then 2-4 mg qd [1, 2, 4 mg tabs].
Angiotensin-II Receptor Blockers:
-Irbesartan (Avapro) 150 mg qd, max 300 mg qd [75,150, 300 mg].
-Losartan (Cozaar) 25-50 mg bid [25, 50 mg].
-Valsartan (Diovan) 80 mg qd; max 320 mg qd [80, 160mg].
-Candesartan (Atacand) 8-16 mg qd-bid [4, 8, 16, 32mg].
-Telmisartan (Micardis) 40-80 mg qd [40, 80 mg].
Beta-blockers:
-Carvedilol (Coreg) 1.625-3.125 mg PO bid, then slowly increase the dose
every 2 weeks to target dose of 25-50 mg bid [tab 3.125, 6.25, 12.5, 25 mg] OR
-Metoprolol (Lopressor) start at 12.5 mg bid,
then slowly increase to target dose of 100 mg bid [50, 100mg].
-Bisoprolol (Zebeta) start at 1.25 mg qd,
then slowly increase to target of 10 mg qd.[5,10 mg].
Digoxin: (Lanoxin) 0.125-0.5 mg PO or IV qd [0.125,0.25, 0.5 mg].
Inotropic Agents:
-Dobutamine (Dobutrex) 2.5-10 mcg/kg/min IV, max of 14 mcg/kg/min
(500 mg in 250 mL D5W, 2 mcg/mL) OR
-Dopamine (Intropin) 3-15 mcg/kg/min IV
(400 mg in 250 cc D5W, 1600 mcg/mL),
titrate to CO >4, CI >2;systolic >90 OR
-Milrinone (Primacor) 0.375 mcg/kg/min IV infusion
(40mg in 200 mL NS, 0.2 mg/mL);titrate to 0.75 mgc/kg/min;
arrhythmogenic; may cause hypotension.
Vasodilators:
-Nitroglycerin 5 mcg/min IV infusion (50 mg in 250 mLD5W).
Titrate in increments of 5 mcg/min to control symptoms
and maintain systolic BP >90 mmHg.
-Nesiritide (Natrecor) 2 mcg/kg IV load over 1 min,
then 0.010 mcg/kg/min IV infusion.
Titrate in increments of 0.005 mcg/kg/min q3h to max 0.03mcg/kg/min IV infusion.
Potassium:
-KCL (Micro-K) 20-60 mEq PO qd if the patient is taking loop diuretics.
Pacing:
-Synchronized biventricular pacing if ejection fraction <40%
and QRS duration >150 msec.
10. Symptomatic Medications:
-Morphine sulfate 2-4 mg IV push prn dyspnea or anxiety.-Heparin 5000 U SQ q12h or enoxaparin (Lovenox) 1mg/kg SC q12h.
-Docusate sodium (Colace) 100-200 mg PO qhs.
-Famotidine (Pepcid) 20 mg IV/PO q12h.
11. Extras: CXR PA and LAT, ECG now and repeat if chest pain or palpitations,
impedance cardiography,echocardiogram.
12. Labs: SMA 7&12, CBC; B-type natriuretic peptide (BNP), cardiac enzymes:
CPK-MB, troponin T, myoglobin TAT and q6h for 24h. Repeat SMA 7 in AM. UA.
