Write admission orders for a 60-year-old white male with two weeks of dyspnea, chest X-ray consistent with congestive heart failure, and mild respiratory distress.

Admission Orders for Acute Decompensated Heart Failure

Admit this patient to a telemetry unit with continuous cardiac monitoring, initiate intravenous loop diuretics (furosemide 40 mg IV bolus or equivalent to home dose if already on diuretics), supplemental oxygen to maintain SpO2 >90%, and consider non-invasive positive pressure ventilation if respiratory distress persists despite initial therapy 1.

Immediate Interventions

Respiratory Support

• Oxygen therapy: Administer supplemental oxygen ONLY if SpO2 <90% - avoid routine oxygen in non-hypoxemic patients as it causes vasoconstriction and reduces cardiac output 1
• Non-invasive positive pressure ventilation (CPAP or BiPAP): Should be considered for persistent respiratory distress to reduce work of breathing and potentially avoid intubation 1, 2
  • CPAP is simpler and adequate for most cases
  • BiPAP preferred if hypercapnia or COPD history present
  • Caution: Monitor blood pressure closely as positive pressure ventilation can reduce BP 1

Diuretic Therapy

Initial IV furosemide dosing 1:

• If diuretic-naive: 20-40 mg IV furosemide
• If on chronic oral diuretics: Give IV dose at least equivalent to oral home dose
• Administer as intermittent boluses or continuous infusion based on response
• Monitor closely: Urine output, daily weights, renal function (BUN/Cr), electrolytes (K+, Mg2+), symptoms 1

Vasodilator Consideration

• IV vasodilators (nitroglycerin, nitroprusside) should be considered if systolic BP >90 mmHg for symptomatic relief 1
• Hold if hypotensive or systolic BP ≤90 mmHg

Diagnostic Orders

Laboratory Studies

• BNP or NT-proBNP: Essential for confirming diagnosis and establishing baseline 3, 2
• Complete metabolic panel (electrolytes, renal function, glucose)
• Complete blood count
• Troponin (rule out acute coronary syndrome)
• Thyroid function tests
• Liver function tests
• Magnesium level

Cardiac Workup

• 12-lead ECG: Assess for ischemia, arrhythmias, conduction abnormalities 3
• Echocardiogram: Determine ejection fraction (classify as HFrEF, HFmrEF, or HFpEF), assess valvular function, wall motion abnormalities 3, 2
• Continuous telemetry monitoring

Imaging

• Chest X-ray already obtained showing CHF findings
• Consider point-of-care ultrasound (POCUS) for rapid assessment of B-lines (pulmonary edema), cardiac function, and IVC diameter 4, 5

Monitoring Orders

• Vital signs: Every 4 hours minimum, more frequently if unstable
• Continuous pulse oximetry and telemetry
• Strict intake and output monitoring
• Daily weights (same scale, same time)
• Respiratory assessment: Monitor work of breathing, lung sounds every 4-8 hours

Activity and Diet

• Bed rest with head of bed elevated 30-45 degrees for comfort
• Sodium restriction: 2 grams per day
• Fluid restriction: Consider 1.5-2 liters per day if hyponatremic
• NPO until respiratory status stabilizes, then advance to cardiac diet as tolerated

Medications to Hold/Avoid

• NSAIDs: Worsen fluid retention and renal function 6
• Negative inotropes: Hold non-dihydropyridine calcium channel blockers if present
• Review and hold nephrotoxic agents if possible

Additional Considerations

Intubation Criteria

Prepare for mechanical ventilation if non-invasive measures fail and patient develops 1:

• PaO2 <60 mmHg despite oxygen therapy
• PaCO2 >50 mmHg with acidosis (pH <7.35)
• Severe respiratory fatigue or altered mental status

Common Pitfalls to Avoid

• Over-diuresis: Can precipitate cardiorenal syndrome - monitor renal function closely
• Routine oxygen in non-hypoxemic patients: Reduces cardiac output 1
• Inadequate diuretic dosing: Patients on chronic diuretics need higher initial doses due to diuretic resistance
• Ignoring blood pressure with positive pressure ventilation: Can cause significant hypotension 1

Refractory Cases

If inadequate response to loop diuretics alone, consider adding 1:

• Thiazide-type diuretic (metolazone)
• Spironolactone
• Increase to continuous infusion of loop diuretic

This structured approach prioritizes immediate stabilization of respiratory distress while establishing the diagnosis and initiating guideline-directed therapy 1.