What are the admission orders for a 63-year-old female with atrial fibrillation (AFib) with rapid ventricular response (RVR), hypertension, diabetes, and a history of transient ischemic attack (TIA), currently taking lisinopril and metformin, and allergic to penicillin?

Admission Orders for Atrial Fibrillation with Rapid Ventricular Response

Primary Diagnosis and Status

• Primary Diagnosis: Atrial Fibrillation with Rapid Ventricular Response (AFib with RVR)
• Status/Condition: Stable
• Code Status: Full code
• Allergies: Penicillin

Admission Details

• Admit to Unit: Telemetry/Cardiac Unit
• Activity Level: As tolerated with assistance
• Diet: Diabetic, low sodium diet

Rate Control Management

For this 63-year-old female with AFib with RVR and history of TIA, hypertension, and diabetes, a rate control strategy with anticoagulation is the most appropriate initial management approach. 1

IV Fluids and Critical Drips

• IV Fluids: Normal saline at 75 mL/hr
• Critical Drips: None at this time

Medications

1. Rate Control:

   • Metoprolol tartrate 5 mg IV push over 2 minutes, may repeat twice at 5-minute intervals if needed for heart rate >110 bpm
   • Transition to Metoprolol tartrate 25 mg PO BID once rate controlled, titrate as needed to maintain heart rate 60-100 bpm at rest 1

2. Anticoagulation:

   • Heparin 80 units/kg IV bolus, followed by 18 units/kg/hr continuous infusion
   • Target aPTT 1.5-2.5 times control
   • Initiate warfarin 5 mg PO daily with goal INR 2.0-3.0 1, 2

3. Chronic Medications:

   • Continue Lisinopril 20 mg PO daily (assuming current dose)
   • Hold Metformin during hospitalization
   • Insulin sliding scale: Regular insulin subcutaneous per protocol
     • Blood glucose <150 mg/dL: No insulin
     • 150-200 mg/dL: 2 units
     • 201-250 mg/dL: 4 units
     • 251-300 mg/dL: 6 units
     • 301-350 mg/dL: 8 units
     • 351-400 mg/dL: 10 units

     • 400 mg/dL: 12 units and notify physician

Respiratory Support

• Oxygen: Nasal cannula at 2 L/min to maintain SpO2 >94%
• Continuous pulse oximetry monitoring

Nursing Orders

• Vital signs: Every 4 hours and PRN
• Continuous cardiac monitoring with telemetry
• Daily weight
• Strict intake and output monitoring
• Neurological checks every 4 hours (given history of TIA)
• Fingerstick blood glucose monitoring before meals and at bedtime

Laboratory and Diagnostic Testing

• CBC with differential
• Comprehensive metabolic panel
• Magnesium, phosphorus
• Thyroid stimulating hormone
• PT/INR, aPTT
• Troponin x 3 sets, 6 hours apart
• BNP
• 12-lead ECG on admission and daily
• Transthoracic echocardiogram
• Chest X-ray

Consults

• Cardiology consult for evaluation and management of new-onset atrial fibrillation
• Endocrinology consult for diabetes management during hospitalization

Patient Education and Health Promotion

• Education on signs and symptoms of stroke
• Education on anticoagulation therapy and bleeding precautions
• Heart-healthy diet and sodium restriction
• Importance of medication adherence
• Blood glucose monitoring

Discharge Planning

• Anticipated length of stay: 3-5 days
• Outpatient follow-up with cardiology within 1-2 weeks
• Outpatient follow-up with primary care physician within 1 week
• Consider home health services for medication management and vital sign monitoring

Clinical Reasoning and Evidence-Based Approach

The management approach prioritizes rate control over rhythm control based on evidence from major trials showing no mortality benefit to rhythm control strategy in most patients with atrial fibrillation 1. Beta-blockers are the preferred first-line agents for rate control in this patient with history of hypertension 1, 2.

Anticoagulation is essential given the patient's CHA₂DS₂-VASc score of at least 4 (age, female gender, hypertension, diabetes, prior TIA), which places her at high risk for thromboembolism 2, 3. Warfarin with a target INR of 2.0-3.0 is appropriate for this patient with multiple risk factors 1.

Metformin is held during hospitalization to avoid potential complications, particularly in the setting of possible contrast studies and risk of lactic acidosis. Subcutaneous insulin is used for glycemic control during the hospital stay 2.

Continuous cardiac monitoring is crucial to assess response to rate control therapy and to detect any rhythm changes or complications. Regular neurological checks are important given the patient's history of TIA and increased risk of stroke with atrial fibrillation 1.

Pitfalls to Avoid

1. Avoid calcium channel blockers like diltiazem or verapamil if there is concern for heart failure with reduced ejection fraction (not yet determined in this patient)
2. Avoid digoxin as sole agent for rate control in this acutely presenting patient
3. Never discontinue anticoagulation without a compelling reason, as this significantly increases stroke risk 1
4. Avoid amiodarone, adenosine, or digoxin in patients with pre-excitation syndromes (though not present in this case) 1