CONGESTIVE HEART FAILURE CLINICAL PATHWAY ACUTE …

1 Discharge Criteria - copy with patient to receiving hospital - original to stay on patient chart MAR Sheet - copy with patient to receiving hospital - original to stay on patient chart Teaching Checklist - copy with patient to receiving hospital - original to stay on patient chartCONGESTIVE HEART FAILURECLINICAL PATHWAYHANOVER AND DISTRICT HOSPITALINCLUSION CRITERIAP rimary admitting diagnosis is CONGESTIVE HEART FAILURE as defined by New York HEART STAGEPATIENT IDHOW TO USE THE CLINICAL PATHWAYEXCLUSION CRITERIAP atients less than 19 years of is a proactive tool to avoid delays in treatment and discharge. These are not orders, only a guide to usual the CLINICAL PATHWAY in the nurses CLINICAL area of the chart. All health care professionals should fill in the master signature sheet at the front of the PATHWAY . Addressograph/sticker each page of the CARE PROFESSIONALS: Initial tasks as completed.

2 Place N/A and initial any box where the task is not applicable to the patient. Additional tasks due to patient individuality can be added to the PATHWAY in OTHER boxes and/or Progress rights reserved. No part of this document may be reproduced or transmitted, in any formor by any means, without the prior permission of the copyright PATIENTS: if patient is transferred to another hospital in Grey-Bruce or to CCAC, send the following:PHYSICIANS: Add or delete tasks according to individual patient complexity, and initial all August 2009 2004-2010 Grey Bruce Health Network1 Review August 2011 Approved August 2009 2004-2010 Grey Bruce Health Network2 Review August 2011 COMORBID CONDITIONS: INITIAL DATE2mm or less = 1 + Edema3 Slight pitting3 No visible distortion3 Disappears rapidlyIMPROVEMENT OF OXYGENATION - <5L O2 REQUIRED BY PRONG; 35% BY MASKWEIGHT DECREASED SINCE ADMISSIONRESPIRATORY RATE <30 IMPROVEMENT OF CRACKLES IN LUNGSA ssessment Chart for Pitting Edema adapted from the Guelph General Hospital CONGESTIVE HEART FAILURE Pathway6-8mm = 4 + Edema3 Pit is very deep3 Lasts as long as 2-5 minutes3 Dependent extremity is grossly distorted (6-8mm)ASSESSMENT OF PITTING EDEMACONGESTIVE HEART FAILURECLINICAL PATHWAYACUTE STAGEHANOVER AND DISTRICT HOSPITALPATIENT OUTCOMES*PROCESSPATIENT IDDATE _____DATE _____ Once all Patient Outcomesare achieved,move to Phase 2 TOLERATES ACTIVITY LEVEL 2 PHASE 1 (Approximately 2 days) ABSENCE OF UNSTABLE ARRHYTHMIASABSENCE OF CHEST PAINPATIENT REPORTS IMPROVEMENT OF DYSPNEAOTHER: PERIPHERAL EDEMA (SEE CHART BELOW)CHEST ASSESSMENTASSESS ANXIETY AND INTERVENE IF NECESSARYCARDIAC MONITOR IF ORDEREDVITALS INCLUDING O2 SATS Q4H x 24H.

3 QID x 24 HDAILY WEIGHT, DISCUSS WITH PATIENT - DOCUMENTEDBY NURSE AND PATIENTASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION)4-6mm = 3 + Edema3 Pit is noticeably deep3 May last more than 1 minute3 Dependent extremity looks fuller and swollen (4-6mm)2-4mm = 2 + Edema3 Somewhat deeper pit3 No readably detectable distortion3 Disappears in 10-15 seconds (2-4 mm indent)MONITOR INTAKE AND OUTPUT (24 HOURS)Updated August 2009 2004-2010 Grey Bruce Health Network3 Review August 2011 MEDICATIONSASSESS DISCHARGE CRITERIA DAILYOTHER:CONSULTS2D ECHOCARDIOGRAM IF ORDEREDCLINICAL NUTRITIONCCAC IF NECESSARYPHARMACIST IF ORDEREDENCOURAGE PATIENT AND FAMILY TO ASK QUESTIONS DIAGNOSTICS/ LABORATORYECGBLOOD WORK AS ORDEREDCARDIAC MARKERSCHEST X-RAY ON ADMISSION (NEXT MORNING IF AFTER HOURS)OTHER:NUTRITIONSEE MAR SHEETSPECIAL DIET IF REQUIRED: _____ASSESS FOR CCACSIT UP FOR 20 MIN (TID)BATHROOM PRIVILEGESMOBILITY/ACTIVITY *UP TO ACTIVITY LEVEL 2 AS TOLERATED BY PATIENTA ctivity Levels (1-4) adapted from the Guelph General Hospital AMI Activity Level GuidelinePSYCHOSOCIAL SUPPORT/ EDUCATION *DISCHARGE PLANNING *DISCUSS DISCHARGE PLAN WITH PATIENT AND FAMILYTREATMENTS/ INTERVENTIONSINTERMITTENT SETO2 AT _____L PRN TO KEEP 85-95%OTHER:DATE _____PROCESSPHASE 1 (Approximately 2 days) DATE _____HEALTHY HEART DIET, 2-3 gm Na BED SIDE COMMODE PRIVILEGE IF STABLEFEED SELFACTIVITY LEVEL 1:ECG WITH CHEST PAIN, NOTIFY PHYSICIANBED RESTASSISTED BATHORIENTATION TO UNIT AND PROCEDURES GIVE PATIENT EDUCATION MATERIALS TO PATIENTANKLE / FOOT EXERCISESDEEP BREATHING / COUGHING / CALF PUMPINGACTIVITY LEVEL 2.

4 INTRODUCE PATIENT PATHWAYBEGIN TEACHING CHECKLISTU pdated August 2009 2004-2010 Grey Bruce Health Network4 Review August 2011 INITIAL DATECONSULTS2mm or less = 1 + Edema3 Slight pitting3 No visible distortion3 Disappears rapidlyHANOVER AND DISTRICT HOSPITALPROCESSPHASE 2(Approximately 2 days) PATIENT IDDATE _____DATE _____CONGESTIVE HEART FAILURECLINICAL PATHWAYACUTE STAGEOTHER: ASSESSMENT OF PITTING EDEMA2-4mm = 2 + EdemaDIAGNOSTICS/ LABORATORYABGs IF CONSIDERED FOR HOME O2 CHEST X-RAY IF ORDEREDBLOOD WORK AS ORDEREDARRANGE HOME O2 IF NEEDEDOnce all Patient Outcomesare achieved, move to Discharge CriteriaASSESS FOR EDEMA (SEE CHART BELOW)PATIENT OUTCOMES* ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION)CHEST ASSESSMENTVITALS INCLUDING 02 SATS BID AND PRN WHEN STABLEOTHER:ABSENCE OF CRACKLES ON LUNGSO2 SATS ON ROOM AIR >90%OFF OXYGEN OR RETURNED TO PRE-HOSPITALIZATION LEVEL OF O2 TOLERATES ACTIVITY LEVEL 3 OR RETURNED TO PRE-HOSPITALIZATION LEVELDAILY WEIGHT, DISCUSS WITH PATIENT - DOCUMENTED BY NURSE AND PATIENTA ssessment Chart for Pitting Edema adapted from the Guelph General Hospital CONGESTIVE HEART FAILURE Pathway4-6mm = 3 + Edema3 Pit is noticeably deep3 May last more than 1 minute3 Dependent extremity looks fuller and swollen (4-6mm)6-8mm = 4 + Edema3 Pit is very deep3 Lasts as long as 2-5 minutes3 Dependent extremity is grossly distorted (6-8mm)3 Somewhat deeper pit3 No readably detectable distortion3 Disappears in 10-15 seconds (2-4 mm indent)Updated August 2009 2004-2010 Grey Bruce Health Network5 Review August 2011 MEDICATIONSMOBILITY/ACTIVITY *WALK IN HALLUP IN ROOM AD LIBSEE MAR SHEETOTHER.

5 HEALTHY HEART DIET, 2-3 gm NaSPECIAL DIET IF REQUIRED: _____NUTRITIONTREATMENTS/ INTERVENTIONSA ctivity Levels (1-4) adapted from the Guelph General Hospital AMI Activity Level GuidelinePROCESSPHASE 2 (Approximately 2 days)DATE _____DATE _____PSYCHOSOCIAL SUPPORT/ EDUCATION *DISCUSS DISCHARGE PLANS WITH PATIENTDISCHARGE PLANNING *CONSIDER FOR CARDIAC REHAB AND CHF CLINIC, IF APPROPRIATE, SECURE PHYSICIAN/NURSE PRACTITIONER ORDERSHOWERREVIEW MEDICATIONS FOR HOMEADDRESS ANY QUESTIONS THE PATIENT MAY HAVEREVIEW PATIENT PATHWAYSIT UP FOR MEALSACTIVITY LEVEL 3AS TOLERATED:COMPLETE TEACHING CHECKLISTCHECK WITH PHYSICIAN REGARDING DISCONTINUINGINTERMITTENT SETSECURE DISCHARGE ORDER ONCE INDICATORS METASSESS DISCHARGE CRITERIA DAILYREVIEW ACTIVITY LEVELS FOR HOMEASSESS NEEDS FOR DISCHARGEU pdated August 2009 2004-2010 Grey Bruce Health Network6 Review August 2011 1 Met Not Met N/A2 Met Not Met N/A3 Met Not Met N/A4 Met Not Met N/A5 Met Not Met N/A6 Met Not Met N/A7 Met Not Met N/ACONSULTSTREATMENTS/ INTERVENTIONSNUTRITIONMOBILITY/ACTIVITYD ISCHARGE PLANNINGECHOCARDIOGRAM COMPLETEDRESPIRATORY RATE IMPROVED SINCE ADMISSIONCONGESTIVE HEART FAILURECLINICAL PATHWAYACUTE STAGEPATIENT IDPSYCHOSOCIAL SUPPORT/ EDUCATIONASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION)HANOVER AND DISTRICT HOSPITALPROCESSDISCHARGE INSTRUCTIONS RE.

6 DISCHARGE MEDS, SALT/FLUID RESTRICTIONS, DAILY WEIGHTS, SYMPTOMS OF WORSENING CHF, FOLLOW UP APPOINTMENTDATE METINITIALPERFORMANCE INDICATORSMEDICATIONSDIAGNOSTICS/ LABORATORYDISCHARGE CRITERIANEW YORK HEART ASSOCIATION (NYHA) FUNCTIONAL CLASSIFICATION IMPROVED BY ONE OR MORE GRADES SINCE ADMISSION: D/C NYHA LEVEL: _____IMPROVEMENT OF PERIPHERAL EDEMA SINCE ADMISSIONBETA BLOCKER PRESCRIBED AT DISCHARGEWARFARIN FOR ATRIAL FIBRILLATION PRESCRIBED AT DISCHARGEWEIGHT MEASURED EACH DAY OF HOSPITALIZATIONSMOKING CESSATION ADVICE/COUNSELLING COMPLETEDACE INHIBITOR PRESCRIBED AT DISCHARGENO CHEST PAIN OR PAIN FROM DYSPNEAWEIGHT DECREASED SINCE ADMISSIONBLOOD PRESSURE WITHIN STABLE LIMITS FOR INDIVIDUALPATIENT VERBALIZES UNDERSTANDING OF HEALTHY HEART DIET, SALT/FLUID RESTRICTIONSORAL MEDS STABLE x 24 HOURSPATIENT VERBALIZES UNDERSTANDING OF SYMPTOMS OF WORSENING HEART FAILURE , WHEN TO CALL PHYSICIAN/COME TO HOSPITALFOLLOW UP APPOINTMENTS.

7 FAMILY PHYSICIAN CARDIAC REHAB CHF CLINIC OFF INOTROPES 48 HOURSPATIENT VERBALIZES UNDERSTANDING OF MEDSPATIENT TOLERATING ACTIVITY LEVEL 3 (NO DYSPNEA/ DIZZINESS)ELECTROLYTES WITHIN NORMAL LIMITSSTABLE RENAL FUNCTION - CREATININE <220 PATIENT VERBALIZES IMPORTANCE OF DAILY WEIGHTSU pdated August 2009 2004-2010 Grey Bruce Health Network7 Review August 2011