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8850304_1.xls

CLINICAL PATHWAY
Congestive Heart Failure
( No Renal Dialysis )
DRG NO 127
PATIENT IDENTIFICATION DRG NO:
Length of Stay: 4.0
Day 1 - ER Admit
ACTIVITY
O.O.B. as tolerated Ambulate in hall as tolerated Ambulate in hall as tolerated Head of Bed elevated 30° Participates with activities of daily Independent with activities of Echo (if > 6 months) / Document EF Electrolytes (as indicated) SPECIMENS
Assess need for Ischemia evaluation on Day 3 Follow Abnormal Tests Follow Abnormal Tests Follow Abnormal Tests If Indicated:
If Indicated:
CK0, CK4, CK8 (if Pt presents w/ chest pain or unexplained CXR CHF)CMP-2ABG - (if Pulse Ox < 90%)CholesterolBNP Nutritional assessment / screen Instruction and diet principles as NUTRITION
Instruction and diet principles as If Indicated:
Restricted fluids as ordered Other restrictions Restricted fluids as ordered IV Diuretic Therapy Medication review / adjustment Medication review / adjustment Change to PO Medications K SupplementAce Inhibitors If Ambulatory:
Consider Discharge Meds:
Clinical pathways are tools to facilitate and guide multi-disciplinary patient care. They do not represent a standard of care or replace physician orders or clinical judgment. Modifications are made based on documented individual patient needs.
PART OF THE MEDICAL RECORD
8850304 Rev. 05/05 Congestive Heart Failure Clinical Pathway_CLINICAL PATHWAYS_MEDICAL AFFAIRS PAGE 1 of 4
CLINICAL PATHWAY
Congestive Heart Failure
( No Renal Dialysis )
DRG NO 127
PATIENT IDENTIFICATION TREATMENTS
Adm Wt before Diuretic Therapy
/CONSULTS
Oxygen by N.C. as indicated Breath sounds Q 4 hr Breath sounds Q 4 hr Breath sounds Q 8 hr Cardiac auscultation Cardiac auscultation Cardiac auscultation Breath sounds Q 4 hr Titrate Oxygen as indicated Cardiac auscultation PT evaluation (if indicated) PT evaluation (if indicated) Continue skin assessment Continue skin assessment If Indicated
Continue skin assessment If Indicated
Cardiac monitoring (if Pt presents Discontinue supplemental O2 w/ chest pain or unexplained CHF) if hypoxia is resolved If no improvement, Cardiology If no improvement, Cardiology If no improvement, Cardiology CONSULTS
Cardiology if indicated Palliative Care consult (if indicated) VITAL SIGNS
Q 4 hr or unit routine Q 8 hr or unit routine Q 8 hr or unit routine Q 8 hr or unit routine DISCHARGE
Initiate Discharge Planning Review D/C Plan with patient / Review D/C Plan with patient / Discharge to safe environment PLANNING
Evaluate support systems and Referral to homecare agency / Meeting with patient / family re: Discuss outcome with PCP discharge patient Referral made to Case Mgt Homecare vs. Placement Patient assessment, contact family TEACHING
Orient Pt to physical surroundings Review Health Teaching Initiate Discharge Teaching Plan
Review all patient / family Assess risk factors Monitoring fluid intake Initiate Health Teaching Plan
Recording body weight Follow up discharge instructions Limitations of salt intake / diet - CHF Management S/S of fluid overload requiring - Patient Compliance medical attention - Smoking Cessation Discharge medications - Fluid Restriction Daily activity / exercisePhysician contact EVALUATION
(Military Time ) DISCHARGE DATE: ( Military Time ) Clinical pathways are tools to facilitate and guide multi-disciplinary patient care. They do not represent a standard of care or replace physician orders or clinical judgment. Modifications are made based on documented individual patient needs.
PART OF THE MEDICAL RECORD
8850304 Rev. 05/05 Congestive Heart Failure Clinical Pathway_CLINICAL PATHWAYS_MEDICAL AFFAIRS PAGE 2 of 4
ADDENDUM TO CHF CLINICAL PATHWAY
Guidelines for Diuretic Therapy in CHF (Congestive Heart Failure)
GOALS OF THERAPY
DOSING OF BUMETANIDE
1. In severely congested patients, a minimum
1. 0.5 mg - 2 mg IV Bolus
of 1000 ml / day urine output is goal.
1. Furosemide (Lasix)
2. 0.5 mg - 2 mg IV BID (max of 10 mg / day)
2. If goal not met, combination therapy or
2. Bumetanide (Bumex)
3. All other recommendations are the same as
increased dosing of intravenous therapy should be assessed.
1. Patient's dry weight
3. When established weight is achieved and
2. Degree of volume overload
clinical status has improved, IV diuretics 3. Blood pressure
may be converted to po. 4. Previous diuretic responses
4. Salt restriction.
5. Acid base disturbance
5. Fluid intake restriction of 800-1200ml / day.
SIDE EFFECTS
1. Hypochloremic Metabolic Alkalosis
2. Ototoxicity (Furosemide)
3. May cause vasocontriction in post MI patients if
no CHF is present.
5. Azotemia
DOCUMENTATION OF ASSESSMENT
DOSING OF FUROSOMIDE
COMBINATION DIURETICS THERAPY
Chart documentation should include: 1. 20-80 mg administered slowly by IV as a
1. Lasix and Zaroxolyn
loading bolus: max of 1 gm / day.
Lasix 40-80 mg IVP BID with Zaroxolyn 1. Initial weight
2. Lower dose range to be utilized in elderly
2.5 mg - 5 mg po once a day.
2. Urinary output
patients and smaller cachectic patients.
2. Lasix and Aldactone
3. Hearing status pre & post diuretic therapy
3. Desired response should be seen within
Lasix 40 mg IVP BID combined w/ Aldactone 4. BMP profile
15-30 min as evidenced by improved clinical 25 mg po TID (max of 200 mg per day).
5. Magnesium levels
status and increased urinary output.
3. Bumex and Aldactone
6. Blood pressure
4. Assess urinary output quantitatively (foley/urinal).
7. Respiratory Therapy note
5. The response to initial bolus should be
8. JVP + Lung exam
documented for the first 2 hrs & recorded in 9. Peripheral edema assessment
Nurse's Notes.
in ICU / CCU / 2S
6. BP responses should be noted and recorded
at 15 min, 30 min & 60 min.
Recommendations are the same however 7. If no urine output has been noted at 30 min
and SBP is > 110, the initial bolus dose 1. Lasix drips may be effective ( 2-5 mg / hr )
should be repeated or doubled.
2. Renal dose dopamine may improve diuresis
8. The initial dose should be repeated 1-2 hrs in
3. IV Inotropes may improve diuresis
moderate/severely congested Pts; if desired 4. IV Natrecor may improve diuresis
response not achieved, consider Natrecor.
9. Volume outputs > 1000 ml may indicate
hypotension, exhibiting a slow response toIV fluid (1/2 NS or NS @ 60-75 ml / hr ) PART OF THE MEDICAL RECORD
8850304 Rev. 05/05 Congestive Heart Failure Clinical Pathway_CLINICAL PATHWAYS_MEDICAL AFFAIRS PAGE 3 of 4
ADDENDUM to CLINICAL PATHWAY
Congestive Heart Failure
GOALS OF ACE 7 INHIBITOR THERAPY
DOSING OF ACE INHIBITORS
DOCUMENTATION / ASSESSMENT
All patients with heart failure due to LV PH Formulary Ace Inhibitors
Outcomes of initial management of systolic dysfunction should receive an Benazepril (Lotensin) signs and symptoms ace inhibitor unless there is known drug Captopril (Capoten) 12.5 mg ; 25 mg tabs intolerance, or have contraindications Enalapril (Vasotec) to the use of this drug class.
Lisinopril (Zestril) Quinipril (Accupril) Therapy should be started relatively Ramipril (Altace) early and continue long term to reduce History of angioedema the risk of disease progression.
Dosage should start low and gradually increase as bloodpressure and clinical status allow.
Contraindications to therapy Therapy is best started when patient iseuvolemic.
Clinical benefits may not be seen until long after discharge.
Discharge plan of care Patient should receive with caution if:
SBP < 80 mmHg
Serum creatinine > 3
Serum potassium > 5
Serum sodium < 130 bilateral
Renal artery stenosis
GOALS OF BETA BLOCKER THERAPY
DOSING OF BETA BLOCKERS
DOCUMENTATION / ASSESSMENT
All patients with stable NYHA class II PH Formulary Beta Blockers for Use in CHF
Outcomes of initial management of or III heart failure due to LV systolic Metoprolol (Lopresor) 50 mg tab ; 1 mg injection signs and symptoms dysfunction should receive a Beta Carvedilol (Coreg) 3.125 mg ; 12.5 mg ; 25 mg tabs Blocker unless there is a BNP level , LVEF, systolic dysfunction contraindication to it's use or if the Beta Blockers are not for use in acute congestive heart patient is unable to tolerate side Response to diuretic therapy effects of drug therapy.
Patients should not receive Beta Blockers if they also have: Clinical stabilization of vital signs Beta Blockers are generally used in conjunction with diuretics and ace Contraindications to therapy advanced heart block
asymptomatic bradycardia < 55
Beta Blockers may reduce the risk ofdisease progression even if the Beta Blockers may be best started just prior to discharge patients' clinical symptoms have not once the patient is ambulatory. Recommended starting responded to therapy.
treatment for in-house patients is:
Coreg 3.125 mg BID -or- Metoprolol 25 - 50 mg BID
Drug therapy may also be initiated after discharge as anoutpatient.
PART OF THE MEDICAL RECORD
8850304 Rev. 05/05 Congestive Heart Failure Clinical Pathway_CLINICAL PATHWAYS_MEDICAL AFFAIRS PAGE 4 of 4

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