Diabetic Ketoacidosis. Severe: Serum Glucose > 250 mg/dl

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1 Respiratory Failure Is the Respiratory Problem, Post Op or from Trauma? Is there any baseline Chronic Respiratory Failure? Is the Acute condition Failure or Insufficiency? ACUTE Respiratory Insufficiency indicators include: - Respirations >28 - Air hunger - Use of accessory muscles of respiration - Inability to speak in full sentences - Cyanosis - ph <7.35 or >7.45 ACUTE Respiratory FAILURE criteria Hypoxic po2 < 60 mmhg or SpO2 < 91% on room air 10 mmhg decrease in po2 over baseline po2/fio2 < 300 Hypercapnic pco2 > 50 mmhg with ph < mmhg increase in baseline CO2 v Document CAUSE of Acute Respiratory Failure: Pneumonia, Exacerbation of Chronic COPD, Pneumothorax CHRONIC Respiratory Failure: CHRONICALLY hypoxic (O2 Sat < 90%) or hypercarbic (CO2 > 50) Patient has home O2. v Document CAUSE of Chronic Respiratory Failure: COPD, Emphysema, Pulmonary Fibrosis Post Op Respiratory Failure, Insufficiency and Hypoventilation Not to be used when patient required post-op intubation time <48hrs Hypoventilation If the Acute Respiratory Failure is due to a chronic underlying condition, document this, Acute respiratory failure following surgery, primarily due to: preexisting CHF severe COPD Intubation for Airway Protection is not Respiratory Failure Diabetic Ketoacidosis Mild: Serum Glucose > 250 mg/dl Anion Gap > 10 meq per L Arterial ph: Mental Status: Alert Serum Bicarbonate: meq per L Serum Ketones: Positive Urine Ketones: Positive Moderate: Serum Glucose > 250 mg/dl Anion Gap > 12 meq per L Arterial ph: Mental Status: Alert/Drowsy Serum Bicarbonate: meq per L Serum Ketones: Positive Urine Ketones: Positive Severe: Serum Glucose > 250 mg/dl Anion Gap > 12 meq per L Arterial ph: < 7.00 Mental Status: Stupor/Coma Serum Bicarbonate: < 10 meq per L Serum Ketones: Positive Urine Ketones: Positive Diabetic Ketoacidosis: Evaluation and Treatment. Dyanne P. Westerberg, DO. Am Fam Physician Mar 1;87 (5): PATA

2 Acute Kidney Injury Acute vs Chronic Acute Renal Insufficiency (ARI)* Dehydration (Pre-Renal) Stone or Prostate (Post-Renal) Acute Renal Failure (ARF) or Acute Kidney Injury (AKI) Serious INTRA Renal Injury/Failure due to Acute Tubular Necrosis (ATN), Glomerular Nephritis or Interstitial Nephritis Chronic Kidney Disease (CKD) Stage 1 to Stage 5 End Stage Renal Disease (ESRD) On Dialysis Note: Do not use Chronic Renal Insufficiency (CRI) Note: ARF = AKI The only terms you need: ARI= Insufficiency ARF/AKI= Injury/Failure CKD=Chronic Disease ESRD=End Stage Renal Always clarify THE CAUSE of the acute condition Always clarify THE STAGE of the CKD *Note: With ARI, the creatinine quickly returns to baseline with treatment of underlying problem. If creatinine does not return to baseline within 24 to 48 hours, it is ARF or AKI Chronic Kidney Disease (CKD) Stage Glomerular Filtration Rate (ml/min) Creatinine (mg/dl) I < 0.9 II III IV V 8-15 > 4.6 ESRD End Stage Renal Disease Dialysis * Serum Creatinine for a 170 lb, 65 yo, white male 2

3 Encephalopathy Delirium is a symptom; Encephalopathy is a diagnosis. Document the Cause of the Encephalopathy Altered Mental Status (AMS) is usually Delirium which is usually Encephalopathy The Words Delirium and Encephalopathy can usually be used Interchangeably Delirium/Encephalopathy: Confusion with Level of Consciousness (LOC) Problem (Inattention); Dementia: Confusion with Intellectual Functioning Problem (Orientation); Psychosis: Confusion with Hallucinations and/or Delusions Pneumonic for Causes of AMS: AEIOU TIPPS Anoxia, Alcohol, Epilepsy, Infection, Insulin (hypo/hyperglycemia), Opiates, Uremia, Trauma, Tumor, Psychosis, Poisons, Stroke, Sepsis Global Dysfunction Toxic Septic Metabolic HTN Urgency/Emergency Hepatic/Renal Focal Structural Problem Tumor CVA/TIA Seizure Concussion Symptoms: Confused Hard to Arouse Hyper Alert Inattentive Behavioral Disturbances Aggressive Combative Violent Wandering Notes: Sun downing is not coded as Encephalopathy because it is integral to the dementia. Demented patients get encephalopathic from minor conditions like UTI, Hyponatremia and Dehydration Post Ictal Confusion is not coded as Encephalopathy. It is integral to the Seizure. CVA usually does not usually cause confusion Aphasia is not confusion. It is a problem speaking or understanding words. A language problem. Alcohol Intoxication is Encephalopathy Delirium is acute in onset, reversible with treatment and fluctuating throughout the day. Characterized by altered LOC (Inattention) Type I (One) MI STEMI NSTEMI Types of MI Elevated Troponin Levels MI CHF End Stage Renal Disease Pulmonary Embolus Aortic Dissection Strenuous Exercise Pericarditis Myocarditis Cardiac Contusion Ablation Chemotherapy Sepsis Tachycardia Severe Systemic Illness Demand-Supply Mismatch Type 2 (Two) MI (Troponin Leak) Type 1: Classic MI caused by Coronary Artery Occlusion Type 2: Myocardial cell death leading to Troponin Leak Type 3: MI causing fatal Cardiac Arrest Type 4: MI related to Cardiac Stent Procedure Type 5: MI related to CABG Surgery Common Troponin Patterns Rising and Falling Pattern: Type I MI Troponin Peaks at > 2-3 times normal Constant Low Level Elevation: Type 2 MI Troponin Levels can be in the Grey Zone ng/dl Copyright Physician Advisor Training Academy 3

4 Copyright 2018 Jeffrey E. Epstein, M 4

5 Congestive Heart Failure i50 Acute Chronic Acute on Chronic Systolic Diastolic Combined Definitions: Systolic: EF < 40% Diastolic: EF > 40% with LVH Acute: Recently Worse (days or weeks) Chronic: Long Standing CHF (months or years) Continue to describe the Heart Failure very precisely for clinical communication Ejection Fraction, Pulmonary Artery Systolic Pressure, Valve Problems Hospice/Palliative Care/Comfort Measures ICD-10 Palliative Care Curative Care Supportive Care Comfort Care Only CVA Dementia Cancer Coma Palliative Care Curative Care with Aggressive Symptom Control Hospice Life Expectation 6 months can be Full Treatment with DNR Comfort Measures No treatment of acute conditions. Treat Symptoms. DNR No CPR if Heart Stops or Breathing Stops 5

6 Mental and Behavioral ICD-10 Dementia/Delirium/Psychosis/Bipolar/Depression/Behavioral Problems/Substance Abuse Type Bipolar Schizophrenia Delirium Dementia Behavior Disturbance Substance Abuse Dementia Vascular Lewy Bodies (Parkinson) Alzheimer's-Early Onset Alzheimer's-Late Onset Psychosis Delusional Hallucinations Mood Disorders Paranoia Hysterical Conversion Disorder Acute Delirium with Dementia Without Behavioral Disturbance With Behavioral Disturbance Behavioral Problems Aggressive Combative Violent Wandering Patient Noncompliance Z91.X Z91.11 Patient's noncompliance with dietary regimen Z Patient's intentional underdosing of medication regimen Z Patient's unintentional underdosing of medication regimen Z91.14 Patient's other noncompliance with medication regimen Z91.15 Patient's noncompliance with renal dialysis Z91.19 Patient's noncompliance with other medical treatment and regimen 6

7 Discharge Planning in Progress Notes Anticipated Date of Discharge Today Tomorrow 2 days More than 2 days *ADOD: Anticipated Date of Discharge Discharge Disposition Home without Services Home with Home Health Assisted Living Facility (ALF) Skilled Nursing Facility (SNF) Acute Inpatient Rehabilitation Custodial Care Hospice Inpatient Psych Special Needs PT/OT/ST O2 Wound Vac IV Abx Life Vest Hemodialysis Chemo Wound Care Vent Discharge Planning in the Assessment & Plan Example (Hospitalists & Specialists) Discharge: ADOD tomorrow. She should go to a SNF. She will need a Wound Vac, IV Abx and PT/OT. Sepsis Syndrome Procalcitonin can be helpful SIRS Criteria *Please note that the meaning of the word septicemia has changed 1. Temp: > (38.0) or < 96.8 (36.0) 2. White Count: > 12,000 or < 4000 or > 10% Bands Urosepsis 3. Respiratory Rate: > 20 breaths/min and paco2 < 32 mm Hg 4. Heart Rate: > 90 bpm Sepsis due to UTI Bacteremia = The presence of microorganisms in the blood without disease. A laboratory finding only. Septicemia* = The presence of microorganisms in the blood with a Systemic Disease that is NOT Sepsis. SEPSIS is a severe Infection with at least TWO (2) SIRS Criteria. Severe Sepsis = Sepsis with end organ dysfunction (Encephalopathy, DIC, Respiratory, Liver or Renal Failure). Septic Shock = Severe Sepsis with Cardiovascular Failure (Hypotension) not responsive to fluids. ***If patient meets Sepsis Criteria but patient does not seem severely ill, consider documenting EARLY SEPSIS or POSSIBLE SEPSIS. If the patient does not have Sepsis, document NOT SEPSIS *** Remember to Document: Present on Admission (POA) and Resolved UTI as Source: Sepsis due to UTI : Fever, White Count & Positive Urinalysis 7

8 What is Sepsis? There are three (3) valid ways of documenting and supporting Sepsis and all 3 methods should be used to determine which patients have Sepsis and which patients should have the Sepsis. 1. Definition from Sepsis Conference #1: Sepsis is defined as Infection plus two or more SIRS criteria. Severe Sepsis is Sepsis with end organ dysfunction and Septic Shock is Sepsis with Low BP unresponsive to fluids alone. 2. Definition from Sepsis Conference #3: Sepsis is defined as 2 or more SOFA criteria. 1. The SOFA criteria (Sequential Organ Failure Assessment) 1. Confusion 2. RR > SPB < Using Complex Medical Decision. If you think a patient has Sepsis, you can document Sepsis, tell why you think it is Sepsis 1. Criteria above is very helpful, but some patients may be Septic and manifest none of the criteria above. Complex Medical Decision by the physician is ALWAYS the final word. Make sure you document your thoughts and WHY you think the patient has Sepsis. RECTAL TEMPS, Cases to Be Super-Alert and SOFA Criteria (AMS, RR, SPB) CAUTION These type patients may be septic without manifesting all signs and symptoms of sepsis Dialysis Patients (line infections and abscesses) Patients on long term steroids (COPD) Elderly patients (thin, fragile, malnourished) Patients being treated for cancer (chemo, radiation) Patients on Immune suppressants (psoriasis, rheum arthritis) Ureteral Stones causing obstruction Patients with implants (pacemaker, spinal implants) RECTAL TEMPERATURES should be routinely done on all patients with suspected infection who do not manifest a fever. If the nurse has not done this, please write an order to do a RECTAL TEMPERATURE. 8