HOW TO USE THE CLINICAL PATHWAY
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1 CONGESTIVE HEART FAILURE CLINICAL PATHWAY ACUTE STAGE HANOVER AND DISTRICT HOSPITAL INCLUSION CRITERIA Primary admitting diagnosis is Congestive Heart Failure as defined by New York Heart Association. EXCLUSION CRITERIA Patients less than 19 years of age. HOW TO USE THE CLINICAL PATHWAY PATIENT ID This is a proactive tool to avoid delays in treatment and discharge. These are not orders, only a guide to usual orders. Place 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 Pathway. PHYSICIANS: Add or delete tasks according to individual patient complexity, and initial all changes. HEALTH CARE PROFESSIONALS: Initial tasks as completed. 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 Notes. 5. TRANSFER PATIENTS: if patient is transferred to another hospital in Grey-Bruce, send the following: 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 chart All rights reserved. No part of this document may be reproduced or transmitted, in any form or by any means, without the prior permission of the copyright owner. Approved (March 2007) Grey Bruce Health Network 1
2 Approved (March 2007) Grey Bruce Health Network 2
3 CONGESTIVE HEART FAILURE CLINICAL PATHWAY ACUTE STAGE HANOVER AND DISTRICT HOSPITAL COMORBID CONDITIONS: PATIENT ID PHASE 1 (Approximately 2 days) IMPROVEMENT OF OXYGENATION - <5L O 2 REQUIRED BY PRONG; 35% BY MASK WEIGHT DECREASED SINCE ADMISSION RESPIRATORY RATE <30 INITIAL PATIENT OUTCOMES* IMPROVEMENT OF CRACKLES IN LUNGS TOLERATES ACTIVITY LEVEL 2 ABSENCE OF UNSTABLE ARRHYTHMIAS Once all Patient Outcomes are achieved, move to Phase 2 ABSENCE OF CHEST PAIN PATIENT REPORTS IMPROVEMENT OF DYSPNEA CARDIAC MONITOR IF ORDERED CHEST ASSESSMENT ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) VITALS INCLUDING O 2 SATS Q4H MONITOR INTAKE AND OUTPUT (24 HOURS) PERIPHERAL EDEMA (SEE CHART BELOW) DAILY WEIGHT, DISCUSS WITH PATIENT - DOCUMENTED BY NURSE AND PATIENT ASSESS ANXIETY AND INTERVENE IF NECESSARY ASSESSMENT OF PITTING EDEMA 2mm or less = 1 + Edema Slight pitting No visible distortion Disappears rapidly 2-4mm = 2 + Edema Somewhat deeper pit No readably detectable distortion Disappears in seconds (2-4 mm indent) 4-6mm = 3 + Edema Pit is noticeably deep May last more than 1 minute Dependent extremity looks fuller and swollen (4-6mm) Assessment Chart for Pitting Edema adapted from the Guelph General Hospital Congestive Heart Failure Pathway Approved (March 2007) Grey Bruce Health Network 3
4 PHASE 1 (Approximately 2 days) CONSULTS DIAGNOSTICS/ LABORATORY MEDICATIONS TREATMENTS/ INTERVENTIONS NUTRITION 2D ECHOCARDIOGRAM IF ORDERED DIETITIAN CCAC IF NECESSARY PHARMACIST IF ORDERED ECG BLOOD WORK AS ORDERED CARDIAC MARKERS CHEST X-RAY ON ADMISSION SEE MAR SHEET INTERMITTENT SET O 2 AT L PRN TO KEEP 85-95% HEALTHY HEART DIET, 2-3 gm Na SPECIAL DIET IF REQUIRED: UP TO ACTIVITY LEVEL 2 AS TOLERATED BY PATIENT MOBILITY/ACTIVITY * ACTIVITY LEVEL 1: ACTIVITY LEVEL 2: BED REST BED SIDE COMMODE PRIVILEGE IF STABLE FEED SELF ASSISTED BATH ANKLE / FOOT EXERCISES DEEP BREATHING / COUGHING / CALF PUMPING SIT UP FOR 20 MIN (TID) BATHROOM PRIVILEGES ORIENTATION TO UNIT AND PROCEDURES PSYCHOSOCIAL SUPPORT/ EDUCATION * INTRODUCE PATIENT PATHWAY BEGIN TEACHING CHECKLIST GIVE PATIENT EDUCATION MATERIALS TO PATIENT ENCOURAGE PATIENT AND FAMILY TO ASK QUESTIONS DISCHARGE PLANNING * DISCUSS DISCHARGE PLAN WITH PATIENT AND FAMILY ASSESS FOR CCAC ASSESS DISCHARGE CRITERIA DAILY Activity Levels (1-4) adapted from the Guelph General Hospital AMI Activity Level Guideline Approved (March 2007) Grey Bruce Health Network 4
5 CONGESTIVE HEART FAILURE CLINICAL PATHWAY ACUTE STAGE HANOVER AND DISTRICT HOSPITAL PATIENT ID PHASE 2 (Approximately 2 days) INITIAL ABSENCE OF CRACKLES ON LUNGS PATIENT OUTCOMES* O 2 SATS ON ROOM AIR >90% OFF OXYGEN OR RETURNED TO PRE-HOSPITALIZATION LEVEL OF O 2 TOLERATES ACTIVITY LEVEL 3 OR RETURNED TO PRE-HOSPITALIZATION LEVEL Once all Patient Outcomes are achieved, move to Discharge Criteria ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) CONSULTS DIAGNOSTICS/ LABORATORY CHEST ASSESSMENT VITALS INCLUDING 0 2 SATS BID AND PRN ASSESS FOR EDEMA (SEE CHART BELOW) DAILY WEIGHT, DISCUSS WITH PATIENT - DOCUMENTED BY NURSE AND PATIENT ARRANGE HOME O 2 IF NEEDED CHEST X-RAY ABGs IF CONSIDERED FOR HOME O 2 BLOOD WORK AS ORDERED ASSESSMENT OF PITTING EDEMA 2mm or less = 1 + Edema Slight pitting No visible distortion Disappears rapidly 2-4mm = 2 + Edema Somewhat deeper pit No readably detectable distortion Disappears in seconds (2-4 mm indent) 4-6mm = 3 + Edema Pit is noticeably deep May last more than 1 minute Dependent extremity looks fuller and swollen (4-6mm) Approved (March 2007) Grey Bruce Health Network 5
6 PHASE 2 (Approximately 2 days) MEDICATIONS SEE MAR SHEET TREATMENTS/ INTERVENTIONS CHECK WITH PHYSICIAN REGARDING DISCONTINUING INTERMITTENT SET NUTRITION HEALTHY HEART DIET, 2-3 gm Na SPECIAL DIET IF REQUIRED: UP IN ROOM AD LIB MOBILITY/ACTIVITY * ACTIVITY LEVEL 3 AS TOLERATED: SIT UP FOR MEALS SHOWER WALK IN HALL PSYCHOSOCIAL SUPPORT/ EDUCATION * REVIEW PATIENT PATHWAY COMPLETE TEACHING CHECKLIST ADDRESS ANY QUESTIONS THE PATIENT MAY HAVE DISCUSS DISCHARGE PLANS WITH PATIENT CONSIDER FOR CARDIAC REHAB, IF APPROPRIATE, SECURE PHYSICIAN/NURSE PRACTITIONER ORDER DISCHARGE PLANNING * REVIEW MEDICATIONS FOR HOME REVIEW ACTIVITY LEVELS FOR HOME ASSESS NEEDS FOR DISCHARGE ASSESS DISCHARGE CRITERIA DAILY SECURE DISCHARGE ORDER ONCE INDICATORS MET Approved (March 2007) Grey Bruce Health Network 6
7 CONGESTIVE HEART FAILURE CLINICAL PATHWAY ACUTE STAGE HANOVER AND DISTRICT HOSPITAL PATIENT ID DISCHARGE CRITERIA MET INITIAL 1 ACE INHIBITOR PRESCRIBED AT DISCHARGE 2 BETA BLOCKER PRESCRIBED AT DISCHARGE PERFORMANCE INDICATORS ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) 3 WARFARIN FOR ATRIAL FIBRILLATION PRESCRIBED AT DISCHARGE 4 WEIGHT MEASURED EACH DAY OF HOSPITALIZATION 5 ECHOCARDIOGRAM COMPLETED 6 SMOKING CESSATION ADVICE/COUNSELLING COMPLETED DISCHARGE INSTRUCTIONS RE: DISCHARGE 7 MEDS, SALT/FLUID RESTRICTIONS, DAILY WEIGHTS, SYMPTOMS OF WORSENING CHF, FOLLOW UP APPOINTMENT NEW YORK HEART ASSOCIATION (NYHA) LEVEL IMPROVED BY ONE OR MORE GRADES SINCE ADMISSION: D/C NYHA LEVEL: IMPROVEMENT OF PERIPHERAL EDEMA SINCE ADMISSION RESPIRATORY RATE IMPROVED SINCE ADMISSION NO CHEST PAIN OR PAIN FROM DYSPNEA WEIGHT DECREASED SINCE ADMISSION BLOOD PRESSURE WITHIN STABLE LIMITS FOR INDIVIDUAL CONSULTS DIAGNOSTICS/ LABORATORY ELECTROLYTES WITHIN NORMAL LIMITS STABLE RENAL FUNCTION - CREATININE <220 ORAL MEDS STABLE x 24 HOURS MEDICATIONS OFF INOTROPES 48 HOURS PATIENT VERBALIZES UNDERSTANDING OF MEDS TREATMENTS/ INTERVENTIONS NUTRITION PATIENT VERBALIZES UNDERSTANDING OF HEALTHY HEART DIET, SALT/FLUID RESTRICTIONS MOBILITY/ACTIVITY PATIENT TOLERATING ACTIVITY LEVEL 3 (NO DYSPNEA/ DIZZINESS) PSYCHOSOCIAL SUPPORT/ EDUCATION PATIENT VERBALIZES IMPORTANCE OF DAILY WEIGHTS PATIENT VERBALIZES UNDERSTANDING OF SYMPTOMS OF WORSENING HEART FAILURE, WHEN TO CALL PHYSICIAN/COME TO HOSPITAL DISCHARGE PLANNING FOLLOW UP APPOINTMENTS: FAMILY PHYSICIAN CARDIAC REHAB CHF CLINIC Approved (March 2007) Grey Bruce Health Network 7
8 Approved (March 2007) Grey Bruce Health Network 8
HOW TO USE THE CLINICAL PATHWAY
1. 2. 3. 4. INCLUSION CRITERIA Primary admitting diagnosis is Congestive Heart Failure as defined by New York Heart Association. EXCLUSION CRITERIA Patients less than 19 years of age. HOW TO USE THE This
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