CONGESTIVE HEART FAILURE CLINICAL PATHWAY ACUTE STAGE GREY BRUCE HEALTH SERVICES Lion's Head Markdale Meaford Owen Sound Southampton Tobermory Wiarton 1. 2. 3. 4. INCLUSION CRITERIA EXCLUSION CRITERIA Patients less than 19 years of age. HOW TO USE THE CLINICAL PATHWAY PATIENT ID Primary admitting diagnosis is Congestive Heart Failure as defined by New York Heart Association. 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 2004-2007 Grey Bruce Health Network 1
POSITION NAME (Please Print) INITIAL SIGNATURE NURSE PT DIETITIAN PLANNER CCAC OTHER (Specify) 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. 2004-2007 Grey Bruce Health Network 2
CONGESTIVE HEART FAILURE CLINICAL PATHWAY ACUTE STAGE GREY BRUCE HEALTH SERVICES Lion's Head Markdale Meaford Owen Sound Southampton Tobermory Wiarton COMORBID CONDITIONS: PATIENT ID PROCESS PHASE 1 (Approximately 2 days) INITIAL IMPROVEMENT OF OXYGENATION - <5L O 2 REQUIRED BY PRONG; 35% BY MASK WEIGHT DECREASED SINCE ADMISSION RESPIRATORY RATE <30 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 x 24H; QID X 24H 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 2-4mm = 2 + Edema 4-6mm = 3 + Edema 6-8mm = 4 + Edema Slight pitting No visible distortion Disappears rapidly Somewhat deeper pit No readably detectable distortion Disappears in 10-15 seconds (2-4 mm indent) Pit is noticeably deep May last more than 1 minute Dependent extremity looks fuller and swollen (4-6mm) Pit is very deep Lasts as long as 2-5 minutes Dependent extremity is grossly distorted (6-8mm) Assessment Chart for Pitting Edema adapted from the Guelph General Hospital Congestive Heart Failure Pathway 2004-2007 Grey Bruce Health Network 3
PROCESS PHASE 1 (Approximately 2 days) 2D ECHOCARDIOGRAM IF ORDERED CLINICAL NUTRITION CONSULTS CCAC IF ORDERED PHARMACIST IF ORDERED ECG ECG WITH CHEST PAIN, NOTIFY PHYSICIAN DIAGNOSTICS/ LABORATORY BLOOD WORK AS ORDERED CARDIAC MARKERS CHEST X-RAY ON ADMISSION (next morning if after hours) MEDICATIONS SEE MAR SHEET TREATMENTS/ INTERVENTIONS INTERMITTENT SET O 2 AT L PRN TO KEEP 85-95% NUTRITION 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 PLANNING * DISCUSS PLAN WITH PATIENT AND FAMILY ASSESS FOR CCAC ASSESS CRITERIA DAILY Activity Levels (1-4) adapted from the Guelph General Hospital AMI Activity Level Guideline 2004-2007 Grey Bruce Health Network 4
CONGESTIVE HEART FAILURE CLINICAL PATHWAY ACUTE STAGE GREY BRUCE HEALTH SERVICES Lion's Head Markdale Meaford Owen Sound Southampton Tobermory Wiarton PATIENT ID PROCESS 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 WHEN STABLE 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 IF ORDERED ABGs IF CONSIDERED FOR HOME O 2 BLOOD WORK AS ORDERED ASSESSMENT OF PITTING EDEMA 2mm or less = 1 + Edema 2-4mm = 2 + Edema 4-6mm = 3 + Edema 6-8mm = 4 + Edema Slight pitting No visible distortion Disappears rapidly Somewhat deeper pit No readably detectable distortion Disappears in 10-15 seconds (2-4 mm indent) Pit is noticeably deep May last more than 1 minute Dependent extremity looks fuller and swollen (4-6mm) Pit is very deep Lasts as long as 2-5 minutes Dependent extremity is grossly distorted (6-8mm) 2004-2007 Grey Bruce Health Network 5
PROCESS 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 PLANS WITH PATIENT PLANNING * CONSIDER FOR CARDIAC REHAB AND CHF CLINIC, IF APPROPRIATE, SECURE PHYSICIAN/NURSE PRACTITIONER ORDER REVIEW MEDICATIONS FOR HOME REVIEW ACTIVITY LEVELS FOR HOME ASSESS NEEDS FOR ASSESS CRITERIA DAILY SECURE ORDER ONCE INDICATORS MET 2004-2007 Grey Bruce Health Network 6
CONGESTIVE HEART FAILURE CLINICAL PATHWAY ACUTE STAGE GREY BRUCE HEALTH SERVICES Lion's Head Markdale Meaford Owen Sound Southampton Tobermory Wiarton PATIENT ID PROCESS CRITERIA MET INITIAL 1 ACE INHIBITOR PRESCRIBED AT 2 BETA BLOCKER PRESCRIBED AT 3 WARFARIN FOR ATRIAL FIBRILLATION PRESCRIBED AT PERFORMANCE INDICATORS ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) CONSULTS DIAGNOSTICS/ LABORATORY MEDICATIONS TREATMENTS/ INTERVENTIONS NUTRITION MOBILITY/ACTIVITY PSYCHOSOCIAL SUPPORT/ EDUCATION PLANNING 4 WEIGHT MEASURED EACH DAY OF HOSPITALIZATION 5 ECHOCARDIOGRAM COMPLETED 6 SMOKING CESSATION ADVICE/COUNSELLING COMPLETED INSTRUCTIONS RE: MEDS, 7 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 ELECTROLYTES WITHIN NORMAL LIMITS STABLE RENAL FUNCTION - CREATININE <220 ORAL MEDS STABLE x 24 HOURS OFF INOTROPES 48 HOURS PATIENT VERBALIZES UNDERSTANDING OF MEDS PATIENT VERBALIZES UNDERSTANDING OF HEALTHY HEART DIET, SALT/FLUID RESTRICTIONS PATIENT TOLERATING ACTIVITY LEVEL 3 (NO DYSPNEA/ DIZZINESS) PATIENT VERBALIZES IMPORTANCE OF DAILY WEIGHTS PATIENT VERBALIZES UNDERSTANDING OF SYMPTOMS OF WORSENING HEART FAILURE, WHEN TO CALL PHYSICIAN/COME TO HOSPITAL FOLLOW UP APPOINTMENTS: FAMILY PHYSICIAN CARDIAC REHAB CHF CLINIC 2004-2007 Grey Bruce Health Network 7
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