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County of Los AngelesDepartment of Health ServicesCongestive Heart Failure (Ward/Stepdown)Physician's Orders - AdmissionThis is a general guideline and does not represent a professional care standard governing provider obligations to patients.Care is revised to meet individual patient needs.I. Admit To:ServiceUnit/Ward:Change of Service/Team as of:MD/NP/PA:Pager No.: ()MD/NP/PA:Pager No.: ()Sr. Resident:Pager No.: ()Pager No.: ()Attending M.D.:Instructions:/ / Time:To:All patients will be placed on this clinical pathway unless excluded for one or more of the following reasons:III. Excluded for:II. Inclusion Criteria:Patient admitted with severe, complicating medical diagnosisNo exclusions, place on pathway for:Patient admitted to hospital for more than 24 hours prior to consideration forplacement on pathwayPrimary diagnosis of congestive heart failurePatient scheduled for revascularization or heart transplantIV. Diagnosis:Congestive heart failureV. Clinically Significant Co-Morbidity(s):VI.NoneDiabetesMorbid obesity (BMI 40 or greater)No home care giverOn research protocolPulmonary diseaseRenal disease (creatinine greaterthan 2.5 mg per dL)Known allergies (specify)b.VIII. Condition:c.VII. Height/Weight: (To be completed by RN)Height: cmGoodFairNo known allergiesa.Substance abuseAllergies:orinSeriousWeight: kgor lbCriticalCPR Status and Patient DirectivesA. CPR status order:All patients are "Full Code" unless one of the following DNR boxes is selected:DNR: Do not start CPR - Continue all other medical/surgical management unless excluded in section [B] belowDNR: Do not start CPR - Patient is terminally ill and requests comfort measures (pain and symptom management) onlyB. Patient directives during this hospitalization:No intubationNo blood drawsNo invasive proceduresNo pressorsNo blood productsNo antibioticsNo dialysisOther:Attending Physician Sig: ID#: Date: / / Time:These orders require concurrent attending approval documented in the progress notes with attending' s signature of order within 24 hrs.Provider Last Name (Print):Provider Signature:Date:/ID#:/Time::AM / PMRN Last Name (Print):RN Signature:Date:Initials://Time:Clerk/LVN Signature:Date:/:AM / PMInitials:/Time:: Copyright 1999-08 LAC-DHS Published: 03/10/2008Comments regarding this form? Call (818) 364-3566!T-HS1042!AM / PMCongestive Heart Failure (Ward/Stepdown)Physician's Orders - AdmissionFORM NO. T-HS1042 (03/10/2008)
County of Los AngelesDepartment of Health ServicesENDCongestive Heart Failure (Ward/Stepdown)Physician's Orders - Day 1 of 5This is a general guideline and does not represent a professional care standard governing provider obligations to patients.Care is revised to meet individual patient needs.INSTRUCTIONS: If an order is desired, please"X" the box; leave blank if not desired. If a pre-checked order is not desired, you may cancel the order by drawing a line throughit, followed by your initials.Assessment:Vital signs:Q2 hrsQ4 hrsQ8 hrsO2 sat by pulse oximetry:Q2 hrsQ4 hrsQ8 hrsRecord strict input andoutput:Q4 hrsQ8 hrsWeigh patient on arrival and daily in am on same scale-1Obtain old chart-1Physician Notification:Notify provider for any of the following:Systolic BP less than 90 or greater than 160 mmHgPulse less than 55 or greater than 110 BPMDiastolic BP less than 60 or greater than 110 mmHgResp. rate less than 12 or greater than 26O2 saturation less than 93% with or without O2 administeredNew onset chest painTemp. less than 36.1 C (97.0 F) or greaterthan 38.6 C (101.5 F)Decreased urine output: Measured intake greaterthan outputWeight gain greater than 2 lbs (1 kg) (within 24 hrs)Activity:Bed rest and bedside commode with assistanceOut of bed into chair or wheelchair TIDBed rest and bathroom privileges with assistanceRange of motion upper and lower extremities5 times each TIDOther:Diet:2 gm sodiumHeart Healthy (low fat, low cholesterol)Consistent Carbohydrate (ADA)Restrict fluids to mL per 24 hrsOther:Treatment:Elevate head of bed to at least 30 Convert IV to saline lock; flush per Unit protocolIV D5W at 15 mL per hr, to keep openO2 via nasal cannula at 1-4L per min to maintainO2 sat greater than 92%Cardiology for:Social services for:Consults:Medication Reconciliation: List all patient’s home medications (include samples, OTC, vitamins, herbals, and others); Select Continueor Discontinue. Do not duplicate orders written here in the next medication order sections. (Prohibited abbreviations: qd, qod,U, IU, lack of leading zero .X, trailing zero X.0, MS, MSO4, MgSO4)Information source:Weight: kg lbsMeasuredStatedFOR THIS ADMISSIONContinuePatient not currently taking medicationHeight: cm ft inCURRENT HOME MEDICATIONSMedication history not tructions/IndicationsProvider Last Name (Print):Provider Signature:Date:/ID#:/Time:/Time:/Time::AM / PMRN Last Name (Print):RN Signature:Date:Initials:/Clerk/LVN Signature:Date:/:AM / PMInitials:: Copyright 1999-08 LAC-DHS Published: 03/10/2008Comments regarding this form? Call (818) 364-3566AM / PMCongestive Heart Failure (Ward/Stepdown)Physician's Orders - Day 1 of 5 / Pg. 1 of 5!T-HS1042!Day 1FORM NO. T-HS1042 (03/10/2008)
Medicine DVT Risk Assessment ToolContraindications to Anticoagulation(consider sequential compression device alone ifanticoagulation is contraindicated)AbsoluteActive hemorrhageHistory of heparin induced thrombocytopenia (HIT)Current severe hypertension (BP 190/110)RelativeActive intracranial lesion/neoplasmBiopsy sites inaccessible to hemostatic controlGI or GU bleed within past 4 weeksPrevious cerebral hemorrhageProliferative retinopathyRecent intraocular or intracranial surgeryThrombocytopenia or other coagulopathyTraumatic or repeated epidural or spinal punctureRelative Contraindications toSequential Compression DeviceAcute superficial or deep vein thrombosisCHF (class III or IV)Severe peripheral artery diseaseRisk Factors(1 point each unless otherwise noted)StasisAcute COPD exacerbationAcute MIAge 40 years or greaterAnticipated immobilization/bed confinement (greater than 24 hrs)CHF (class III or IV) (3 points)Leg swelling, ulcers or varicose veinsMechanical ventilation (3 points)Obesity (BMI 30 or greater)Patient hospitalized, in SNF or nursing home within 90 days (3 points)PneumoniaRecent confining travel (air or ground) greater than 4 hrsSpinal cord injury with paresis (3 points)Stroke with paresis (3 points)HypercoagulabilityDocumented history of DVT or PE (3 points)Estrogenic hormone use (estrogen, tamoxifen, etc.)Family history of DVT or PEHypercoagulable states (lupus anticoagulant, etc.) (3 points)Indwelling central venous catheterInflammatory bowel disease or systemic vasculitisMyeloproliferative disorder (non-hemorrhagic)Nephrotic syndromePregnant, or postpartum less than 1 monthSevere systemic infection or sepsisVisceral malignancyRisk Categories and Suggested DVT ProphylaxisEarly ambulation recommended for all patients, if possible.Low Risk1 point or lessModerate Risk2 pointsHigh Risk3 pointsVery High Risk4 points or greaterEarly ambulationHeparinorSequential compression deviceHeparinorEnoxaparin [LOVENOX]Heparin or Enoxaparin [LOVENOX]andSequential compression deviceAnti-coagulation Medication DosingMedicationUsual DoseCommentsHeparin5,000 units subcutaneous Q8 hrsNo adjustment needed in renal insufficiencyConsider lower dose for small/frail/elderly patientEnoxaparin[LOVENOX]40 mg subcutaneous Q24 hrsFor CrCl less than 30 mL per min: 30 mg subcutaneous Q24 hrs Copyright 2006-08 LAC-DHS Published: 03/10/2008Comments regarding this form? Call (818) 364-3566Medicine DVT Risk Assessment
County of Los AngelesDepartment of Health ServicesENDCongestive Heart Failure (Ward/Stepdown)Physician's Orders - Day 1 of 5FOR THIS ADMISSIONContinueCURRENT HOME ndicationsComfort Medications - Do not exceed 4 gms acetaminophen per 24 hrsDocusate [COLACE] 100 mg PO BID (hold for diarrhea)Milk of magnesia 30 mL PO Q12 hrs PRN constipationAluminum hydroxide/magnesium hydroxide/simethicone [MYLANTA] 30 mL PO Q4 hrs PRN dyspepsiaAcetaminophen [TYLENOL] 650 mg PO Q4 hrs PRN. Specify PRN indication(s) below.Mild painTemp. greater than 38.5 C (101.3 F)Diphenhydramine [BENADRYL] 25 mg PO Nightly PRN insomniaDiphenhydramine [BENADRYL] 50 mg PO Nightly PRN insomniaOther:DVT Prophylaxis (Calculate DVT risk from DVT Risk Assessment Tool); Consider lower dose for small/frail/elderly patientRisk assessment completed: pharmacologic prophylaxis risk outweighs benefitHeparin 5,000 units subcutaneous Q8 hrs (moderate, high, or very high DVT risk)Enoxaparin [LOVENOX] 40 mg subcutaneous Q24 hrs (high or very high DVT risk)Enoxaparin [LOVENOX] 30 mg subcutaneous Q24 hrs (high or very high DVT risk, and CrCl less than 30 mL per min)Sequential compression device to lower extremitiesOther:M.D. Signature:Date:ID#:Time:R.N. Signature:Date:Init:Time:Clerk Signature:Date:Init:Time: Copyright 1999-08 LAC-DHS Published: 03/10/2008Comments regarding this form? Call (818) 364-3566Congestive Heart Failure (Ward/Stepdown)Physician's Orders - Day 1 of 5 / Pg. 2 of 5!T-HS1042!Day 1FORM NO. T-HS1042 (03/10/2008)
County of Los AngelesDepartment of Health ServicesENDCongestive Heart Failure (Ward/Stepdown)Physician's Orders - Day 1 of 5ACE-Inhibitor (Should be used unless contraindicated)10 mg PO DailyBenazepril [LOTENSIN]40 mg PO Daily20 mg PO DailyCaptopril [CAPOTEN]6.25 mg PO Q8 hrs50 mg PO Q8 hrs12.5 mg PO Q8 hrs100 mg PO Q8 hrs25 mg PO Q8 hrsCaptopril titration (Goal is SBP 82-90 mmHg. If GFR less than 50, consider slower titration)6.25 mg PO now. If SBP greater than 90 mmHg, double the dose Q8 hrs to amaximum dose of 100 mg Q8 hrs. Do not double dose if SBP 82 - 90 mmHg;continue with last dose given. If SBP less than 82 mmHg, hold dose and call MD.Other:Captopril [CAPOTEN] titrationAnticoagulant (Do not use pharmacologic DVT prophylaxis if patient is anticoagulated)Enoxaparin [LOVENOX]Specify dose: mg1 mg per kg per dose subcutaneous Q12 hrsWarfarin [COUMADIN]2.5 mg PO DailyOther:5 mg PO DailyAntiplatelet81 mg PO DailyAspirin (with food)165 mg PO DailyBeta Blocker (Do not initiate beta blocker therapy during acute clinical decompensation)3.125 mg PO BID12.5 mg PO BIDCarvedilol [COREG]Metoprolol [LOPRESSOR]6.25 mg PO BID25 mg PO BID12.5 mg PO BID50 mg PO BID25 mg PO BID100 mg PO BID0.125 mg PO Daily0.25 mg PO DailyCardiac Glycoside (Systolic dysfunction)Digoxin [LANOXIN]M.D. Signature:Date:ID#:Time:R.N. Signature:Date:Init:Time:Clerk Signature:Date:Init:Time: Copyright 1999-08 LAC-DHS Published: 03/10/2008Comments regarding this form? Call (818) 364-3566Congestive Heart Failure (Ward/Stepdown)Physician's Orders - Day 1 of 5 / Pg. 3 of 5!T-HS1042!Day 1FORM NO. T-HS1042 (03/10/2008)
County of Los AngelesDepartment of Health ServicesENDCongestive Heart Failure (Ward/Stepdown)Physician's Orders - Day 1 of 5DiureticFurosemide [LASIX] - NOW20 mg PO one dose now20 mg IVP one dose now40 mg PO one dose now40 mg IVP one dose now80 mg PO one dose now80 mg IVP one dose nowOther:Furosemide [LASIX]20 mg PO BID3 mg per hr IV continuous40 mg PO BID5 mg per hr IV continuous80 mg PO BID7.5 mg per hr IV continuous20 mg IVP BID10 mg per hr IV continuous40 mg IVP BIDOther:80 mg IVP BIDSpironolactone [ALDACTONE]12.5 mg PO Daily25 mg PO Daily20 mEq PO Daily40 mEq PO DailyPotassium ReplacementKCL (liquid)30 mEq PO DailyKCL (tablet) [K-DUR]20 mEq PO Daily20 mEq PO BID40 mEq PO Daily40 mEq PO BID60 mEq PO Daily60 mEq PO BID10 mg PO TID75 mg PO TID25 mg PO TID100 mg PO TIDVasodilatorHydralazine [APRESOLINE]50 mg PO TIDIsosorbide Dinitrate [ISORDIL]Isosorbide Mononitrate(Extended release)M.D. Signature:Date:40 mg PO TID w/meals30 mg PO Daily120 mg PO Daily60 mg PO Daily180 mg PO DailyTime:Init:Time:Clerk Signature:Date:30 mg PO TID w/meals20 mg PO TID w/mealsID#:R.N. Signature:Date:10 mg PO TID w/mealsInit:Time: Copyright 1999-08 LAC-DHS Published: 03/10/2008Comments regarding this form? Call (818) 364-3566Congestive Heart Failure (Ward/Stepdown)Physician's Orders - Day 1 of 5 / Pg. 4 of 5!T-HS1042!Day 1FORM NO. T-HS1042 (03/10/2008)
County of Los AngelesDepartment of Health ServicesENDCongestive Heart Failure (Ward/Stepdown)Physician's Orders - Day 1 of 5Insulin:Fingerstick glucose level:Before each mealtime and at bedtimeMaintenance l:(Correction dose)Less than70 mg per dL:Other:Give subcutaneous NPH/Regular insulin 30 minutes before meals (or bolus tube feed).Give subcutaneous rapid acting (Lispro) insulin with meals (or bolus tube feed).If patient NPO:Hold Regular/rapid acting insulin. Give ½ maintenance NPH insulin timeunitsw(1) With each fingerstick glucose level before meals , give additional subcutaneous Regular insulin perglucose level below, unless patient is NPO. (2) At bedtime , if glucose is 250 or less, give NO supplementalinsulin. If glucose 251 or greater at bedtime, give ½ the supplemental dose selected. (3) If more than 8 units ofsupplemental insulin required in 24 hrs, call provider to re-assess and adjust maintenance insulin dose.Hold maintenance Regular or rapid acting insulin for this one dose; continue other insulin. If alert and able totolerate PO fluids, give 120 mL juice PO now; otherwise give 25 mL D50 slow IVP now. Repeat fingerstick glucoselevel in 20 min. Call provider to re-assess and adjust insulin dose.70-150 mg per dL: No supplemental dose required.Lower dose:Higher dose:Other:151-200: units (None if at bedtime)151-200: 4 units (None if at bedtime)151-200: 2 units (None if at bedtime)201-250: units (None if at bedtime)201-250: 6 units (None if at bedtime)201-250: 4 units (None if at bedtime)251-300: units ( units if at bedtime)251-300: 8 units (4 units if at bedtime)251-300: 6 units (3 units if at bedtime)301-350: units ( units if at bedtime)301-350: 10 units (5 units if at bedtime)301-350: 8 units (4 units if at bedtime)Greater than 350: units ( units ifGreater than 350: 12 units (6 units ifGreater than 350: 10 units (5 units ifat bedtime), call MDat bedtime), call MDat bedtime), call MDLabs/Tests:All orders are "next routine" (next a.m. for blood/urine) unless ordered otherwise.MagnesiumNa, K, Cl, C02, BUN, Cr, Glu, Chol, AST, TP, Bili-T, AlbCBC with differentialUrinalysisTSHINR (if on Warfarin)Digoxin levelECGEchocardiogram (if LVEF unknown or severe change instatus)Chest x-ray PA/LAT (suspected CHF)Chest x-ray stat portable (suspected CHF)Other:Other:Other:Other:M.D. Signature:Date:ID#:Time:R.N. Signature:Date:Init:Time:Clerk Signature:Date:Init:Time: Copyright 1999-08 LAC-DHS Published: 03/10/2008Comments regarding this form? Call (818) 364-3566Congestive Heart Failure (Ward/Stepdown)Physician's Orders - Day 1 of 5 / Pg. 5 of 5!T-HS1042!Day 1FORM NO. T-HS1042 (03/10/2008)
County of Los AngelesDepartment of Health ServicesENDCongestive Heart Failure (Ward/Stepdown)Physicians Orders - Day 2 of 5This is a general guideline and does not represent a professional care standard governing provider obligations to patients.Care is revised to meet individual patient needs.INSTRUCTIONS: If an order is desired, please "X" the box; leave blank if not desired. If a pre-checked order is not desired, you may cancel the order by drawing a line throughit, followed by your initials.Assessment:Vital signs:Q4 hrsQ8 hrsActivity:Ambulate 3 - 5 mins TID or as toleratedDiet:2 gm sodium3 gm sodiumHeart Healthy (low fat, low cholesterol)Consistent Carbohydrate (ADA)Other:Treatment:Convert IV to saline lock; flush per Unit protocolConsults:Dietary for:Labs/Tests:Social services for:All orders are "next routine" (next a.m. for blood/urine) unless ordered otherwise.Na, K, Cl, C02, BUN, Cr, GluMagnesiumINR (if on Warfarin)Other:Provider Last Name (Print):Provider Signature:Date:/ID#:/Time:/Time:/Time::AM / PMRN Last Name (Print):RN Signature:Date:Initials:/Clerk/LVN Signature:Date:/:AM / PMInitials:: Copyright 1999-08 LAC-DHS Published: 03/10/2008Comments regarding this form? Call (818) 364-3566!T-HS1042!Day 2AM / PMCongestive Heart Failure (Ward/Stepdown)Physicians Orders - Day 2 of 5 / Pg. 1 of 1FORM NO. T-HS1042 (03/10/2008)
County of Los AngelesDepartment of Health ServicesENDCongestive Heart Failure (Ward/Stepdown)Physicians Orders - Day 3 of 5This is a general guideline and does not represent a professional care standard governing provider obligations to patients.Care is revised to meet individual patient needs.INSTRUCTIONS: If an order is desired, please "X" the box; leave blank if not desired. If a pre-checked order is not desired, you may cancel the order by drawing a line throughit, followed by your initials.Assessment:O2 sat by pulse oximetry:Q8 hrsQ12 hrsQ24 hrsIf O2 saturation is greater than 94% after 1/2 hr on room air, discontinue pulse oximetry and O2 therapy0Activity:Ambulate 5 -10 mins TIDDiet:Ad lib(Recommended sodium intake should be consistent with patient's realistic "at home" intake)2 gm sodiumDiscontinue fluid restrictions3 gm sodiumOther:4 gm sodiumTreatment:Convert IV to saline lock; flush per Unit protocolLabs/Tests:All orders are "next routine" (next a.m. for blood/urine) unless ordered otherwise.Na, K, Cl, C02, BUN, Cr, GluDischarge Plan:INR (if on Warfarin)0Anticipate discharge within the next 24 hrsGOALS: Write discharge order by 9:00 a.m. and discharge patient by 12:00 noon Send discharge medication prescription(s) to pharmacy today Arrange for home durable medical equipment/supplies as neededSchedule follow-up outpatient clinic appointment in days week(s)Specify clinic/location/MD:Discharge unlikely within the next 24 hrsOther:Provider Last Name (Print):Provider Signature:Date:/ID#:/Time:/Time:/Time::AM / PMRN Last Name (Print):RN Signature:Date:Initials:/Clerk/LVN Signature:Date:/:AM / PMInitials:: Copyright 1999-08 LAC-DHS Published: 03/10/2008Comments regarding this form? Call (818) 364-3566!T-HS1042!Day 3AM / PMCongestive Heart Failure (Ward/Stepdown)Physicians Orders - Day 3 of 5 / Pg. 1 of 1FORM NO. T-HS1042 (03/10/2008)
County of Los AngelesDepartment of Health ServicesENDCongestive Heart Failure (Ward/Stepdown)Physicians Orders - Day 4 of 5This is a general guideline and does not represent a professional care standard governing provider obligations to patients.Care is revised to meet individual patient needs.INSTRUCTIONS: If an order is desired, please "X" the box; leave blank if not desired. If a pre-checked order is not desired, you may cancel the order by drawing a line throughit, followed by your initials.Assessment:O2 sat by pulse oximetry:Q8 hrsQ12 hrsQ24 hrsIf O2 saturation is greater than 94% after 1/2 hr on room air, discontinue pulse oximetry and O2 therapy0Activity:Ad libTreatment:Discontinue sequential compression deviceLabs/Tests:All orders are "next routine" (next a.m. for blood/urine) unless ordered otherwise.Na, K, Cl, C02, BUN, Cr, GluDischarge Plan:INR (if on Warfarin)0Anticipate discharge within the next 24 hrsGOALS: Write discharge order by 9:00 a.m. and discharge patient by 12:00 noon Send discharge medication prescription(s) to pharmacy today Arrange for home durable medical equipment/supplies as neededSchedule follow-up outpatient clinic appointment in days week(s)Specify clinic/location/MD:Discharge unlikely within the next 24 hrsOther:Provider Last Name (Print):Provider Signature:Date:/ID#:/Time:/Time:/Time::AM / PMRN Last Name (Print):RN Signature:Date:Initials:/Clerk/LVN Signature:Date:/:AM / PMInitials::AM / PM Copyright 1999-08 LAC-DHS Published: 03/10/2008Comments regarding this form? Call (818) 364-3566!T-HS1042!Day 4Congestive Heart Failure (Ward/Stepdown)Physicians Orders - Day 4 of 5 / Pg. 1 of 1FORM NO. T-HS1042 (03/10/2008)
County of Los AngelesDepartment of Health ServicesENDCongestive Heart Failure (Ward/Stepdown)Physicians Orders - Day 5 OR Discharge DayThis is a general guideline and does not represent a professional care standard governing provider obligations to patients.Care is revised to meet individual patient needs.INSTRUCTIONS: If an order is desired, please "X" the box; leave blank if not desired. If a pre-checked order is not desired, you may cancel the order by drawing a line throughit, followed by your initials.Treatment:Discontinue saline lockDischarge Plan:Discontinue IV1Refer to CHF Disease Management ProgramDischarge patient today (Goal: discharge by 12:00 noon)Discharge discussed with attending and attending concursACE-inhibitor or ARB considered prior to dischargeInfluenza vaccine and Pneumovax considered prior to dischargeDo not discharge today due to: (Note: pathway orders will continue)Symptoms of heart failure, i.e. orthopnea, PND or edema, have not been adequately controlledOther:Other:Provider Last Name (Print):Provider Signature:Date:/ID#:/Time:/Time:/Time::AM / PMRN Last Name (Print):RN Signature:Date:Initials:/Clerk/LVN Signature:Date:/:AM / PMInitials:: Copyright 1999-08 LAC-DHS Published: 03/10/2008Comments regarding this form? Call (818) 364-3566!T-HS1042!AM / PMCongestive Heart Failure (Ward/Stepdown)Physicians Orders - Day 5 ORDischarge Day / Pg. 1 of 1D/C DayFORM NO. T-HS1042 (03/10/2008)
Department of Health ServicesCounty of Los AngelesCongestive Heart Failure (Ward/Stepdown)Daily Care Documentation - Day 1 of 5This is a general guideline and does not represent a professional care standard governing provider obligations to patients.Care is revised to meet individual patient dkfj sdkAdmission Date: / /Time:On Pathway Date: / jl;kasdfjINSTRUCTIONS: Every Pathway Milestone and Care Event must have a "Y","N" or "Not ordered"response. "Y" Pathway Milestone or Care Event met;"N" not met. If "N", complete Variance Documentation form. For Care Events only requiring one documentation per 24 hrs., document in Day (D) Shiftbox and initial in actual shift. Pathway Milestones are in bold. Micro Indicators are italicized.(N) Shift(D) Shift(E) Shift(N) ShiftNotCare Elements / Care Events/OutcomesCare Elements: Care cv1. Assessmentcv 1. O2 saturation 93% or greater1cv 2. Admission height/weight obtained1cv 3. Old chart available within 12 hrs of MD order1cv-12. PhysicianNotification1. Emergent signs and symptoms absent Systolic BP less than 90 or greater than 160 mmHg Diastolic BP less than 60 or greater than 110 mmHg Temp. less than 36.1 C (97.0 F) or greater than38.6 C (101.5 F) Pulse less than 55 or greater than 110 BPM Resp. rate less than 12 or greater than 26 New onset chest pain O2 saturation less than 93% with or without O2 administered Weight gain greater than 2 lbs (1 kg) (within 24 hrs) Decreased urine output: Measured intake greater than outputcv03. Consults1. All consults obtained as ordered4. -1Diet1. Fluids restricted as ordered2. Consumed and tolerated ordered diet5. Activity1. Ordered activity tolerated06. Teaching Plan01. Patientverbalizes understanding of pain scaleand pain intervention options02. CRMinpatient teaching guide given topatient/family/significant other03. Patientverbalizes understanding andacceptance of need for hospitalization.7. Medication01. All medication administered as ordered02. Patient free of adverse drug re/Title:Init.:Date: Copyright 1999-08 LAC-DHS Published: 03/10/2008Comments regarding this form? Call (818) 364-3566!T-HS1042!Day 1Congestive Heart Failure (Ward/Stepdown)Daily Care Documentation - Day 1 of 5 / Pg. 1 of 2FORM NO. T-HS1042 (03/10/2008)
Department of Health ServicesCounty of Los AngelesCongestive Heart Failure (Ward/Stepdown)Daily Care Documentation - Day 1 of 5Care Elements / Care Events/OutcomesCare Elements: Care Events/OutcomesNotOrdered(N) ShiftYNInit.(D) ShiftYNInit.(E) ShiftYNInit.(N) ShiftYNInit.8. 0Treatment1. Oxygen therapy effective2. Elevate head of bed at least 30 3. All treatments completed as orderedcv9. Labs/Tests1. -1Electrocardiogram (ECG) completed0 diagnostic tests performed as ordered2. Allcv10. Discharge Plan01. Discharge plan initiatedAdditional documentation:(not for variance tracking - for unusual patient activity not recorded on any other existing patient care Title:Init.:Date: Copyright 1999-08 LAC-DHS Published: 03/10/2008Comments regarding this form? Call (818) 364-3566!T-HS1042!Day 1Congestive Heart Failure (Ward/Stepdown)Daily Care Documentation - Day 1 of 5 / Pg. 2 of 2FORM NO. T-HS1042 (03/10/2008)
Department of Health ServicesCounty of Los AngelesCongestive Heart Failure (Ward/Stepdown)Daily Care Documentation - Day 1 of 5Date: / /This is a general guideline and does not represent a professional care standard governing provider obligations to patients.Care is revised to meet individual patient t(forMacro imeandoutcome(s);6-InitialDx ottom.entryandsignatatbottom.Element #:Event #:Time:Outcome:Description:Action:Init.:Element #:Event Init.:Outcome:Description:Action:Init.:Element #:Event nt #:Event :Init.:Date: Copyright 1999-08 LAC-DHS Published: 03/10/2008Comments regarding this form? Call (818) 364-3566!T-HS1042!Day 1Congestive Heart Failure (Ward/Stepdown)Daily Care Documentation - Day 1 of 5 / Pg. 1 of 1FORM NO. T-HS1042 (03/10/2008)
Department of Health ServicesCounty of Los AngelesCongestive Heart Failure (Ward/Stepdown)Daily Care Documentation - Day 2 of 5This is a general guideline and does not represent a professional care standard governing provider obligations to patients.Care is revised to meet individual patient needs.INSTRUCTIONS: Every Pathway Milestone and Care Event must have a "Y","N" or "Not ordered"response. "Y" Pathway Milestone or Care Event met; "N" not met. If "N", complete Variance Documentation form. For Care Events only requiring one documentation per 24 hrs., document in Day (D) Shift boxand initial in actual shift. Pathway Milestones are in bold. Micro Indicators are italicized.NotOrderedCare Elements: Care Events/OutcomesCare Events/Outcomes(D) ShiftYNInit.(E) ShiftYN(N) ShiftInit.YNInit.1. Assessment11. O2 saturation 93% or greater12. Output minus intake greater than 1,500 mL13. Weight loss 3 lbs (1.4 kg) or greater (within last 24 hrs)14. Advance directive discussed with patient and if assistance isneeded, Social Services notified5. Patient states feeling better (less anxious and breathingeasier)0-1-1-1 Notification2. -1Physician1.Emergent signs and symptoms absent Systolic BP less than 90 or greater than 160 mmHg Diastolic BP less than 60 or greater than 110 mmHg Temp. less than 36.1 C (97.0 F) or greater than38.6 C (101.5 F) Pulse less than 55 or greater than 110 BPM Resp. rate less than 12 or greater than 26 New onset chest painO2 saturation less than 93% with or without O2 administeredWeight gain greater than 2 lbs (1 kg) (within 24 hrs)Decreased urine output: Measured intake greater than outputcv3. Consults-100 1. All consults obtained as ordered-10 2. Cardiology consult completed00-10000004. Diet1. Fluids restricted as ordered2. Consumed and tolerated ordered diet-10-1-100-1-15. -1Activity1.0 Ordered activity tolerated6. Teaching Plan1.Patient/family/significant other verbalizes understanding of CRMinpatient teaching guide01002.CRM post-discharge teaching guide given topatient/family/significant other01007. Medication1. All medication administered as ordered-1-1-1-12. Patient free of adverse drug reaction-1-1-1-1-1-18. Treatment0 All treatments completed as ure/Title:Init.:Date: Copyright 1999-08 LAC-DHS Published: 03/10/2008Comments regarding this form? Call (818) 364-3566!T-HS1042!Day 2Congestive Heart Failure (Ward/Stepdown)Daily Care Documentation - Day 2 of 5 / Pg. 1 of 2FORM NO. T-HS1042 (03/10/2008)
Department
Congestive Heart Failure (Ward/Stepdown) END ACE-Inhibitor (Should be used unless contraindicated) Benazepril [LOTENSIN] 10 mg PO Daily 40 mg PO Daily 20 mg PO Daily Captopril [CAPOTEN] 6.25 mg PO Q8 hrs 50 mg PO Q8 hrs 12.5 mg PO Q8 hrs 100 mg PO Q8 hrs 25 mg PO Q8 hrs Captopril [CAPOTEN] titration Captopril titration (Goal is SBP 82-90 mmHg.
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