Failure*
S
Situation
Dr. Heart, this is ______ from _______. I am calling about Mrs. White, who is a 76 year old HF patient of yours who has gained 6 pounds over the weekend.
B
Background
She was admitted to home health in August following hospitalization for heart failure exacerbation and is currently on telehealth monitoring.
Her vital signs are: B/P 128/75, Pulse 94, Respirations 18.
She has 2+ edema in her feet and ankles and is complaining of increased shortness of breath. She is currently taking Lasix 40 mg po, daily and KCL 20 Meq daily.
A
Assessment
I am concerned about exacerbation of her heart failure.
R
Recommendation
Could Ms White take an extra dose of Lasix for the next two days? Do you want to give any additional potassium with the extra Lasix?
Is there any lab you would like me to draw?
Would you like me to call you with her weight after the two doses of Lasix?
Could we have a PRN order for additional diuretic for weight gain of 3 pounds overnight or more than 5 pounds in a week?
* This example courtesy of Paula Suter, Director Center of Excellence for Chronic Care Management, Baptist Health Home Health