CDI Foundations Flashcards
7 D’s of CDI
Definition, Diagnosis, Documentation (providers); Deciphering, Delineation, Deployment (CDI/coders); Defense (everyone, w/audits)
Principal Diagnosis
The condition found after study to be chiefly responsible for occasioning the inpatient admission. *based on circumstances of admission, dx approach, treatment rendered
What is heart failure?
Inability of heart to effectively pump blood out with each beat.
What are the clinical indicators of heart failure?
Increased BNP, sx of pulmonary or systemic congestion (wheezing/resp distress, edema, weight gain, HTN, arrhythmias, JVD, decreased SpO2)
How do you know if a diagnosis is present or a “history of”?
History of = no longer present, no longer treated. Present = may be treated (meds, therapies, etc), but can be more or less asymptomatic d/t being well controlled. Ie breast cancer pt on tamoxifen, still “has” breast cancer d/t ongoing tx.
What is HF with reduced EF or preserved EF?
Reduced EF (systolic HF) = < 50% EF; Preserved EF (diastolic HF) = > 50% EF
What defines heart failure being “decompensated”?
Requiring urgent, unplanned/unscheduled care to manage. IE IV diuretics, increased monitoring, etc.
What are the different types of altered mental status?
Delirium: acute change in arousal and content
Depression: chronic change in arousal
Dementia: chronic change in arousal and content
Coma: dysfunction of arousal and content
Psychosis: acute change
Can you explain underlying causes of different types of altered mental states?
Possibilities: primary intercranial disease(s), systemic diseases affecting the CNS, exogenous toxins (toxic encephalopathies), drug withdrawal.
Consider: hypoglycemia, hypoxia, infection/sepsis,
Toxic vs metabolic encephalopathy
Toxic: usually d/t (external) toxic exposure; worksite neurotoxins, drugs, alcohol, CO2, hydrogen sulfide, cyanide, heavy metals
Metabolic: usually d/t internal factors; hypoglycemia, ischemia, hypoxia, hypercapnia, vitamin deficiencies, d/t peripheral organ dysfunction (hepatic, uremic/dialysis)
PATIO
Present at the time of inpatient (admission) order
What is sepsis?
The body’s systemic inflammatory response TO infection (not an infection itself).
Sepsis-2
Systemic Inflammatory Response to Infection.
clinical indicators = pt “looks” septic
organ dysfunction not required
Sepsis-3
Dysregulated host response to infection resulting in organ dysfunction.
requires documentation of “severe sepsis” or “septic shock” to be coded as sepsis-3
Septic shock
Patients who require vasopressors to maintain MAP > 65 mmHg or greater and lactate > 2 mmol/L in the absence of hypovolemia.
Sepsis vs cytokine release syndrome
Sepsis: body’s response to infection, Interferon rarely elevated, IL-6 and ferritin levels often very high
CKS: not d/t infection
Which conditions may present like sepsis but not be due to infection?
Anaphylaxis, aspiration pneumonitis, adrenal insufficiency, SBO, DKA, heat emergencies, hypovolemia, PE, pancreatitis, intestinal ischemia, thyroid disease (thyrotoxicosis/thyroid storm), toxicity (ODs) and withdrawals, malignant hyperthermia, neuroleptic malignant syndrome, vasculitis
Recommended anti-infective tx for adults with CAP and no concerns for Psuedo or MRSA:
Combination therapy: beta-lactam (ampicillin, rocephin, cefotaxime) AND macrolide (azithromycin or clarithromycin).
Monotherapy: respiratory flouroquinolone (levofloxacin)
Recommended anti-infective tx for adults with CAP and concerns for MRSA:
Vanco or Zyvox (linezolid)
Recommended anti-infective tx for adults with CAP and concerns for Pseudomonas Aeruginosa:
Zosyn (piperacillin-tazobactam), Cefepime, ceftazidime, aztreonam, meropenem, imipenem
Respiratory insufficiency
Shortness of breath
Respiratory distress
labored, difficult breathing
Respiratory failure
Failure to ventilate or oxygenate (hypoxia, hypercapnia) AEB elevated PCO2 or decreased O2.
How to differentiate between acute and chronic hypercapnic respiratory failure?
Acute: pH < 7.33
Chronic: pH > 7.33 (compensated)
What is shock?
life-threatening circulatory failure that leads to tissue hypoperfusion and tissue dysoxia (abnormal tissue oxygen utilization)
What are the 4 classifications of shock?
Cardiogenic, Distributive (septic, vasodilatory), Hypovolemic, Obstructive (think large PE blocking pulm artery and left ventricle)
Clinical indicators of shock
sx of poor peripheral perfusion - cold, clammy skin, delayed cap refill, mottling
tachycardia
urine output
abnormal BPs
altered level of consciousness
Lab values supporting shock dx
lactate levels (#1 cause of elevated lactate = shock, but not the only cause)
What makes a debridement excisional vs non-excisional?
Excisional debridements are done by scalpel only. Other sharp instruments (scissors, curette, etc) do not apply to excisional debridements.
Essentials of a condition: M.U.S.I.C.
Manifestation
Underlying Cause
Severity/Specificity - organism?
Instigating cause - what precipitated?
Consequences?
