Lesson 1Criteria an red flags fi urgent escalation or hospital readmission (worsenin dyspnea, hypotension, risin creatinine, severe hyperkalemia)Explain clinical thresholds an changin signs weh need urgent step-up or readmission. Stress pattern spotin fi breakdown, structured triage questions, an clear action paths fi patients an clinicians.
Worsening dyspnea and new hypoxiaHypotension, syncope, and poor perfusionRising creatinine and oliguria patternsSevere hyperkalemia and ECG changesRapid weight gain and edema progressionDesigning clear escalation algorithmsLesson 2Coordination wid specialty care: when fi refer to cardiology, endocrinology, an nephrologyOutline when an how fi involve cardiology, endocrinology, an nephrology. Stress referral criteria, urgency levels, shared-care models, an talk strategies fi avoid repeat an gaps in follow-up.
Indications for cardiology referralWhen to involve endocrinology teamsCriteria for nephrology consultationUrgent versus routine referral pathwaysShared-care and co-management modelsEffective interspecialty communicationLesson 3Initial follow-up schedule after ED discharge: timeline fi clinic visits, labs, an imaginin (1–2 weeks, 2–4 weeks, 3 months)Gi a structured follow-up timetable after ED discharge, includin clinic visits, labs, an imaginin at 1–2 weeks, 2–4 weeks, an three months, wid flex base on risk an treatment strength.
Risk stratification to set visit timingVisit goals at 1–2 weeks post dischargeVisit goals at 2–4 weeks post dischargeThree-month reassessment prioritiesCoordinating labs and imaging windowsAligning follow-up with patient logisticsLesson 4Usin remote monitorin an telehealth: home BP, weight logs, phone follow-up, an role a nurse-led titration clinicsCover practical use a home check devices, telehealth visits, an nurse-led titration clinics. Focus on data flows, safety checks, an how remote ways support timely med adjust an early spot a worsen.
Home blood pressure and heart rate logsDaily weight diaries and symptom trackersStructured phone and video follow-upNurse-led titration clinic protocolsAlert thresholds and response workflowsPatient education for remote tools useLesson 5Monitorin plan fi drug-specific adverse effects (renal function after RAAS inhibitors, glucose when changin diabetes meds, potassium wid MRAs)Detail check schedules fi drug-specific bad effects, includin kidney function wid RAAS block, potassium wid MRAs, an blood sugar wid diabetes regimen changes, stressin timin, thresholds, an fix strategies.
Renal labs after RAAS inhibitor changesPotassium monitoring with MRAs and diureticsGlucose checks after diabetes med changesRecognizing early signs of drug toxicityAdjusting doses versus stopping therapyPatient counseling on warning symptomsLesson 6Stepwise therapy adjustments if inadequate response: uptitration, switchin classes, addin second-line agentsDescribe a step-by-step frame fi adjustin therapy when response not enough, includin uptitration, switchin drug classes, an addin second-line agents, while balancin safety, other conditions, an patient likes.
Confirming adherence and measurement accuracySafe uptitration schedules and limitsWhen to switch within a drug classAdding second-line or adjunctive agentsMonitoring closely after each adjustmentDocumenting rationale for therapy changesLesson 7Documentation templates an safety-netting instructions fi patients wid limited access to careGi templates an phrasin fi short documentation, includin risk talk, follow-up plans, an safety-net. Tailor instructions fi patients wid limited access, low readin, or unstable house fi cut preventable harm.
Key elements of follow-up documentationStandardized discharge and clinic templatesPlain-language safety-netting phrasesAdapting plans for limited access to careUse of teach-back to confirm understandingRecording shared decision-making detailsLesson 8Short-term an medium-term monitorin parameters: vitals, weight, symptoms, orthostatic BP, serum creatinine, electrolytes, HbA1c, an natriuretic peptidesDefine short- an medium-term check targets after discharge, focusin on vital signs, weight, symptoms, standin blood pressure, an key lab markers fi spot congestion, kidney hurt, metabolic mix-up, an early treatment poison.
Prioritizing vital signs and symptom reviewDaily weight and fluid status trackingOrthostatic blood pressure technique and timingCreatinine and eGFR trends after dischargeElectrolytes, HbA1c, and natriuretic peptidesIntegrating findings into risk stratificationLesson 9How fi interpret response: definitions fi success, partial response, an failure fi symptoms, BP, an glycemic controlDefine how fi judge treatment response usin symptoms, blood pressure, an blood sugar measures. Clear up thresholds fi success, partial response, an failure, an link each to specific follow-up an adjust actions.
Baseline symptom and risk documentationTargets for symptom improvementBlood pressure control thresholdsGlycemic control and HbA1c goalsDefining success, partial response, failureLinking response category to next steps
