Download DISEASE MANAGEMENT: Standards of Practice / Protocol – CHF

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2/23/06
DISEASE MANAGEMENT: Standards of Practice / Protocol – CHF
I.
II.
III.
IV.
V.
VI.
Primary goal, for patients with CHF, is preventing the disease’s acute exacerbation and getting patients back
to an appropriate functional level. Patient/Caregiver education is the key to accomplishing this goal.
Initial assessment goal is to be sure the patient / caregiver has basic information to remain safely in the
home until the next skilled nurse visit – SNI- HC. It will include an assessment of appropriateness for Telemonitoring, review of their medications and will also include patient / caregiver ability and motivation to learn
and/or be compliant.
Responsibilities of the admission nurse include;
 Informing patient/family of the 3 day diet log to assist in evaluation of diet related issues. (RD will initiate
diet log with first contact)
 Providing the “Heart Failure” patient teaching book for patient/caregiver review. Document given under
Admission Items note.
 Assess the appropriateness of mandatory consults, communicate to scheduling, need for, or no need for:
OT, MSW, RD and Tele-Med. If pt not taking this services need to document why not in assess note. If pt
not utilizing MSW, OT, RD must erase visit schedule in Pctc. Communicate plan for services to MD.
 Completion of the OASIS assessment
 Refer to Split Admission Process.
 Do initial summary
Tasks at subsequent skilled nurse visits will include;
 Review the Heart Failure teaching booklet as outlined in the pathway.
 Teachings addressed need to be highlighted on the heart failure booklet.
 ach clinician will date and initial pages s/he has reviewed with the patient/caregiver.
 Document teachings under I/E or teaching subjects in the computer.
REMEMBER!
 Weight gain of 2# in a day or 5# in a week will be evaluated and reported to the M.D. as appropriate.
 Instruct pt/family on the purchase of equipment around week 4-5.
 When patient / caregiver can do daily weights, check BP independently patient should purchase own
equipment and Tele-med removed. This should be around week 6-7.
Schedule recommended frequency for visit guidelines; (if frequency varies will need to document why.)
RN visit Schedule with Tele-med
RN visit Schedule without Tele-med
# of RN
For # of
Misc.
# of RN
For # of
Misc.
visits
weeks
visits
weeks
3X
in first 7
3X
in first 7
days
days
1X week
2
RN must add 1 tele1X week
2
RN must add 1 teleassessment for each
assessment for each
week in BZM.
week in BZM.
0X week
3
RN must add 1 tele0X week
1
RN must add 1 teleassessment for each
assessment for each
week in BZM.
week in BZM.
1X week
1
Discharge paperwork &
1X week
1
No tele-assessment.
check for scale and BP
cuff.
0X week
1
RN must add 1 tele0X week
1
RN must add 1 teleassessment for each
assessment for each
week in BZM.
week in BZM.
1X week
1
Discharge.
1X week
1
No tele-assessment.
Discharge paperwork &
check for scale and BP
cuff
2 prn visits available
0X week
1
RN must add 1 teleassessment for each
week in BZM.
Total
visits
should be less than 12.
1X week
1
Discharge.
2 prn visits available
Total
visits
should be less than 12.
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VII.
Inter-disciplinary approach is the expected standard of care.
Consults with or without Tele. need to included; 1 MSW 1-2 OT

VIII.
1 RD
Additional consult may include 1-2 HHA (initial visit to be on day 2 or 3 if patient lives alone.)
Education is the key to meeting the goals for CHF.
The following is a reminder guide of key teaching / learning .
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Reinforce the need to do weighing first thing every morning after urinating and with the same amount of
clothes on. They should write this down.
Stress the need to decrease their intake of sodium. Encourage patient/caregiver to read labels on food
packages.
Stress the need to increase their intake of fruits and vegetables.
Review 1-2 medications each visit. Cover the uses and side effects. Start with new meds / cardiac meds.
Document in I/E med. Subject.
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Reinforce OT’s teaching of energy conservation techniques. Remind them to utilize them as they
gradually increase their activity level.
Reinforce MSW teaching of lifestyle changes (ex. smoking cessation,.) and use of community resources.
Review the symptoms of increased heart failure:
 Weight gain
 Orthopnea
 CNS changes
 Increased fatigue or dyspnea with exertion
 Paroxysmal / Nocturnal Dyspnea
IMPORTANCE of COMPLIANCE with TREATMENT and MEDICATION protocols.
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Remember you may want to include these as additional teachings; examples fluid restriction, smoking
cessation, potassium replacement
For the best success the caregiver MUST be involved in the teachings /learning.
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