Download HEART FAILURE TOOLKIT

A tool from HFMA’s Leadership publication:
hfma.org/leadership
Tool: Heart Failure Patient Education Checklists for Nursing and Pharmacy
At The Doctors Hospital of Manteca, a 73-bed hospital in Manteca, Calif., heart failure patient education now
starts when a patient is admitted to the hospital and continues through 30 days post-discharge. The hospital
adopted the teach-back methodology, which involves having patients explain self-care instructions back to a
clinician to help ensure that the patients understand what they have been taught. Pharmacy and nursing staff
were trained in the teach-back methodology and took on responsibility for providing all patient education,
including applicable education on behalf of physical therapy, case management, and dietary.
By focusing on patient education and post-discharge follow up, The Doctors Hospital of Manteca improved 30day heart failure readmissions by more than 70 percent in two years.
On the following pages are the teach-back guides that were developed for nursing and pharmacy staff.
Source: Doctors Hospital of Manteca, January 2015. Used with permission.
Part 1. Nursing Checklists for Heart Failure Patient Education
*133*
133 DHM R01/2013
UNIT:
NURSING: HEART FAILURE PATIENT TEACHING CHECKLIST
Admission and Duration:
Your doctor has documented that you have heart failure. It is important to know your symptoms and
how to manage yourself. We would like to go over some important information:
1. Heart failure overview and smoking cessation
2. Call MD: Weight management and what to do if symptoms worsen.
a. Weight gain of more than 2 or 3 lbs in one day.
b. Increase in shortness of breath.
c. Increase in leg swelling.
3. Review medication related to heart failure and potential for adverse reactions.
4. Diet/fluid restrictions (review and provide a copy of the “Sodium and Fluid Restrictions for Heart
Failure” handout).
5. Activity and exercise level (do you have any questions about your activity level?)
6. See discharge instruction sheet for MD follow-up scheduled appointment.
Patient signature:
Date:
Time:
Guardian signature & relationship:
Date:
Time:
RN signature & instructed by:
Date:
Time:
Note: Signature acknowledges that the patient and or guardian has received and understands the
information provided in the above checked teaching checklist.
NURSING HEART FAILURE PATIENT
TEACHING CHECKLIST
*«PatientNumber»
*
«PatientName» «BirthDate»
ACCT# «PatientNumber» «AdmitDate» «AdmitTime»
«AdmittingDoctorName» MR:«MedicalRecordNumber» «Gender» «Age»
DHM HSV:«HospitalService» FC:«FinClass» PT:«PatientType»
*133*
133 DHM R01/2013
NURSING TEACH-BACK QUESTIONS TO VALIDATE HEART FAILURE EDUCATION: DO EACH SHIFT.
Date
Time
Initial
Barriers to
Learning
DAY 0
ADMISSION



 Patient
 Caregiver
Name
START Heart Failure Tool kit
Smoking Cessation
Complete Patient Teaching Checklist (Exit care)
DAY 1
HEART FAILURE / SYMPTOMS / NOTIFICATION PARAMETERS (CORE MEASURE)
 Patient
 Caregiver
Name


 Patient
 Caregiver
Name

 Patient
 Caregiver
Name




 Patient
 Caregiver
Name


 Patient
 Caregiver
Name





 Patient
 Caregiver
Name



 Patient
 Caregiver
Name



DVD Overview: Heart Failure
Tell me in your own words what the words “heart failure” mean
to you.
Tell me which heart failure symptoms you remember.
Optional Questions You May Ask

Tell me the symptoms you would call in to your doctor or
healthcare provider.
How will eating too much salt make your symptoms worse?
DAY 2
DAILY WEIGHTS / DRY WEIGHT / ACTIVITY (CORE MEASURE)
Do you have a scale at home?
Tell me how you will weigh yourself each day?
When will you notify your doctor/provider?
Tell me how would you know if you are pushing too hard when
doing activities?
Optional Questions You May Ask
Can you recall when to notify your MD regarding your weight?
Tell me how you will be active at home every day?
DAY 3
MEDICATION / SALT / FLUID LIMITATION (C0RE MEASURE)
DVD Overview: Heart Failure Medication
Name a seasoning to avoid.
Tell me how you will limit your fluids each day.
Tell me two foods high in salt.
Can you tell me the name of your water pill?
Optional Questions You May Ask
Name two frozen liquids that count as fluid.
Name a side effect of your Beta blocker (BP or heart pill).
Name a side effect of your ACE Inhibitor (BP or heart pill).
DISCHARGE
FOLLOW-UP APPOINTMENT/SYMPTOMS (CORE MEASURE)

Initials



What is your family doctor’s name?
Tell me the date and time of your scheduled follow-up
appointment after discharge
Tell me what zone you are in if you have gained 3 lbs and have
swelling in your feet today.
If you are in the green zone, what does this mean?
Signature
Initials
Signature
If discharge anticipated < 4 days, include next day teaching in plan of care.
If in-patient > 3 days, restart teaching from Day 1.
HEART FAILURE NURSING TEACHBACK
*«PatientNumber»
*
«PatientName» «BirthDate»
ACCT# «PatientNumber» «AdmitDate» «AdmitTime»
«AdmittingDoctorName» MR:«MedicalRecordNumber» «Gender» «Age»
DHM HSV:«HospitalService» FC:«FinClass» PT:«PatientType»
NURSE’S GUIDE FOR HEART FAILURE TEACH-BACK
DAY 1
DAY 0
DAY
TEACHING POINTS
 Heart Failure Admission Educational Tool
kit given to patient.
 Patient signs Patient Teaching Checklist.





DAY 2



DAY 3



DISCHARGE
DATE




ANSWERS
 Patient received Heart Failure Tool Kit.
Explain heart failure.
Review symptoms.
Symptoms to call MD.
Explain salt or sodium makes your body
hold on to extra fluid and fluid is heavy,
making you gain fluid weight.


ASK THE PATIENT IF THEY HAVE A
SCALE.
Review steps to weigh daily. Scale must
be on a hard surface.
This is a review question important to
ensure they can recall when to notify MD.
Review importance of being active every
day. Pace activity and with rest periods.
Explain walking plan.
Discuss limiting salt intake to 2000 mg
each day. Remind patient to remove the
salt shaker from table and stove, no salt
substitutes, pick low-sodium foods, and
read labels.
Review fluid restriction of 2 liters. Teach
about being thirsty and what can be done
to combat thirst. Remind about the
connection of fluid and weight gain.
Review diuretic, ACE, and BB if patient is
taking including side effects. Cover
medication to avoid such as NSAIDS,
antacids, and decongestants.

Family doctor’s name:
Date and time of F/U appointment made by
pt or caregiver.
Review Heart Failure zones.










Weak heart, not pumping correctly, etc.
Symptoms include SOB, coughing; fluid
in lungs, belly, feet, and legs; and tired.
3 lb weight gain overnight or 5-7 lbs in a
week.
Salt makes me gain weight, have more
fluid in lungs, legs and belly.
Weigh every morning before eating, at
same time, and in same type of clothes.
2-3 lbs weight gain overnight or 5 lbs in a
week.
Pace activity, rest in between activity.
No extra fluid.
Walking plan to slowly increase walking
time if no symptoms.
Patient states 2000 mg sodium diet, no
salt or salt substitutes, remove salt
shaker from table, store, etc. Pick lowsalt foods, read labels.
Limit fluid to 2 liters; frozen items or
liquids include ice, jello, soup, popsicles,
etc.
Tired, low blood pressure or heart rate.
Low blood pressure, dry cough, high
potassium levels, swelling of tongue,
throat, or mouth.
Record Date/Time or follow-up
Appointment.
With MD on discharge instruction sheet.


Use Heart Failure Zone magnet as a
Teach Back Guide.
HEART FAILURE (HF)
What is heart failure?
 Your heart is not pumping blood to the rest of
the body like it should.
Causes of heart failure:
 Heart attack
 High blood pressure
 Coronary artery disease
 Damaged heart valves
Medications:
 Relax blood vessels
 Strengthen the heart
 Pump with more strength
 Get rid of extra water
Diet:
 No more than 1 teaspoon of salt a day
 No more than one 2-liter bottle of liquids
 Low cholesterol
 Avoid or less saturated fats
 Avoid or less trans fat
What are the signs/symptoms?
 Short of breath
 Low energy
 Swelling in the ankles, feet, or legs (weight
gain)
Related health problems:
 Severe anemia
 Diabetes
 Emphysema
 Kidney or liver failure
 Irregular heart beat
Physical Activity:
 Normal daily activities if able
 Exercise regularly if able
 Short walks at an easy pace
 Do activities or hobbies that you enjoy
 Rest after activity and meals
Notify your doctor if you have these
symptoms:
 Get tired faster
 Not going to the bathroom (urinating less)
 Trouble breathing
 Chest pain or tightness
 Side effects from your medications
 More than usual swelling in the stomach,
ankles, feet, or legs
 Gain more than 3 lbs a day or more than 5
lbs a week
KEY POINTS TO REMEMBER:
 Weigh yourself every day and record it on your calendar.
 Stop smoking if you smoke.
 Be aware of your signs and symptoms and know what to do. Call 911, go to the emergency room,
or get medical attention if your symptoms become worse.
 Take your medications.
 Eat a healthy low-fat and low-salt diet. Read labels on packages and cans of processed and
preserved foods.
 Stay active and do activities within your limits.
 Make and go to your doctor appointments.
 Call the Heart Failure Clinic if you have any questions:
[Name, telephone number]
SODIUM AND FLUID RESTRICTIONS FOR HEART FAILURE
Limit sodium to 2,000
milligrams per day (Salt)
Use less added salt
Limit canned foods
Limit processed foods
Limit salted foods
Limit cured foods
Fluid restriction
R
Use these
measurements to
help you track
fluid intake:
1 cup = 8 oz.
4 cups = 32 oz.
This is about the amount of sodium in 1 teaspoon of salt.
Even if you don’t add salt to the foods you eat or when you cook, you may still be getting a lot
of sodium in your diet. Most foods that are canned or processed have a lot of salt. Frozen
dinners are also high in sodium. Almost all restaurant meals (especially fast-food restaurants)
have a lot of sodium.
High in sodium
Use these instead
Salt
Onion salt
Lemon juice
Low-sodium broth
Seasoned salt
Garlic Salt
Fresh garlic
Vinegar
Soy sauce
MSG
Fresh onion
Black pepper
Baking soda
Bouillon cubes
Fresh or dried
Hot peppers
Baking powder
Tenderizers
herbs
Hot pepper
Fish sauce
Teriyaki sauce
Salt-free herb
sauce
Worcestershire sauce
and spice
(like Tabasco)
mixes (like Mrs. Dash)
High in Sodium
Try These Instead:
Canned soup
 Buy fresh or frozen vegetables
Canned vegetables
 Rinse and drain canned foods, do not use
Canned meats
the liquid in the can
Canned fish (tuna, sardines,
 Look for “no salt added” canned foods. Be
anchovies)
careful though! Some things labeled
Canned vegetable juices (tomato or
“reduced salt” still have a lot of sodium or
V8 juice)
salt.
High in Sodium
American cheese
Cottage cheese
Processed cheese spread
Frozen dinners
Packaged dinner mixes (like
Instant hot cereal
Hamburger Helper)
Flavored rice/pasta mixes (like
Ramen noodles
macaroni and cheese, Rice-a-Roni)
Lunch meat (bologna, salami)
High in Sodium
Try These Instead:
Salted crackers
 Unsalted chips, pretzels, or crackers
Salted popcorn
 Unsalted nuts
Salted chips
 Sprinkle popcorn with dried herbs
Salted pretzels
Salted nuts and seeds
High in Sodium
Ham
Pastrami
Hot dogs
Corned beef
Sausage
Bacon
Koshered meat
Smoked meat
Smoked fish
Olives
Pickles
Sauerkraut
Your provider may limit the amount of liquid
you drink each day, including any liquids
taken with medications. Drinking too many
liquids may force your heart to work harder.
Fluids include foods that are liquid at room
temperature. Other foods may be high in
water/fluids.


Try These Instead:
Turkey, chicken, or roast beef in
sandwiches
Turkey bacon, turkey sausage, and turkey
or chicken hot dogs are usually lower in
fat. However, many still have a lot of
sodium.
Fluids: Water; juice, ice cubes, coffee, milk,
cream, popsicle, soup, tea, soups.
Foods: Yogurt, pudding, ice cream, sherbet,
gelatin (Jell-O), follow-up with high water
content (ex. Watermelon)
Suggestions to help with thirst:
Suck on hard candies, lemon slices, use a
humidifier, and chewing gum.
MEDICATIONS FOR HEART FAILURE (HF)
Type
Diuretics
(water pill)
Potassium
Supplement
How Does it Work?
Things to Remember
Helps to get rid of extra
water in your body.


Take early in the day
Frequently urination and
thirst are common
Sudden weight changes,
abdominal or muscle
cramps, swelling in legs or
belly, dizziness.
Replaces potassium that
may be lost through water
pill.


May cause stomach upset.
Take with food to prevent
stomach upset.
Drink a lot of water, avoid
caffeinated liquids.
Heartburn, diarrhea,
dizziness, weakness or
heaviness in the legs,
tingling in the hands and
feet, rash.
Do not skip doses.
Keep diet consistent.
Take medication around the
same time every day.
Do not stop without calling
your doctor.
Check heart rate and write
down regularly.
Bloody/black stools,
coughing up blood, red/dark
brown urine, and unusual
bruising or bleeding.
Dizziness, swelling or big
weight gain, feeling very tired
or weak.
Check and write down
blood pressure regularly.
Dizziness, trouble breathing,
cough that doesn’t go away,
and fast heartbeat.

Blood Thinner
Helps to prevent clots from 
forming.


Beta Blockers
Lowers the blood pressure
by slowing heart rate and
strengthening your heart.

Lowers blood pressure to
help heart pump more
easily by relaxing blood
vessels

(blood pressure / heart pill)
ACE Inhibitor or ARB
(Blood pressure / heart pill)
Symptoms to Call MD

COPING WITH SMOKING WITHDRAWAL
For the first few days after you quit smoking, you may feel cranky, restless, depressed,
or low on energy. These are symptoms of withdrawal. It’s your body’s way of
recovering from smoking. Your symptoms should lessen within a few days.
COPING WITH THE URGE TO
 Deep breath: Inhale through your nose.
SMOKE
Count to five. Slowly exhale through your
mouth.
 Drink water: Drink eight or more 8 ounce
glasses of water a day.
 Keep your hands busy: Wash your car. Draw.
Do a puzzle. Build a birdhouse.
 Delay: The urge to smoke lasts only 3 to 5
minutes.
GET SUPPORT
CONTROL STRESS
SLEEP BETTER
GET FIT
QUIT SMOKING PRODUCTS
Individual, group, telephone counseling can help
keep you on track. Ask your doctor for more
information about resources available to you.
After you quit, you may feel irritable and
stressed. Try taking a warm bath or shower.
Listen to music. Try yoga or meditate. Call
friends or talk with a professional.
You may feel tired, and have trouble falling
asleep. Try to relax before bed. Read a while.
Avoid caffeine for a few hours before bedtime.
You may notice an increased appetite. Many
people who quit smoking gain weight. Limit
weight gain, by watching what you eat. Cut back
on fat. Snack on low-calorie foods, like fresh
fruits and vegetables. Drink low-calorie liquids.
Regular exercise can also help you stay fit.
Remember; your main goal is to be a nonsmoker.
There are a number of products that can help
you quit smoking. They are available over the
counter or by prescription. Ask your healthcare
provider if any of these could help you quit
smoking.
HEALTH EFFECTS OF SECOND-HAND SMOKING
Health studies have shown that smoking can affect your heart as well as your lungs.
Smoking also raises your risk of certain cancers. These are all good reasons to quit.
HOW SMOKING AFFECTS
YOUR BODY:
Smoking has been linked with many serious illnesses. It
also has been shown to increase signs of aging. A few
of the health effects of smoking are listed below:
 Increases you risk of lung cancer, bladder cancer,
and cervical cancer.
 Raises blood pressure, which increases your risk of
heart attack or stroke.
 Reduces blood flow, which can slow healing and
cause wrinkles.
 In pregnant women, causes bleeding problems,
miscarriage stillbirth, or birth defects.
FACING FACTS:
When you smoke, your breathing becomes shallow and
your lungs fill with smoke. Smoking cigarettes also fills
your body with chemicals, such as nicotine and tar.
SMOKE:
Cigarette smoke contains carbon monoxide. This gas
takes the place of oxygen in your blood.
NICOTINE:
This drug raises your blood pressure and heart rate. It
reduces blood flow to your arms and legs, and slows
digestion.
TAR:
Tar is what’s left after tobacco is smoked. The sticky
brown material gums up your lungs, so less oxygen gets
into your blood stream.
OTHER CHEMICALS:
Cigarette smoke contains over 4,000 other chemicals;
including formaldehyde, arsenic, and lead. Dozens of
these chemicals are known to cause cancer.
Part 2. Pharmacy Checklists for Heart Failure Patient Education
*119*
138 DHM R03/2013
PHARMACY TEACH-BACK QUESTIONS TO VALIDATE HEART FAILURE DISCHARGE EDUCATION:
Date
Discharge Date:
Time
Initial
Barriers to
Learning
HEART FAILURE DISEASE / CONDITION



 Patient
 Caregiver
Name
Heart failure patient information handout
Overview of heart failure and smoking cessation
Tell me in your own words what “heart failure” means
to you.
HEART FAILURE (SYMPTOMS, NOTIFICATION PARAMETERS, CORE MEASURES)

 Patient
 Caregiver
Name

Tell me 1 or 2 symptoms you would tell your doctor
about.
New symptoms from medication(s)
Shortness of breath during rest, sleep, or activity
unusual for you. Increased tiredness
Tell me how you would weigh each day.
Swelling of the hands, feet, ankles, or abdomen
Feeling of fullness in your abdomen or develop
nausea or appetite loss
Chest pain and tightness






Diet – sodium, fluid intake, and fat content
Tell me 2 foods high in salt.
Activity level as recommended
Tell me how you will be active at home every day.
Blood pressure monitoring
When would you notify your MD about your weight?





SELF – CARE MANAGEMENT
 Patient
 Caregiver
Name
MEDICATIONS/POTENTIAL ADVERSE REACTIONS/INTERVENTIONS
 Patient
 Caregiver
Name




Name a side effect of your beta blocker
(BP or heart pill)
Name a side effect of your Ace Inhibitor
(BP or heart pill)
Tell me the name of your diuretic (water pill)
Discuss warfarin if patient has AFIB or Hx A-FIB
EQUIPMENT
 Patient
 Caregiver
Name



Provide pill box and instructions
Provide zone magnet and instructions
Provide scale and instructions
FOLLOW-UP APPOINTMENT / CONTACT NUMBERS
Follow-up doctor’s visit in one
week:
With Dr.
Address:
Phone No:
Contact numbers
Phone No:
Alternate No:
Alternate No:
/
/
Completed by:
Date:
Patient Signature:
Date:
PHARMACY – HEART FAILURE DISCHARGE
EDUCATION CHECKLIST
*«PatientNumber»
*
«PatientName» «BirthDate»
ACCT# «PatientNumber» «AdmitDate» «AdmitTime»
«AdmittingDoctorName» MR:«MedicalRecordNumber» «Gender» «Age»
DHM HSV:«HospitalService» FC:«FinClass» PT:«PatientType»
PHARMACIST’S GUIDE FOR HEART FAILURE TEACH BACK





















TEACHING POINTS
ANSWERS
HEART FAILURE DISEASE/CONDITION
Heart failure patient information handout.
 Patient view heart failure information handout.
Overview of Heart Failure and smoking cessation.
 Weak heart not pumping normally.
HEART FAILURE (SYMPTOMS, NOTIFICATION PARAMETERS, CORE MEASURES)
Review symptoms.
 Symptoms include SOB, coughing, fluid in stomach,
feet, and legs, tiredness.
Symptoms to call MD.
 2–3 lbs weight gain overnight or 5 or more lbs in a
Optional questions to ask:
week.
 Tell me the symptoms that you would call your
doctor about.
 Salt makes me gain weight. Have more fluid in the
 How will eating too much salt make your
lung, legs, and stomach.
symptoms worse?
SELF–CARE MANAGEMENT
Diet – Salt (sodium) – limit 2,000 mg (1
 Salt causes weight gain and increases fluid in
teaspoonful) a day
lungs, stomach, feet, and legs.
 Fluid restriction – 2 liters
 2,000 mg sodium diet. Pick low-salt food. Read
 Fat content: Less saturated fats, less
labels.
cholesterol, less trans fat
 Limit fluids to 2 liters.
Review importance of being active every day. Pace  Less saturated fats, cholesterol, and trans fats in
activity with rest periods.
diet.
Daily weights before breakfast
 Pace activity. Rest in between activity.
Smoking cessation
 Weigh every morning after getting up before
Optional questions to ask:
breakfast in same type of clothes.
 Tell me how you will be active at home every
 No more than 2-3 lbs weight gain a day or 5 or
day.
more lbs a week.
 Tell me how you will weigh each day.
 Stop smoking.
MEDICATIONS/POTENTIAL ADVERSE REACTIONS/INTERVENTIONS
Review beta blocker
 Beta blocker affects blood pressure, heart rate, etc.
Review diuretic
 Diuretics get rid of fluid.
Review ACE inhibitor / ARB.
 ACE inhibitor/ARB relaxes blood vessels.
Review warfarin or other anticoagulant (if
 Warfarin or other anticoagulant thins the blood.
applicable)
 Low blood pressure or heart rate.
Optional questions to ask:
 Low potassium level.
 Name a side effect of your beta blocker.
 Name a side effect of your diuretic.
EQUIPMENT
Provide pill box and instructions.
 Patient receives pill box.
Provide zone magnet and instructions.
 Use zone magnet as teach-back guide.
Provide scale and instructions (if applicable)
 Patient receives scale and understands
instructions.
Optional questions to ask:
 If you are in the green zone, what does it
 Green zone means symptoms are under control.
mean?
This is your goal.
 What zone are you in if you have gained 3 lbs
 Yellow zone means a warning. May need to call MD
in one day and have swelling in your feet?
if certain symptoms persist.
FOLLOW-UP APPOINTMENT/CONTACT NUMBERS
Follow-up doctor’s appointment.
 Record follow-up doctor’s appointment date and
time.
Contact information and phone numbers.
 Record contact information and phone numbers.
MEDICATIONS FOR HEART FAILURE (HF)
Type
Diuretics
(water pill)
Potassium
Supplement
How Does it Work?
Things to Remember
Helps to get rid of extra
water in your body.


Take early in the day
Frequent urination and
thirst are common
Sudden weight changes,
abdominal or muscle
cramps, swelling in legs or
belly, dizziness.
Replaces potassium that
may be lost through water
pill.


May cause stomach upset.
Take with food to prevent
stomach upset.
Drink a lot of water, avoid
caffeinated liquids.
Heartburn, diarrhea,
dizziness, weakness or
heaviness in the legs,
tingling in the hands and
feet, rash.
Do not skip doses.
Keep diet consistent.
Take medication around the
same time every day.
Do not stop without calling
your doctor.
Check heart rate and write
down regularly.
Bloody/black stools,
coughing up blood, red/dark
brown urine, and unusual
bruising or bleeding.
Dizziness, swelling or big
weight gain, feeling very tired
or weak.
Check and write down
blood pressure regularly.
Dizziness, trouble breathing,
cough that doesn’t go away,
and fast heartbeat.

Blood Thinner
Helps to prevent clots from 
forming.


Beta Blockers
Lowers the blood pressure
by slowing heart rate and
strengthening your heart.

Lowers blood pressure to
help heart pump more
easily by relaxing blood
vessels

(blood pressure/heart pill)
ACE Inhibitor or ARB
(Blood pressure/heart pill)
Symptoms to Call MD
