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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