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Designed for the Unique Needs
of Homecare Providers
This site provides homecare clinicians with access to chronic care management models, best practices and downloadable resources for homecare patients.
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"The body of knowledge that serves as the rationale for nursing practice determines the areas of specialty to develop as well as the manner in which that knowledge is organized, tested and applied." -Carper, 1978
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level 1
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Therapy should be based on the prescence of co-morbidities and the assessment of food preferences.
Other considerations are:
- Dentition/swallowing ability
- Food availability
- Cultural appropriateness
- Willingness to engage in a diet specific to reduce risk of fluid overload, dehydration, or other complicating conditions common in heart failure such as diabetes, HTN, and/or dyslipidemia
- Finances
- Cooking facilities
- Adequate caloric intake
- Appropriate use of diuretics
- Weight history
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| Assess
(5 documents) |
| Progress towards goals must be assessed every visit with intervention and goals revised accordingly. Especially important to evaluate are patient's verbalized and demonstrated knowledge, behavior and status. |
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| Plan
(4 documents) |
| The plan of care includes measurable patient specific goals that are realistic and obtainable. It needs to include buy-in and understanding on the part of the patient and caregiver taking into consideration culture, ethnicity, tradition, individual preferences and economic circumstances. |
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| Implement
(46 documents) |
| Implementation is the critical stage when an assessment and a plan are put to work. Ongoing communication among all professionals, patient and caregivers involved in the treatment plan is essential to maximizing fluid status and weight stability. |
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| Evaluate
(6 documents) |
| Patient's response to interventions and teaching needs to be continually evaluated by assessing measurable outcomes. The problems, the goals and the interventions for heart failure patients are evaluated regularly and revised to achieve desired health outcomes. Use the questions in the evaluation area and “Important Considerations” to assist you in measuring progress towards goals for your patients. |
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