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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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Heart Failure
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Monitoring
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Best Practice:
Homecare patients with heart failure should have a self-care action plan that includes daily weights and symptom evaluation. References
A comprehensive self-care action plan also includes: |
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- A diet based upon the need to reduce overall risk.
- An exercise plan based on individual functional capacity.
- A medication regimen that is understood by and appropriately managed by the patient and/or the family/caregiver.
- Age appropriate screenings and immunizations.
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| Assess
(7 documents) |
| It is especially important to evaluate the patient’s verbalized and demonstrated knowledge, behavior and status. Do they have a clear understanding of the important role that they play in their management plan? Are they aware of the component parts of that plan and how to incorporate them into their daily life? |
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| Plan
(4 documents) |
| The plan of care should include measurable, specific goals that are realistic. The patient and/or the caregiver needs to have an understanding of the components of and how to implement their self-care action plan. |
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| Implement
(29 documents) |
| When implementing a Monitoring program for a patient with heart failure, consider individualized signs and symptoms of fluid overload, co-morbidities, left ventricular function (ejection fraction), type of heart failure- systolic vs diastolic and risk factors for re-admission. |
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| Evaluate
(5 documents) |
| Continually update the patient's progress by assessing measurable outcomes. The goals and interventions for all heart failure patients need to be evaluated regularly and revised to achieve desired health outcomes. |
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Monitoring
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