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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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Problem Solving
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| Best Practice:
Patients with heart failure should receive contact information for community, state or national resources for heart failure care. Primary care providers should be invited to consider potential referrals to specialty providers. When specialty providers are the homecare referral source, the patient should also have a primary care provider. |
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Referrals sources are dependent upon superimposed risks such as diabetes and COPD. Sources include pulmonologists, endocrinologists, psychologists, social workers, psychiatrists, advanced practice nurses, physical therapists and registered dietitians. Other resources include the American Heart Association, the Heart Failure Society of America, and cardiac rehabilitation programs and wellness centers. References
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| Assess
(4 documents) |
| It is important to assess the patient's and/or caregivers self-care knowledge of heart failure as well as their own unique warning signs of a change in fluid status. The self-care action plan should include an assessment of what the patient would do given specific warning symptoms or signs that require attention.
In addition, the awareness of valuable resources so they can remain current about heart failure and heart failure management is important.
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| Plan
(3 documents) |
| A self-care action plan should include the appropriate patient response to scenarios common in patients with heart failure. This includes the response to fluid overload or dehydration as well as to chest pain.
It is important to work in tandem with the provider in order to make appropriate referrals. A list of community and national resources can be made available to the patient and/or the caregivers in order to assist them in initiating these relationships. |
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| Implement
(22 documents) |
| A self-care plan should include the appropriate patient response to scenarios common in patients with heart failure. This includes the response to fluid overload or dehydration as well as to chest pain. |
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| Evaluate
(4 documents) |
| Continually update progess by assessing measurable outcomes. The goals and interventions for all heart failure patients are evaluated regularly and revised to achieve desired health outcomes.
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Problem Solving
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