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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 2
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Heart Failure
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Problem Solving
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Plan
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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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Include specific measurable patient goals in the plan of care. Use "Plan Characteristics” below as tools to build a nursing plan and find resources to set and to reach goals.
Characteristics of a good plan
- Include a defined time frame.
- Developed with the patient's thoughts on what things they want to achieve.
- Consider a patient’s readiness to change.
- Outline the support they need to make changes.
- Include the individualized interventions to meet patient’s goals.
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*Under Implement category you will find
tools to help you carry out patient goals.
Important considerations
- Target goal for blood pressure
- Target goals for cholesterol
- Target goals for A1c
- Target dry weight
- Current recommended standards of clinical care
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Levels of evidence
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Level 1
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Systematic reviews and repeated studies, thoroughly researched.
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Level 2
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Experimental (Single or Quasi experimental study) and non-experimental (Exploratory or qualitative study).
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Level 3
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Recommendations of respected, experienced homecare authorities.
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Level 4
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Not Recommended.
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Plan
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