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Heart Failure Clinic Care Plan

Heart Failure Clinic Care Plan

Nurses use a systematic process in delivering care to the patients. The five interrelated stages include investigation, diagnosis phase, planning stage, implementation, and evaluation. The planning stage involves identifying the desired outcomes and the interventions that will be applied to achieve the results. Implementation, on the other hand, refers to establishing a plan of action and observing the initial responses. A discharge plan is usually based on the investigation that is done during the phase of collecting data and the collected information during hospitalization (Barnason, Zimmerman, & Young, 2012).  This includes such factors as the limitations of the patient, his/her family, environment, caregiver and the resources at their exposure. Inadequate discharges of patients from the hospital as well as the non-adherence of the patient to the instructions are factors indicated to have led to re-hospitalization of patients suffering from heart failure. Heart Failure (HF) is a condition where the heart fails to pump the required volumes of blood to meet the metabolism demands of the tissues. A congestive heart failure is an acute form of rapid onset or change of the symptoms with urgent therapy being required (Desai & Stevenson, 2012).  This paper will develop an appropriate discharge plan for patients with acute heart failure. This discharge plan will include two sections that include health education and nursing care.

Evidence-Based Plan for Health Care Delivery

The department recognizes that with improved knowledge on self-care, the cases of morbidity and mortality as well as the costs related to HF will be reduced greatly. Health education helps the patients to observe self-care by monitoring their weight, restriction of the intake of fluids and sodium, undertake programmed individual exercises, compliance to medication prescriptions and monitoring for symptoms that indicate worsening of the condition (Lambrinou, Kalogirou, Lamnisos, & Sourtzi, 2012). It has been established that lack of knowledge regarding the condition and the treatment options, failure to accept the disease, poor support from family, temporal improvement of signs, side effects of medication, and the prolonged treatment of the disease without a prospect for cure are some factors that undermine self-care (Desai & Stevenson, 2012).  

Apart from giving the health education to patients, we recognize that nursing care regarding the instructions given promotes adherence to treatment as well as improving the clinical outcomes. Besides, a trusted nurse-patient relationship plays a fundamental role in adherence and healing process. Additionally, there should be proper, open and reliable communication between the two parties to enhance the quality of care, education as well as the structuring of the discharge plan (Fleming & Kociol, 2014).

The plan shall rely heavily on the professional requirement to document all information during all the phases beginning with initiation of the discharge plan, education, and prescription of medication, giving of written instruction and during home visits (Fleming & Kociol, 2014).

Accountability Tools and Procedures Used To Measure Effectiveness

The nursing department shall educate the patients concerning their disease and the relationship between healthy living and the disease. They will also elaborate on how pharmacological therapy can influence patient’s cure to reduce re-hospitalization. To achieve this milestone, the nurses shall make use of books, videos, web pages, educational booklets among other strategies to ensure that the patient understands the information being passed on (Lambrinou et al., 2012).  Besides, the nurses will make sure that they provide an opportunity for follow-up by phone or through support groups given that the amount of information given at the time of discharge is usually large (Barnason, Zimmerman, & Young, 2012).  

We shall also consider the use of a frequent educational scheme. The nurses will draw a table that has the name of the patient together with the medication schedule that highlights the type of medication, its name, dosage, indication, time and the potential side effects (Fleming & Kociol, 2014).

The patients should be given some of these educational materials at the time of discharge. The written discharge instructions shall contain lists of medication and their respective doses, daily weight control and a guide to deteriorating symptoms. This supports the ability of the patients to identify the symptoms of heart failure (Lambrinou et al., 2012).

The nursing department shall, on an individual plan from the onset of hospitalization up to discharge, determine the demographic, physiological and psychosocial domains that lead to readmissions. Understanding these domains, the nurses shall devise a plan that suits each individual to curb the possibility of re-hospitalization (Lambrinou et al., 2012).

We shall also use a model that focuses on the physical, emotional and social needs of each patient. The first phase of this model is called “Care,” which deals with the activities done by the nurse on a daily basis to reduce the anxiety and increase the comfort of the patient. During this phase, education and discharge plan are initiated (Lambrinou et al., 2012). The second phase called the “Cure,” is concerned with treatment and the final phase, “Core,” focuses on the social and emotional state of the patient. This model is critical because it enhances knowledge and the capacity for the patients to self-manage their condition and preventing it from worsening and the subsequent re-admissions (Lambrinou, et al., 2012).

Above all, documentation should be done at all phases including the information that is given during discharge and the capacity of the patients to comprehend the instructions (Fleming & Kociol, 2014).

Professional and Legal Standards In Support Of A Care Plan

The nurses have a professional duty to ensure that the patients under their care receive the necessary support during their healing process. To perform these tasks for discharged persons suffering from HF, they will make follow-ups by way of visits and phone calls as a standard nursing practice to strengthen the kno*****************

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