Heart Failure Clinic Care Plan

Document Type:Essay

Subject Area:Computer Science

Document 1

Family and caregiver involvement in heart failure management on discharge Orientation schedule Time (from admission) topic objective Mode of delivery People to be involved evaluation 24 hours since admission (stable patient) or 24 hours of patient attaining stability Introduction to heart failure The patient will understand the disease course. This promotes their involvement in care Patient education delivered orally with face to face communication with the patient, family or caregiver and the primary nurses. Patient Caregiver Family members Primary nurses Patient will be evaluated by the primary care nurses for their understanding of the condition during their period of admission and report of their understanding shared with clinic nursing staff Day 3 of admission Self-care for heart failure, nutrition and exercise orientation Medication follow-up To gauge patient ability to care for self and utilize information learned in the first days of introduction Use of face to face patient interaction can be done for groups of patients not exceeding three.

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Patient Caregiver/family member Nutritionist Primary nurse The patient will provide a return explanations and answer questions on self-care. Further evaluation during discharge The care orientation plan will be flexible and will be designed following the guidelines to fit the needs and cultural or language needs of the patients to ensure it cares for diverse patient cultural and language backgrounds (Douglas et al. Nurse, patient family members and the caregiver Telephone follow-up for the patient and regular physical home visits to establish patient’s adherence to discharge plans. The discharge plan will be individualized per individual needs incorporating their culture, language and religious practices. Caregiver involvement will be critical to ensure a successful discharge plan and follow-up is established. The Joint Commission standards require for patient caregivers to be involved in sharing discharge information for the patient (The Joint Commission).

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The legal requirements require for nurses to disclose essential information that may affect the patient outcome with the patients to ensure patient safety. d). Care coordination as a best practice is also a key nursing practice standard and one of the effective evidence-based practices. The success of the care coordination plan will be assessed using a comprehensive care checklist for each patient. The successes of the care coordination plan will be indicated by positive patient outcomes, reduction in readmission rates for heart failure patients, improved patient adherence to medications and treatment plans and efficient management of comorbidities for the specific patients. The information will be recorded and reported in each patient's health information which can be assessed by each patient care team.

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