Evidence-based practice in Establishing Care Plans for the Home Health Patient: CHF

Evidenced-based practice is considered the best available evidence derived from systematic research, clinical experience, and tested expertise to achieve expected and/or improved patient outcomes (Institute for Healthcare Improvement, 2008 ). The new protocols for surveyors have moved the focus to data driven and outcome oriented (CMS, 2011) and the need to establish a well-defined plan of care foreshadows the need to follow evidence based practices for specific diseases to achieve the expected outcomes (even though, at this time, CMS has not yet mandated their use). The following are evidenced based practice SmartCues to remind the clinician as to specific processes/interventions to be considered in planning care.

A Focus on CHF

To significantly improve care, impact the quality of life, and reduce emergent and inpatient admissions several diagnoses require aggressive attention.  That attention requires evidenced based interventions.

Congestive Heart Failure (CHF)

Chief symptoms of CHF are dyspnea and fatigue which limits tolerance to exercise and promotes fluid retention that leads to pulmonary congestion and dependent edema. Because volume overload is not always seen at the time of evaluation, sometimes the term heart failure is used instead of congestive heart failure.

CHF effects over 5.5 predominately elderly individuals with 660,000 new cases diagnosed annually. According to the Journal of the American Heart Association, CHF is the underlying cause for 12-15 million office visits and 6.5 million hospital days per year. It ranks as the primary and secondary diagnoses for all hospitalizations over the age of 65. The financial burden is in excess of $40 billion dollars annually (AHA, 2008, 2009).

It is reported by CMS that “inadequate treatment, discharge planning, and follow-up, many patients with CHF are caught in a ‘revolving door’ process” leading to re-hospitalization (Jencks, S, CMS, 2005).

Home health care plan intervention per HHQI, the American Heart Association, and the National Heart, Lung, and Blood Institute would include the following SmartCues. However, all plans of care should be approved by the patient’s physician:

 

Symptom

Patient Instructions

Clinician Instructions

Assess for shortness of breath (dyspnea) Instruct patient  to identify its triggers. Clinician should reassess each visit.
Assess activity tolerance. Instruct patient  to identify activity daily and/or number of feet walked before dyspnea occurs. Consider Physical Therapy referral for muscle strengthening exercises for legs and upper arms. Teach exercise safety. Teach energy conservation when appropriate. Clinician should note baseline and assess activity levels and dyspnea changes each visit.
Assess for increased weakness and fatigue Instruct patient in energy conservation to achieve ADLs life quality. Clinician should note baseline and progress each visit.
Assess for signs of orthopnea Instruct patient to identify any change in number of propped pillows needed to breathe comfortably when lying down. Clinician should note baseline and changes each visit.
Assess for paroxysmal nocturnal dyspnea (feeling of smothering or fullness in the chest when lying down and resolves when standing up) Instruct patient how to identify changes in symptamotology. Clinician should assess each visit and note progress each visit. This symptom as well as increased orthopnea is usually an intermediate sign of fluid retention and per HHQI, “intervention at this point could still prevent rehospitalization.”
Assess for symptoms of chest pain or heaviness Instruct patient when to contact clinician or physician. Instruct as to utilization of and safety aspects of O2, if ordered by physician. Clinician should verify any occurrence each visit and identify S3 and S4. Assess for any new or recurrent dysrhythmias or murmurs. Per HHQI, “changes in heart rhythm can lead to poor cardiac output and worsening heart failure. Note: Extra sounds can be a warning of impending heart failure exacerbation.” Clinician to also assess lung sounds to identify any changes or note wheezes, crackles, rhonchi, or diminished breath sounds.Clinician should discuss with physician; pneumococcal vaccination and influenza immunization.
Assess for changes in B/P especially elevated B/P Instruct patient re proper technique to obtain B/P and heart rate (pulse). Clinician should obtain B/P sitting/standing, Heart Rate (HR), Respiratory Rate (RR), and Jugular Venous distension each visit.
Assess for edema of feet, ankles, hands, abdomen, or sacrum (anasaca) Instruct patient re how to assess every day. Clinician to obtain baseline and assess fluid retention (focus on feet/ankles, hands, sacrum, scrotal area, and abdomen) each visit.
Assess for increase in weight of 2-3 pounds in 24 hours or 3 pounds in one week. Instruct patient to weigh self daily and when to alert home health agency. Clinician should weigh patient and measure abdominal girth each visit.
Assess for diminished urinary output. Instruct patient to report decreased urinary output. Clinician to monitor at each visit as this is a signal of potential impending renal failure, or heart failure decomposition, or the body’s attempt to increase blood pressure.
Assess for appetite changes especially decreased appetite. Instruct patient on physician ordered low-fat, low-sodium diet and to record days of lowered appetite, as well as when to contact the clinician. Clinician should assess patient appetite each visit and if diminished appetite is reported, verify if there is abdominal fluid retention which could cause feelings of fullness and satiety.
Assess for depression or lack of interest in surroundings and difficulty with focus. Instruct patient as to psychosocial coping skills to maintain optimum self-care-management. Clinician should assess for symptoms of depression on each visit as well as assess family and support systems.
Assess for smoking Instruct patient as to negative effects on health. Encourage regular exercise as tolerated and commensurate with stamina and endurance. Clinician should ask re smoking and discourage both first and second-hand smoke.
Assess for medication understanding and medication compliance. Instruct patient on medication management. Meds may include an Angiotension Converting Enzyme (ACE) Inhibitor, a beta blocker, diuretic if needed, digoxin, and an anticoagulant. Clinician will monitor medication safety and compliance and should seek blood chemistry results and INR (as ordered by physician) and obtain heart rate, B/P, and clinical status with each dosage change.

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