CHF Program and COPD Program
The Congestive Heart Failure program is designed to increase the patient’s knowledge regarding heart failure, thus improving their quality of life and reducing re-hospitalizations.
A Registered Nurse will visit the patient at home, assess their cardiac status and a teaching program will be instituted which includes:
- Explanation of congestive heart failure
- Causes of heart failure
- Signs and symptoms associated with heart failure
- Treatment Guidelines
- Proactive Disease Management Education program with emphasis on disease processes, symptom management and behavior modifications, i.e. low sodium diet, exercise and weight management.
- Full nursing assessment of the patient and the home environment.
- CHF Weight Guidelines carefully reviewed and documented with the patient and their caregivers.
- Front loading visits
- Tele-Health: All CHF/COPD patients can participate in our tele-health program which focuses on physical status (such as weight, edema status, oxygen use, etc.) self management behavior
- modification and teaching (i.e. occupational therapy- energy conservation).
- Tele-monitors are incorporated into our Plan of Care for High Risk Patients.
- Emergency Care Plans are reviewed with the patient and their families.
- Emphasize the importance of communication with the patient as well as the physician, pharmacist and caregivers.
The Registered Nurse will instruct the importance of recording weight and recognizing early symptoms, healthy food choices including limitation of sodium and fluids, and tips regarding medication management.
The Registered Nurse will report the patient’s condition to the patient’s doctor and together, they will formulate a plan of care for their patient.
Referrals for physical and occupational therapy may be needed. If the patient needs counseling or long term planning, a Social Worker may be referred.