C.H.F. - Clinical Pathway Training

Clinical-Pathway-Training

CHF Clinical Pathway

CHF Stages

class1 class2
class3 class4

The CHF Clinical Pathways vary depending on
whether patients are in Class I or II or Classes III or
IV. For the purposes of the Pathway, the RN can
determine the patient’s stage based on symptoms
and no physician diagnosis of stage is required. The
Pathway for Classes I and II includes 8 skilled nurse
home visits, 2 skilled nurse telephone encounters
and 8 physical therapy visits. The CHF Pathway for
Classes III and IV include 12 nursing visits, 4 telephone
encounters and 6 physical therapy visits. The visits
should be scheduled over the entire certification
period with more visits scheduled at the beginning of
the episode and then tapering to less frequent visits
towards the end of the episode.

The Pathway serves only as a guideline to ensure
adequate assessment and teaching is done to enable
patients and caregivers to manage the patient’s
disease process and maintain as much independence
as possible. Additional nursing or therapy visits may
be added as warranted and ordered by the physician
depending on changes in the patient’s condition.
The ultimate goal of the CHF Pathway is to equip the
patient to manage his/her disease, maintain
independence and prevent hospitalization.

CHF Clinical Pathway Classes I & II

Skilled Nursing

Assessment points required for every visit: weight, VS, oxygen saturation (if ordered), edema, dyspnea, orthopnea, and cough

Visit Assess Review Teach
1st Oxygen use
Dietary compliance
Fluid restriction (if applicable)
Medication compliance
Functional abilities: need for
HHA, PT, OT
Availability/willingness of
caregiver(s)
Need for additional DME
(coordinate with PT after
initial PT visit)
Medication
regimen
including
OTC and
supplements
All required admission items
Explain use of clinical pathway
Introduce CHF teaching materials
Visit schedule
Discharge plan
Goal is pt.
(independence in mgt of CHF )
*Daily weights
(use tracking sheet)
2nd Daily weight record
Dietary compliance
Medication compliance
Daily weight
compliance
Start diet diary
*Medication 1
(start with oxygen use if applicable
or if no O2 then most
relevant to CHF diagnosis)
*S/S CHF exacerbation
*When to call your doctor
3rd Daily weight record
Diet record
Medication compliance
Medication 1
S/S CHF
exacerbation
When to call
your doctor
*Medication 2
*What is CHF?
*What causes CHF?
*Fluid restriction, if applicable
4th Daily weight record
Diet record
Medication compliance
Fluid restriction compliance
Medication 2
What is CHF?
What causes
CHF?
Fluid restriction
*Medication 3
*CHF exacerbation causes
*What to do for exacerbation
5th Daily weight record
Diet record
Medication compliance
Fluid restriction compliance
Medication 3
CHF exacerbation
causes
What to do for
exacerbation
*Medication 4
*Heart healthy diet
*Low sodium diet
1st
Phone
Call
Telephone encounter:
1. Have you had any shortness of breath? (describe)
2. Have you had any edema? (where and describe)
3. Have you had any pain? (describe)
4. How much did you weigh this morning?
5. When is your next doctor’s appointment?
6. Do you have any questions?
As appropriate to patient’s
answers to questions
6th Daily weight record
Diet record/compliance
Medication compliance
Fluid restriction compliance
Medication 4
Heart healthy diet
Low sodium diet
*Medication 5
*Assessment of edema
Discharge plan — in 2 visits if
stable or start new clinical
pathway for secondary
disease process
7th Daily weight record
Diet record/compliance
Medication compliance
Fluid restriction compliance
Medication 5
Assessment of
edema
*Medications 6 & 7
*Tobacco cessation if applicable
*Lifestyle changes
Discharge notice for next
SNV, if applicable
2nd
Phone
Call
Telephone encounter:
1. Have you had any shortness of breath? (describe)
2. Have you had any edema? (where and describe)
3. Have you had any pain? (describe)
4. How much did you weigh this morning?
5. When is your next doctor’s appointment?
6. Do you have any questions?
As appropriate to patient’s
answers to questions
8th Daily weight record
Diet record/compliance
Medication compliance
Fluid restriction compliance
Medications 6 & 7
Tobacco
cessation if
applicable
Lifestyle changes
Medications 8 & 9
Discharge instructions,
if applicable
*Indicates required skill for visit

CHF Clinical Pathway Classes I & II

Physical Therapy

Assessment points required for every visit: VS, oxygen saturation (if ordered), edema, activity tolerance,
dyspnea, orthopnea, and level of mobility

Visit Assess Review Teach
1st Functional status ADLs/IADLs
Need for OT referral
Response to position changes
Posture/balance
Transfers
ROM
Thoracoabdominal movements
Home safety
Strength
Medication
Regimen including
OTC and
supplements
Home exercise program
Home safety modifications and
equipment needed
(order equipment as needed).
Therapeutic exercises for
aerobic conditioning, strength
and stretching
Goals of therapy
Discharge plan
2nd Was equipment obtained and
home modifications completed
or started
HEP
Goals of therapy
Discharge Plan
Use of assistive devices
Therapeutic exercises for
aerobic conditioning, strength
and stretching
Gait, locomotion and
balance training
3rd Appropriate use of devices
Safety
Endurance
HEP
Gait locomotion
and balance
training
Energy conservation
techniques
Progression from short
duration exercises to longer less
frequent sessions
Therapeutic exercises for
aerobic conditioning, strength
and stretching
Gait, locomotion and
balance training
4th Appropriate use of devices
Safety
Endurance
HEP
Energy
conservation
techniques
Breathing exercises and
ventilatory muscle training
Therapeutic exercises for
aerobic conditioning, strength
and stretching
Gait, locomotion and
balance training
5th Appropriate use of devices
Safety
Endurance
HEP
Breathing
exercises and
ventilatory muscle
training
Activities or postures to
relieve symptoms
(dyspnea, orthopnea or edema)
Therapeutic exercises for
aerobic conditioning,
strength and stretching
Gait, locomotion and
balance training
6th Appropriate use of devices
Safety
Endurance
HEP
Activities or
postures to relieve
symptoms (dyspnea,
orthopnea
or edema)
Therapeutic exercises for
aerobic conditioning, strength
and stretching
Gait, locomotion and
balance training
7th Appropriate use of devices
Safety
Endurance
HEP Therapeutic exercises for
aerobic conditioning, strength
and stretching
Gait, locomotion and
balance training
Discharge notice for
next PT visit
8th Appropriate use of devices
Safety
Endurance
HEP
Energy
conservation
Breathing
techniques
Activities or
postures to relieve
symptoms
Therapeutic exercises for
aerobic conditioning, strength
and stretching
Gait, locomotion and
balance training
Discharge instructions

CHF Clinical Pathway Classes III & IV

Skilled Nursing

Assessment points required for every visit: weight, VS, oxygen saturation (if ordered), edema, dyspnea, orthopnea, and cough

Visit Assess Review Teach
1st Oxygen use
Dietary compliance
Fluid restriction (if applicable)
Medication compliance
Functional abilities: need for
HHA, PT, OT
Availability/willingness of
caregivers
Need for additional DME
(coordinate with PT after initial
PT visit)
Medication
regimen
including OTC
and supplements
All required admission items
Explain use of clinical pathway
Introduce CHF teaching materials
Visit schedule
Discharge plan
Goal is pt. independence in
mgt of CHF
*Daily weights
(use tracking sheet)
2nd Daily weight record
Diet record
Medication compliance
Daily weight
compliance
Start diet diary
*Medication 1
(start with oxygen use if
applicable or if no O2 then most
relevant to CHF diagnosis)
*S/S CHF exacerbation
*When to call your doctor
3rd Daily weight record
Diet record
Medication compliance
Medication 1
S/S CHF
exacerbation
When to call
your doctor
*Medication 2
*What is CHF?
*What causes CHF?
4th Daily weight record
Diet record
Medication compliance
Medication 2
What is CHF?
What causes
CHF?
*Medication 3
*Fluid restriction, if applicable
5th Daily weight record
Diet record
Medication compliance
Fluid restriction compliance
Medication 3
Fluid restriction
*Medication 4
*CHF exacerbation causes
*What to do for exacerbation
1st
Phone
Call
Telephone encounter:
1. Have you had any shortness of breath? (describe)
2. Have you had any edema? (where and describe)
3. Have you had any pain? (describe)
4. How much did you weigh this morning?
5. When is your next doctor’s appointment?
6. Do you have any questions?
As appropriate to patient’s
answers to questions
6th Daily weight record
Diet record
Medication compliance
Fluid restriction compliance
Medication 4
CHF exacerbation
causes
What to do for
exacerbation
*Medication 5
*Heart Healthy Diet
*Low Sodium Diet
7th Daily weight record
Diet record
Medication compliance
Fluid restriction compliance
Medication 5
Heart healthy diet
Low sodium diet
*Medications 6
*Assessment of edema
2nd
Phone
Call
Telephone encounter:
1. Have you had any shortness of breath? (describe)
2. Have you had any edema? (where and describe)
3. Have you had any pain? (describe)
4. How much did you weigh this morning?
5. When is your next doctor’s appointment?
6. Do you have any questions?
As appropriate to patient’s
answers to questions
8th Daily weight record
Diet record
Medication compliance
Fluid restriction compliance
Medications 6
Assessment of
edema
Medications 7
*Tobacco cessation if applicable
9th Daily weight record
Diet record
Medication compliance
Fluid restriction compliance
Medication 7
Tobacco
cessation if
applicable
*Medication 8
*Lifestyle changes
3rd
Phone
Call
Telephone encounter:
1. Have you had any shortness of breath? (describe)
2. Have you had any edema? (where and describe)
3. Have you had any pain? (describe)
4. How much did you weigh this morning?
5. When is your next doctor’s appointment?
6. Do you have any questions?
As appropriate to patient’s
answers to questions
10th Daily weight record
Diet record/compliance
Medication compliance
Fluid restriction compliance
Medication 8
Lifestyle Changes
*Medication 9
Discharge plan – in 2 visits if stable
or start new clinical pathway
for secondary disease process
11th Daily weight record
Diet record/compliance
Medication compliance
Fluid restriction compliance
Medication 9
*Medication 10
Discharge notice for next SNV,
if applicable
4th
Phone
Call
Telephone encounter:
1. Have you had any shortness of breath? (describe)
2. Have you had any edema? (where and describe)
3. Have you had any pain? (describe)
4. How much did you weigh this morning?
5. When is your next doctor’s appointment?
6. Do you have any questions?
As appropriate to patient’s
answers to questions
12th Daily weight record
Diet record/compliance
Medication compliance
Fluid restriction compliance
All medications *Any remaining medications
Discharge instructions,
if applicable
*Indicates required skill for visit

 

CHF Clinical Pathway Classes III & IV

Physical Therapy

Assessment points required for every visit: VS, oxygen saturation (if ordered), edema, activity tolerance, dyspnea, orthopnea, and level of mobility

Visit Assess Review Teach
1st Functional status ADLs/IADLs
Need for OT referral
Response to position changes
Posture/balance
Transfers
ROM
Thoracoabdominal movements
Home safety
Strength
Medication
regimen including
OTC and
supplements
Home exercise program
Home safety modifications and
equipment needed.
(order equipment as needed).
Therapeutic exercises for
aerobic conditioning, strength
and stretching
Goals of therapy
Discharge plan
2nd Was equipment obtained and
home modifications completed
or started
HEP
Goals of therapy
Discharge plan
Use of assistive devices
Therapeutic exercises for
aerobic conditioning, strength
and stretching
Gait, locomotion and
balance training
3rd Appropriate use of devices
Safety
Endurance
HEP
Gait locomotion
and balance
training
Energy conservation
techniques
Progression from short
duration exercises to longer less
frequent sessions.
Therapeutic exercises for
aerobic conditioning, strength
and stretching
Gait, locomotion and
balance training
4th Appropriate use of devices
Safety
Endurance
HEP
Energy conservation
techniques
Breathing exercises and
ventilatory muscle training
Therapeutic exercises for
aerobic conditioning,
strength and stretching
Gait, locomotion and
balance training
5th Appropriate use of devices
Safety
Endurance
HEP
Breathing
exercises and
ventilatory muscle
training
Activities or postures to
relieve symptoms
(dyspnea, orthopnea or edema)
Therapeutic exercises for
aerobic conditioning,
strength and stretching
Gait, locomotion and
balance training
6th Appropriate use of devices
Safety
Endurance
HEP
Activities or
postures to relieve
symptoms
(dyspnea,
orthopnea
or edema)
Energy
conservation
Breathing
techniques
Therapeutic exercises for
aerobic conditioning,
strength and stretching
Gait, locomotion and
balance training
Discharge Instructions

C.H.F. Patient Education

What is Congest iveHeart Failure?

Congestive Heart Failure is also known as CHF or heart failure. Your heart is a pump that pumps nutrients and oxygen to all parts of your body and helps remove waste products. Heart Failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not pumping the way it should. The weakening of your heart’s pumping ability causes the backup of blood and fluid into your lungs or feet and ankles.

What causes CHF?

The leading causes of heart failure are coronary artery disease, high blood pressure and diabetes.
Heart failure becomes more common with advancing age. You are also at increased risk for developing heart failure if you are overweight, have diabetes, smoke cigarettes, abuse alcohol, or use cocaine.

Signs and Symptoms of CHF

• Shortness of breath (dyspnea) when you exert yourself or when you lie down
• Fatigue and weakness
• Swelling (edema) in your legs, ankles and feet
• Rapid or irregular heartbeat
• Reduced ability to exercise
• Persistent cough or wheezing with frothy white or pink blood-tinged phlegm
• Swelling of your abdomen (ascites)
• Sudden weight gain from fluid retention
• Lack of appetite and nausea
• Difficulty concentrating or decreased alertness
• Increased urination at night

When to see a doctor

See your doctor if you experience any of the signs or symptoms associated with heart failure. These include:
• Chest pain
• Fatigue and weakness
• Rapid or irregular heartbeat
• Shortness of breath (dyspnea) when you exert yourself or when you lie down
• Reduced ability to exercise
• Persistent cough or wheezing with white or pink blood-tinged phlegm
• Swelling in your abdomen, legs, ankles and feet
• Difficulty concentrating or decreased alertness

Importance of Daily Weights

Sudden weight gain may be an indication of CHF exacerbation so monitoring your weight daily is a good way to monitor your condition.
You should weigh yourself daily:
• At the same time of day (preferably in the morning)
• Unclothed (or with the same clothing on, such as underwear)
• On the same hard, flat surface

• Using the same scale
Report a weight gain of 3 or more pounds in a 24 hour period or a gradual weight gain over days to your doctor immediately.
Ass essment of Edema Edema is a medical word for “fluid retention.” To check for fluid retention, push the skin against your ankles and shins. If an  impression of your finger remains, then you are retaining fluids. Larger amounts of fluid retention are indicated by a deeper finger impression that takes a longer period of time (minutes instead of seconds) to go away. If you are experiencing edema make sure your socks and clothing are not too restrictive. Raise your feet above the level of your heart to decrease edema in your feet and ankles.

What Brings on an “Att ack” of CHF?

The precipitating factors of CHF exacerbation are:
• Poor pumping capacity of the heart
• Increased salt intake
• Failure to take medications as ordered
• Unusually large amounts of fluid intake

What To Do When you Are Having an Att ack

If you are having an attack you should:
• Notify your doctor and make a visit to your doctor if she or he recommends it
• Take your medication as prescribed
• Position yourself to ease breathing
• Elevate your legs above the level of your heart if you have edema in your ankles or legs
• Think back to your diet and evaluate your salt and fluid intake. Learn from your mistakes
• Do not eat anything that contains salt or sodium
• Limit fluid intake to 1 ½ quarts in a 24 hour period unless otherwise instructed by your doctor.

Fluid Rest riction

Some people with severe congestive heart failure may require fluid restriction. Your doctor will let you know if you should restrict your fluid intake. Basically, two cups (one pint or about 500 cc) of fluid will equal roughly one pound of fluid weight gain.
All beverages and foods that are liquid at room temperature are considered to be fluids. Don’t forget products that contain “hidden fluids” such as
non-dairy creamer, pudding, syrup, yogurt, sour cream, watermelon, grapefruit, popsicles, ice cubes, and gravy.
Tips on limiting fluid intake:
• Drain fluid from canned fruits and vegetables before consumption
• Place your allowed amount of water per day in your own personal container so you can monitor your fluid intake; poor water out of the container when you receive “extra fluids” from another source
• Avoid coffee, tea, soft drinks, and alcoholic beverages
• Use lemon wedges or hard candies to moisten a dry mouth; this can often take the edge off thirst
• Rinse your mouth with water but do not swallow it
• Take your medications with your allowed fluids at mealtime
• Become aware of how much fluid your coffee cup, bowls, and water glasses hold; if possible use smaller cups and glasses

Heart Healthy Diet

A generally healthy diet for people with heart disease should include:
• Control calories
Eat just enough calories to achieve and maintain a healthy weight.
• Eat quality fats Use virgin olive oil and other unsaturated, low-cholesterol fats. Limit the use of butter, lard and shortening.
• Eat the right amount of fats, carbohydrates and protein
Limit your fat intake to 20 or 30 %, but don’t substitute simple carbohydrates for fat. Less than 7% of the day’s total calories should come from saturated fat.
• Avoid fad diets
Eat a well-rounded diet instead. Eat small, frequent meals. Avoid large and heavy meals.
• Limit cholesterol in diet To less than 200 milligrams a day.
• Eat enough dietary fiber Whole grains are best.
• Eat plenty of fresh fruits and vegetables
• Magnesium Eat foods rich in magnesium. Heart failure drugs can deplete the body’s stores of magnesium. This has been correlated with more severe symptoms and a higher death rate. Foods high in magnesium include wheat germ, soybeans, oatmeal, nuts, seeds, low-fat diary items, and seafood.
• If you are taking a diuretic you may need to eat potassium rich foods such as bananas, apricots, raisins, oranges, grapefruit, and peas.

Low Sodium Diet

Sodium is a component of salt. Too much sodium contributes to water retention, which makes your heart work harder and causes shortness of breath
and swollen legs, ankles and feet. All congestive heart failure patients should limit salt intake to 1,000-1,500 mg of sodium per day. One teaspoon of salt contains about 2,300 mg of sodium.
Salt comes in many forms. You are most familiar with table salt. Some salt is hidden. Read content labels carefully and avoid foods that list “salt” or
“sodium” compounds as one of the first three ingredients.

Some general guidelines to decrease salt intake are:
• Only use minimal amounts of salt while cooking
• Do not add salt to any foods once prepared
• When eating out ask that foods be prepared without salt
• Avoid:
- Fast foods
- Luncheon meats
- Processed cheese (American cheese, cheese spreads)
- Cured meats such as ham, bacon and sausage
- Salted pretzels, chips or other crunchy salted snacks
- Anything that is pickled such as pickles, olives, hot peppers
- Frozen or processed meals
- Canned soups and meats
- Seasonings that contain salt: soy sauce, steak sauce, ketchup, garlic and onion salt and monosodium glutamate.
There are many foods that you can eat. Use common sense and remember that if you cheat by adding more salt than usual, you heart and lungs
will feel the difference.

You can safely eat:

- Freshly prepared meats
- Fresh vegetables or plain frozen vegetables (not containing a sauce)
- Fresh, frozen or canned fruits
- Unsalted snack foods – boxes marked “salt free” or “unsalted”
- Low sodium cheeses
- Unsalted butter or spreads (check the label!)

Life style Changes

Making lifestyle changes can often help relieve signs and symptoms of heart failure and prevent the disease from worsening. These changes may be
among the most important and beneficial you can make:
• Stop smoking
Smoking damages your blood vessels, reduces the amount of oxygen in your blood and makes your heart beat faster. If you smoke, ask your doctor
to recommend a program to help you quit.
• Maintain a healthy weight If you’re overweight, work with your doctor on a weight loss plan that is right for you.
• Limit fats and cholesterol
In addition to avoiding high-sodium foods, limit the amount of saturated fat, trans fat and cholesterol in your diet. A diet high in fat and cholesterol is a risk factor for coronary artery disease, which often underlies or contributes to heart failure.
• Limit alcohol
Your doctor likely will recommend that you don’t drink alcohol if you have heart failure, since it can interact with your medication, weaken your heart muscle and increase your risk of abnormal heart rhythms.
• Exercise
Moderate exercise helps keep the rest of your body healthy and conditioned, reducing the demands on your heart muscle. Before you start exercising though, talk to your doctor about an exercise program that’s right for you. Your doctor may suggest a walking program. Check with your local hospital to see if it offers a cardiac rehabilitation program; if it does, talk to your doctor about enrolling in the program. Do not exercise on days when your weight has gone up from fluid retention or when you are not feeling well.
• Reduce stress
When you’re anxious or upset, your heart beats faster and you breathe more heavily. This can make heart failure worse, since your heart is already having trouble meeting the body’s demands. Find ways to reduce stress in your life. To give your heart a rest, try napping or putting your feet up when possible.
• Take your medications as directed. Carry a list of medications with you wherever you go.
• Elevate
your feet above the level of your heart if your feet or legs are swollen.
• If you have high blood pressure learn how to take your blood pressure and check it everyday. Take a record of your results to your doctor’s appointments.
• Sleep easy
If you’re having shortness of breath, especially at night, sleep with your head propped up at a 45-degree angle using a pillow or a wedge. If you
snore or have had other sleep problems, make sure you get tested for sleep apnea. To improve your sleep at night, prop up your head with
pillows and avoid big meals right before bedtime.
Also, discuss with your doctor changing the time for taking medications, especially diuretics. Taking diuretics earlier in the day may keep you from
having to urinate as often during the night.

Common medications chf diary

Doctors usually treat heart failure with a combination of medications. Depending on your symptoms, you might take one or more of these drugs.
They include:
• Angiotensin-converting
enzyme (ACE) inhibitors
These drugs help people with heart failure live longer and feel better. ACE inhibitors are a type of vasodilator, a drug that widens blood vessels to
lower blood pressure, improve blood flow and decrease the workload on the heart. Examples include enalapril (Vasotec), lisinopril (Prinivil, Zestril) and captopril (Capoten).
• Angiotensin II receptor blockers (ARBs)
These drugs, which include losartan (Cozaar) and valsartan (Diovan), have many of the same benefits as ACE inhibitors. They may be an alternative for people who can’t tolerate
ACE inhibitors.
• Digoxin (Lanoxin)
This drug, also referred to as digitalis, increases the strength of your heart muscle contractions. It also tends to slow the heartbeat. Digoxin reduces heart failure symptoms and improves your ability to live with the condition.
• Beta blockers
This class of drugs slows your heart rate and reduces blood pressure. Examples include carvedilol (Coreg), metoprolol (Lopressor) and bisoprolol (Zebeta).
These medicines also reduce the risk of some abnormal heart rhythms. Beta blockers may reduce signs and symptoms of heart failure and improve heart function.
• Diuretics
Often called water pills, diuretics make you urinate more frequently and keep fluid from collecting in your body. Commonly prescribed diuretics for heart failure include bumetanide(Bumex) and furosemide (Lasix). The drugs also decrease fluid in your lungs, so you can breathe more easily. Because diuretics make your body lose potassium and magnesium, your doctor may also prescribe supplements of these minerals. If you’re taking a diuretic, your doctor will likely monitor levels of potassium and magnesium in your blood through regular blood tests.
• Aldosterone antagonists
These drugs include spironolactone (Aldactone) and eplerenone (Inspra). They’re primarily potassium-sparing diuretics, but they have additional properties that help the heart work better, may reverse scarring of the heart and may help people with severe heart failure live longer.
Unlike some other diuretics, spironolactone can raise the level of potassium in your blood to dangerous levels, so talk to your doctor if increased potassium is a concern.

chf diary

Date Weight BP food/fluid intake
(Include all meals and snacks with
type of food and amount)
symptoms
you are experiencing (edema, shortness
of breath, cough, fatigue, etc.)

 

 

 

 

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