Heart Failure Clinic Care Plan Sample Essay

FP4012 Heart Failure Clinic Care Plan

Heart Failure Clinic Care Plan Scoring Guide

Heart Failure Clinic Care Plan

Discharge Plan

In providing health care to patients, the nurses use a systematic approach that involves an integration of five stages of investigation, diagnosis, planning, implementation and evaluation. These stages can overlap each other as planning can happen at the same time as diagnosis. Planning is fundamental because it requires the nurses to identify the desired outcomes and decide on the interventions that should be applied if the results are to be achieved. Implementation of a plan involves instituting an action plan at the same time observing the initial responses to the schedule (Lingle, 2013).

 A discharge plan must be based on the information that is gathered during the investigation and diagnosis phases. The information collected covers aspects like the environment, caregiver and what resources are at their exposure, the limitations the patient may have, the family among others (Lingle, 2013). Ineffective discharge plans and non-adherence of the patients to the provisions of the plan are key factors that lead to re-hospitalization of patients especially those that suffer from heart failure. Heart failure (HF) is characterized by the inability of the heart top pump enough blood to meet the demands of metabolism. When the onset is rapid or the symptoms change suddenly and urgent therapy is required, then the condition is referred to as congestive or acute heart failure (Fleming & Kociol, 2014). This paper will develop an evidence-based discharge plan; discuss the tools that will be used to measure the effectiveness of the plan as well as the professional and legal standards that support the care plan.

Evidence-Based Plan for Health Care Delivery

In an effort to reduce the direct medical costs of re-hospitalizations, cases of morbidity and mortality that result from HF, improving knowledge on self-care is a critical component. By offering the appropriate health education, the patients are empowered to observe self-care. Some of the components of self-care include weight monitoring, checking on the fluid and sodium intake, carry out programmed individual physical exercises, complying with the medical prescriptions and monitoring for signs of a worsening condition (Lingle, 2013). Studies have shown that lack of knowledge concerning the condition and the treatment options available, poor support from the family, side effects of medication failing to accept the presence of the disease contribute to undermining self-care. Besides, when temporal improvement signs are observed together with prolonged treatment with little prospect of a cure, the patients tend to stop the self-care programs (Fleming & Kociol, 2014).

Besides, our department establishes that to improve clinical outcomes and adherence to medication, we need to improve our nursing care to complement the efforts of the health education. We shall also continuously encourage and implement a trusted nurse-patient relationship which is critical to achieving positive health outcomes. Above all, the department is executing an open and reliable communication policy among the various parties that concerned in the entire health care continuum (Lambrinou, Kalogirou, Lamnisos, & Sourtzi, 2012).

The nursing department shall, therefore, educate the patients about the conditions of their own illnesses, what relationship exists between the healthy living and the disease. The use of pharmacological therapy to influence their cure and reduce the rates of re-hospitalization shall also be emphasized. In achieving this success, the use of books, videos, and educational booklets shall be applied to ensure that the patients understand every piece of information being given (Barnason, Zimmerman, & Young, 2012).  

Our discharge plan shall make use of a three-phase model that focuses on the physical, emotional and social needs of an individual patient. The first phase, called the ‘Care’ shall include all the activities carried out by the nurse on a daily basis aimed at reducing the anxiety and increasing the comfort of the patient. We shall initiate the education and discharge plan during this stage. The second phase is called the ‘Cure’ and primarily concerned with treatment. The final phase, the ‘Core’, deals with the social and emotional needs of the patients. The model is vital as it enhances the capacity and knowledge of the patients to self-care their condition.

Accountability Tools and Procedures to Measure Effectiveness

We also recognize the crucial role of proper documentation of all information during the various stages of developing a discharge plan because it is a professional requirement. Starting from the initiation of the discharge plan, education, prescription, giving of instructions and paying home visits, we shall ensure that all data is recorded for reference and appropriate actions (Lingle, 2013).

To ensure that the patients adhere to the discharge plan, the nurses shall ensure that they give an opportunity for follow-ups by use of phones, support groups or physical visits because the amount of information given during discharge is usually big. Making use of an educational scheme is also a tool that we can use to ensure effectiveness (Lingle, 2013). This scheme involves drawing a table that has the name of the patient with the highlights of the type of medication, dosage, indication, time as well as the potential side effects. The scheme allows for an easy check up on the progress of the patients and earlier recognition of improvements or worsening of the condition.

To curb the possibility of re-admissions, the department shall determine the demographic, physiological and psychosocial domains that result to re-hospitalization.by understanding these domains; the nurses shall develop a plan that suits each patient (Fleming & Kociol, 2014).

Professional and Legal Standards in Support of a Care Plan

It is the professional duty and requirement of nurses to provide the necessary support to the patients under their care during the diagnostic, treatment and healing stages. The nurses carry out this function by making visits, phone calls, and using other technologies to establish the state of the patients. By accomplishing these tasks, a better nurse-patient relationship is achieved which enhances adherence to the discharge plan (Fleming & Kociol, 2014). Besides, such follow-ups help the patient to memorize the guidelines and instructions given and seek any clarifications on any issues that they may require during the healing process.

Acting ethically, by ensuring the safety and privacy of the patient is a basic professional and legal requirement. Adhering to the provisions of the American Association of Nurses (ANA) guidelines is mandatory for all of our nurses. Apart from taking internal disciplinary measures for any gross breach of the regulations, we shall forward the individual to the relevant bodies for further action. Another law that shall help the department in ensuring that our practice is unquestionable is the HIPAA (Lambrinou et al., 2012). Ensuring that all records of the patients are secured and that they are not shared with any unauthorized personnel for purposes other than helping the patient improve his health is vital in upholding integrity. The records in question include conversational information.

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