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Assessment and Planning

First visit and ongoing:

Assess for other disciplines: PT, OT, Speech, SW, HHA. If needed;

  • Obtain approval from D.O.N
  • Speak with MD, obtain verbal orders; site and send interim orders
  • Request in Managed Care Report

Reassess d/c plan at every visit
If further visits needed- at least 1 week prior to planned D/C date:

  • Obtain approval from D.O.N
  • Speak with MD, obtain verbal orders, write and send Interim Orders,
  • Write Managed Care Report 1 week prior to any change.

INTERVENTIONS TO OCCUR DURING CARE PERIOD

  1. Assess/reconcile all medications, Assess knowledge. Instruct in purpose, route, frequency, side effects.
  2. Assess circulatory/cardiac status: VS; heart rate/rhythm; weight, edema; note change in status. Initial visit, establish target weight, take BP in both arms in 2 positions, identify arm with higher BP, document and continue using that arm for BP.
  3. Assess level of dyspnea with activity and at rest, note change in status.
  4. Assess LE edema, measuring bilateral ankle and calf at SOC and regularly. Instruct in self assessment. If edema, assess regularly for skin, breakdown, and instruct in self assessment.
  5. Instruct to record weight daily, report gain of 2-3 lbs. one day/5 lbs. one week or as per physician order.
  6. Instruct on use of oxygen for disease process, if applicable.
  7. Instruct on self-monitoring: weight, edema, pulse, S/S pain; actions to take with abnormal findings.
  8. Instruct on hidden sources of sodium in commercial foods; provide written information as needed.
  9. Instruct on effects of cholesterol, salt, and fat on cardiac disorders.
  10. Instruct on salt substitutes and need for physician approval and how to flavor foods with herbs and spices.
  11. Instruct on foods high in potassium if on potassium-depleting diuretic; provide list of foods.
  12. Instruct on importance of frequent rest periods, pacing activities, and avoiding overexertion.
  13. Instruct to elevate feet/legs when sitting or laying if appropriate.
  14. Instruct on semi or high fowlers position to improve breathing/ respirations if appropriate.
  15. Assess home for fire extinguisher and other oxygen safety precautions.
  16. Evaluate knowledge of safe and correct use of oxygen, instruct as needed.
  17. Instruct to reduce or stop smoking if applicable.

PATIENT/CAREGIVER OUTCOMES (V) VERBALIZE (D) DEMONSTRATES

  1. Compliance/understanding of purpose, route, frequency, side effects of all medications. (V)
  2. Importance of monitoring daily weight. Weight consistent with goals. (D & V)
  3. Compliance with activities to improve cardiac status; gradual increases, feet/legs elevated, positioning, etc. (V & D)
  4. Decreased edema, if appropriate. (D)