Policy Manual sample

MDT Home Health Care Agency, Inc. • Breathlessness • Number of pillows used at night • Sleep patterns • Nutrition • Urine output and character • Last echocardiogram & results • Systolic or diastolic failure • Medication regimen Prevention and management of CHF exacerbations • Assess for early recognition, thorough Patient’s Physician communications, clinical assessment and management of worsening CHF. • To ensure early recognition, clinical assessment and management of worsening CHF. • To prevent hospitalization and adverse events. • Patient self-monitoring of their daily weight in accordance with a negotiated action plan. • Reassessment of functional status. • Reassessment of adherence to Prescribed Plan of Care (including medicines), lifestyle risk factors, cognitive function, depression and ability to self-care. • Assessment of potential precipitants, such as infection, adverse effects of medicines, comorbidity and hot weather. • Assessment of the patient’s social factors (e.g. coping, carer burden and access to services). • Provision of clear instructions to the patient or carer on who they should contact at each step of the action plan. • Ensuring all members of the patient’s home care team are informed of changes in health status or management plan. • Prevent CHF exacerbations and hospitalizations due to pneumonia or influenza. (Provision of influenza and pneumococcal vaccinations to patients, as recommended in current evidence-based guidelines) • Manage infection risk through prevention and early detection. • Provide healthcare and advice with attention to both the health implications of CHF and general health considerations applicable to the patient’s age and social, cultural and economic circumstances. • Promotion of patient skin care, bladder and bowel hygiene to prevent common infections (e.g. cellulitis and lower urinary tract infections), and regular dental check-ups to optimize periodontal health. • Early intervention (e.g. prompt referral to patient’s Physicain) if the patient’s symptoms suggest urinary tract or chest infections. • Monitoring the patient for risks of thromboembolism, particularly during periods of prolonged bed rest and in patients with atrial fibrillation. Home Health Agency Nursing Care & Procedures K-231