Running head: DISCHARGE PLAN 1

Discharge Plan: Heart Failure

Jeanine M. Diaz

Cedar Crest College

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Abstract

Patient medical information was collected during the course of their hospital stay. This

information was reviewed and analyzed to create a detailed discharge plan including discharge

goals and patient teaching for congestive heart failure. The METHODS plan was followed, and

teach-back was used to provide optimal teaching to the patient and verify patient understanding.

Discharge teaching included newly prescribed medications, environment changes to be made to

ensure adequate safety in the home, exercise, treatment for congestive heart failure, health

teaching, signs and symptoms for the patient to report, diet, and spiritual and psychological

needs. Discharge details were then summarized.

Keywords: congestive heart failure, discharge plan, teach back, patient teaching
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Discharge Plan: Heart Failure

J.D. is an 85 year old female admitted to the hospital on August 27, 2017. Upon arriving

to the emergency department, J.D. reported feeling short of breath (more than normal), Two plus

edema in her lower extremities bilaterally, fatigue, and a weight gain of seven pounds in the past

week. J.D. has a past medical history of atrial fibrillation, hypertension, chronic obstructive

pulmonary disease, chronic kidney disease (stage IV), chronic respiratory failure, stroke,

tricuspid regurgitation, and mitral regurgitation. During J.D’s hospital stay a diagnosis of heart

failure was made. J.D. has 19 medication allergies such as digoxin, angiotensin receptor

antagonists, and ace inhibitors to name a few. Over a course of six days, J.D. was able to return

to her baseline and is ready for discharge.

Discharge Goals

The following are J.D’s priority discharge goals:

1. The patient will demonstrate improved ventilation, adequate tissue perfusion, and

adequate cardiac output as evidenced by absence of cyanosis, abnormal breathing

pattern, and dyspnea. The patient will have a capillary refill of less than 3 seconds,

arterial blood gases within the client’s usual parameters and absence of edema in

lower extremities. Patient will report back to the emergency department with any

worsening of these symptoms.

2. The patient will verbalize symptoms using the teach-back method to report to

caregiver immediately or the need to call 911 which could represent worsening or

recurrent heart failure as evidence by verbalization of discharge teaching.

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3. The patient will verbalize heart failure self-management such as medications, activity,

weight, and diet using the teach-back method as evidence by verbalization of

discharge teaching.

Discharge Instructions using METHODS

Medications

I am going over the medications your doctor has given you to help take care of your heart

failure. I will let you know how and when to take them, and anything you need to know to report

to your health care provider. It is important for you to take your medicine exactly as explained,

and at the same time each day for the medicine to work its best. Also, it is important to check

with your doctor before taking any over the counter medicines, herbal therapies, or new

medications to avoid any possible interactions. If you have trouble affording any of your

medications please let your doctor know so they can work with you to see if there are other

medications he can prescribe that are more affordable, or help you with assistance in other ways.

You are being given furosemide, otherwise known as Lasix. Some people refer to this

medicine as a water pill as it helps get rid of the extra fluids in your body. As this medicine does

its job you should see a decrease in the swelling of your lower legs and ankles and notice a

decrease in shortness of breath. Also, you will notice that you have to use the bathroom more as

your body gets rid of the extra water. This medicine can be taken first thing in the morning and

you can take it by mouth with food or milk to help decrease any stomach irritation. If you forget

to take this medicine, take it as soon as you remember but do not take more than one pill. Try not

to take it past five o clock so bathroom trips do not interrupt your sleeping (Davis, 2015). You

will take one pill each day. Each pill contains 40 mg. It is important for you to use sunscreen and

protective clothing while outdoors in the sun as this medicine can make you more sensitive to
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sunlight (Davis, 2015). Also, you will need to report to your doctor if you notice a weight gain of

more than 3 pounds in one day, or have a rash, muscle weakness, cramps, nausea, dizziness, and

any numbness or tingling of extremities (Davis, 2015). These are symptoms of not having

enough potassium in your body and can be dangerous. It is important to include foods high in

potassium in your diet such as avocado, spinach, and sweet potatoes while taking this medicine

to help replace the potassium you will lose while taking Lasix. I will include a list of foods that

are high in potassium with your discharge papers. You will also need to be more careful of

falling as this medicine can change the way fluid moves in your body and can make you feel

dizzy. It is important for you to get up or change positions slowly.

You are also being given metoprolol 50 mg to be taken by mouth. This medicine is

known as a beta blocker and helps treat heart failure by slowing the rate of your heart which will

allow your heart more time for it to fill with blood to pump out to the rest of your body providing

the oxygen and nutrients it needs (Muller-Werdan, Stockl & Werdan, 2016). It will also help

decrease your blood pressure. You will take one pill each day and you can take it at the same

time you take your Lasix. I will teach you how take your pulse, and you will need to take it

before taking this medicine each time. If your heart rate is less than 60, you will need to notify

your doctor before taking it. This is important because if your heart rate goes too low it could be

dangerous. It is also important not to stop taking this medication suddenly, as this could have

serious effects on your heart (Davis, 2015). Make sure to continue taking all of your previously

prescribed breathing treatments as directed as well.

Environment/Exercise

Since the diagnosis of heart failure can make you feel weak and more tired than usual,

and the medications you are taking can make you feel dizzy, it is important for you and your
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family to ensure your home is safe to decrease the risk of falling. Things you can do in your

home to improve safety include avoiding the use of throw rugs which could cause you to trip.

Make sure all areas of the home are well lit so you can see appropriately, clear walkways of any

clutter and make sure railings are secure and present on any stairways. It is also important to use

non-slip bath mats and grab bars in the shower and next to the toilet. Additionally, any spills or

wet areas should be dried immediately. You should avoid the use of stools or climbing on

anything, and ask for help if you cannot reach something. You should also avoid any steep stair

cases such as steps leading to the basement or attic.

Although it is recommended that you stay as active as possible, it is important for you to

balance rest with activity. Developing a regular exercise routine such as walking is a good idea,

however you do not want to overdo it and you will need to stop at any signs of distress such as

significant shortness of breath, feeling light headed, or have chest pain. Furthermore, you should

not start an exercise routine until your symptoms of swelling in your legs and shortness of breath

have resolved. When you are ready to introduce exercise, you can start out by walking 200 to

400 feet per day, three times a week and then gradually increase this amount as you feel up to it

(Ignatavicius & Workmas, 2016). It is important for you to rest after any activity.

Treatments

The symptoms that you presented to the hospital with have led your doctors to diagnose

you with heart failure. You may have also heard it called congestive heart failure (CHF) which is

the same thing. When a person has heart failure it means that the heart is not able to pump

effectively to deliver the correct amount of blood to the rest of your body (American Heart

Association, 2017.). Additionally, since circulating blood delivers nutrients and oxygen to the

body as well as removes waste, an ineffective pump causes fluid to back up into the lungs and
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other areas of the body such as hands, feet, ankles, legs and the stomach which is what causes

swelling and shortness of breath (American Heart Association, 2017). To treat heart failure, a

combination of therapy will be used. This includes taking the medications you have been

prescribed, it is important for you to take these medicines every day and stay on top of refills as

needed (Inamdar & Inamdar, 2016). Additionally, you will need to pay special attention to

symptoms to report to your doctor that may indicate worsening of your heart failure (Inamdar &

Inamdar, 2016). I will go over these symptoms with you. It will be important for you to weigh

yourself at the same time each day using the same scale, and in the same clothing if possible to

monitor for an increase of fluid in your body (Ignatavicius & Workman, 2016). You will also

need to stick to all follow up appointments, avoid smoking and alcohol use, and follow a sodium

and fluid restricted diet that I will go over with you (Inamdar & Inamdar, 2016). You are also

encouraged to stay active as tolerated.

It is also recommended that you have a positive support system. Surrounding yourself

with people who can encourage and make you feel good will help you feel your best. People with

heart failure can live a healthy lifestyle if they follow the treatment guidelines. I will provide

information on support groups and ways to improve your diet as well.

Health Teaching

https://youtu.be/QAPj_QZ8l58

Observable Signs and Symptoms

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It is important for you to be aware of any signs and symptoms of worsening heart failure

so you can report these to your doctor immediately. Catching these symptoms early can help

your health care provider to treat you more effectively and avoid further damage to your heart

and body. The symptoms to look out for and report include, a weight gain of three pounds in one

week, or one to two pounds overnight, a decrease in exercise tolerance lasting two to three days,

cold symptoms such as a cough lasting more than three to five days, excessive awakening at

night to urinate not associated with taking Lasix too close to bedtime, developing, or worsening

shortness of breath, chest pain at rest or worsening chest pain, and any increase in swelling of

your hands, feet, ankles or stomach (Ignatavicius & Workman, 2016). I have also included the

number for your doctor in your discharge instructions for you to report any of these symptoms

to. If you feel that it is an emergency, such as having chest pain or worsening shortness of breath

please call 911 or go to the closest emergency department if you have a ride.

Diet/Nutrition

During this hospital visit, your doctor has prescribed that you follow a 2-gram low

sodium diet at home and to limit the amount of fluid you drink each day. This includes avoiding

the use of table salt by not adding salt during or after meal preparation, avoiding milk and milk

products because they contain a large amount of sodium, limit prepared and canned foods, and

avoid foods that have a high sodium content as per the food label (Ignatavicius & Workman,

2016). Prepared and canned foods are known to be high in salt content, which is why it is

important to avoid these types of foods. I will go over with you how to read a food label to make

sure you have a clear understanding of how to determine which foods have a high salt content. It

is also important to understand that sodium and salt are the same thing. It may also help to add

lemon, spices and herbs to enhance low salt food and make it more desirable (Ignatavicius &
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Workman, 2016). It is important for you to follow this diet to avoid worsening of your heart

failure and to help keep your blood pressure in a healthy range for you. Sodium, or salt attracts

water, so limiting this in your diet will help keep your swelling down as well. Your doctor would

also like you to drink no more than two liters of fluids a day. This is equivalent to about 67

ounces or eight measured cups. It is also important for you to avoid alcohol as this can interfere

with your medications and is not good for your heart. I will include with your discharge papers a

list of foods that are high in sodium so you know what to avoid, as well as low sodium foods so

you know what are good options for you to eat. This diet may be hard to get used to at first, but

the more you follow it, the easier it will become and the better you will feel.

Spiritual/Psychological

I have included names and phone numbers for local support groups of other people

dealing with CHF in your discharge instructions. Additionally, if you are not able to make it to

these support groups I have included the web addresses for several online CHF forums. These

forums allow you to connect with other people dealing with CHF online and share personal

stories and support.

Discharge Details

The patient was provided with health teaching using the teach-back method. The patient

and family both verbalized understanding by restating the correct information back to the nurse.

The patient was provided with a copy of all written discharge instructions including;

medications, exercise, dietary restrictions, signs and symptoms of worsening heart failure to

monitor and report, and treatment to adhere to. Questions and concerns were addressed, and
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follow-up appointments were arranged. The patient’s discharge condition remained unchanged

from previous assessment (at 9/1/17 1100), neurologically intact (A&O x 4), vital signs

unchanged from previous, and reports no pain (0/10). The discharge team will follow-up with a

phone call within one to three days following discharge. Both the patient and family were

provided with phone numbers to call with any questions and concerns. The patient was

accompanied to the front door via wheelchair and left in the care of her daughter by car at 1330

on 9/1/17.

Conclusion

Upon collection of the patient’s health data, a detailed discharge plan was created. This

discharge plan included prioritized discharge goals and patient education in order for the patient

to understand how to manage congestive heart failure. Furthermore, the patient was instructed

how to address signs of worsening heart failure. Following these instructions will help the patient

to live a healthy lifestyle and avoid future readmission.

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References

Ignatavicius, D., & Workman, M. (2016). Medical Surgical nursing: Patient-centered

collaborative care (8th ed.). St Louis, MI: Elsevier

Inamdar, A., & Inamdar, A. (2016). Heart failure: Diagnosis, management and

utilization. Journal of Clinical Medicine, 5(7), 62. doi:10.3390/jcm5070062

Muller-Werdan, U., Stocki, G., & Werdan, K. (2016). Advances in the management of heart

failure: the role of ivabrandine. Vascular Health and Risk Management, 12, 4530470.

doi: 10.2147/VH12M. S90383

Vallerand, A., Sanoski, C., & Deglin, J. (2015). Davis's drug guide for nurses (14th ed.).

American Heart Association (2017, May). What is heart failure? Retreived from

www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/What-is-Heart-

Failure_UCM_002044_Article.jsp.