The RN will provide 6 visits over 6 weeks to educate the client and caregiver about self-management of congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). The RN will teach the client to monitor symptoms, manage medications, recognize worsening conditions, and contact providers appropriately. The visits will include assessing the client's health status, reviewing disease self-management, and ensuring the treatment plan is optimized in collaboration with other providers. The goal is for the client to successfully demonstrate understanding of CHF/COPD through discussion of symptoms, medications, and when to seek medical attention.

1. SERVICE PATHWAYS

2. CHF AND COPD
TRIAL

3. 6 VISITS/6WEEKS

4. SELF MANAGEMENT
RN will educate the Client/Caregiver to
understand symptom management and early
intervention.
RN will teach and review the aspects for client
self-management of CHF and submit reports
detailing nursing interventions and the clients
ability to self-manage upon discharge of CCAC
services.

5. SELF-
MANAGEMENT
RN will assess the client’s cognitive and
emotional status that may influence the ability
to self-manage.
RN will assess the client’s functional status
and physical assessment to include blood
pressure, heart rate, JVP elevation, pulmonary
auscultation, abdominal girth measurement,
and lower extremity assessment.

6. SELF-MANAGEMENT
RN will liaison with Primary Care Providers
and Specialists to ensure the client’s
treatment plan is optimized.
RN will report changes in functional status to
the Primary Care Provider and consult with
the Care Co-ordinator re: service needs.

7. CHF LEARNING OUTCOMES
WEEKS 1 and 2
Understands CHF and the importance of self-care
to prevent/reduce complications.
Recognizes the signs and symptoms of CHF
worsening and who to contact. Client education
tool “CHF status Zone Reference Tool”.
Understands and follows the medication regimen
including: type of
medication, dosage, administration
schedule, mechanism of action, and importance
of compliance.

8. WHAT IS CONGESTIVE HEART
FAILURE?

9. CHF
• Heart failure (HF), also known as congestive heart failure, is a common
condition that develops after the heart becomes damaged or weakened
by diseases of the heart including heart attacks and other medical
conditions. HF occurs when the pumping action of your heart is not strong
enough to move blood around, especially during increased activity or
under stress. In addition, the heart muscle may not relax properly to
accommodate the flow of blood back from the lungs to the heart. These
abnormalities in heart function can cause fluid to back up in your lungs
and in other parts of your body such as your ankles. The congestion in
your lungs and lack of oxygen may make you feel tired and short of breath.
Sometimes the fluid in your lungs can accumulate to the point where it
can cause a life-threatening condition called acute pulmonary
edema, requiring emergency treatment.
•
http://www.heartandstroke.com

10. TEACH-BACK TOOL

11. TEACH-BACK “WHAT IS CHF”
“Your heart is a pump. CHF occurs when the
pumping action of your heart is not strong
enough to move blood around, especially
during increased activity or under stress. In
addition, the heart muscle may not relax
properly to allow the flow of blood back from
the lungs to the heart.”

12. TEACH-BACK “WHAT IS CHF”
“The signs of heart failure are:
• Shortness of breath,
• Weight gain from fluid build up,
• Swelling in the tummy, hands, feet, and
ankles,
• Feeling more tired. No energy.

13. TEACH-BACK “WHAT IS CHF”
“I want to make sure I explained it clearly to you
clearly. Could you explain it back to me in your
own words?”

14. EVERYDAY
 Weigh yourself in the morning, after going to the
bathroom, and before breakfast. Write down the date
and how much you weigh.
 Take your medicines as ordered by your doctor.
 Check for swelling in your hands, legs, and feet.
 Eat foods with low salt (sodium). Don’t add salt at the
table. Avoid processed, packaged, and prepared foods.
 Balance activity with rest.
 Keep walking or join a cardiac rehab program.
What Zone ARE YOU IN TODAY Green YELLOW RED

15. GREEN
NO increase in shortness of breath.
NO weight gain. Your weight stays the same.
NO new swelling of your ankles, legs, or feet.
NO new chest pain.
NO new feelings of fatigue, dizziness, or
confusion.
Have you had your flu shot?

16. YELLOW
Call your doctor or nurse if you have any of these.
o Weight gain of 2 lbs in 2 days.
o Shortness of breath that is worth than usual.
o Swelling is worse in your hands, feet, or ankles.
o New tiredness that is not made better by rest.
o Fever of 38 Celsius (100.4 Fahrenheit) or higher.
o New or increased shortness of breath when lying
down.
o New dizziness or feeling light headed.
o Wheezing that is worse than usual.

17. RED
Go to the Emergency Department or call 911 if
you have any of these :
o New chest pain or chest pain that is worse
than usual.
o Shortness of breath that is much worse than
usual.
o Confusion. Not able to think clearly.
o Severe dizziness or fainting.

18. CHF LEARNING OUTCOMES
WEEKS 3 and 4
Understands the reason for fluid restriction
and follows the prescribed daily limit.
Weighs self daily and keeps a daily log. Knows
when to call Primary Care Provider (2 lbs. in 2
days).
Receives diet counseling and understands the
reason for adhering to a low salt diet
(<2000mg/day). Adheres to a low salt healthy
heart diet and restricts alcohol consumption.

19. CHF LEARNING OUTCOMES
WEEKS 5 and 6
Conserves energy to allow for ADLs by
ensuring adequate rest and sleep.
Understands the importance of smoking
cessation for improved health outcomes
Client/Caregiver successfully passes the Teach-
Back by zone (Green/Yellow/Red). Provide
with written materials to support learning.

20. EVERYDAY
 Weigh yourself in the morning, after going to the
bathroom, and before breakfast. Write down the date
and how much you weigh.
 Take your medicines as ordered by your doctor.
 Check for swelling in your hands, legs, and feet.
 Eat foods with low salt (sodium). Don’t add salt at the
table. Avoid processed, packaged, and prepared foods.
 Balance activity with rest.
 Keep walking or join a cardiac rehab program.
What Zone ARE YOU IN TODAY Green YELLOW RED

21. GREEN
NO increase in shortness of breath.
NO weight gain. Your weight stays the same.
NO new swelling of your ankles, legs, or feet.
NO new chest pain.
NO new feelings of fatigue, dizziness, or
confusion.
Have you had your flu shot?

22. YELLOW
Call your doctor or nurse if you have any of these.
o Weight gain of 2 lbs in 2 days.
o Shortness of breath that is worth than usual.
o Swelling is worse in your hands, feet, or ankles.
o New tiredness that is not made better by rest.
o Fever of 38 Celsius (100.4 Fahrenheit) or higher.
o New or increased shortness of breath when lying
down.
o New dizziness or feeling light headed.
o Wheezing that is worse than usual.

23. RED
Go to the Emergency Department or call 911 if
you have any of these :
o New chest pain or chest pain that is worse
than usual.
o Shortness of breath that is much worse than
usual.
o Confusion. Not able to think clearly.
o Severe dizziness or fainting.

24. TEACH-BACK “YELLOW ZONE”
“I would like to talk about a few things that
might come up. I just want to make sure that
you know what you would do if any of this
happens.”

25. YELLOW
Call your doctor or nurse if you have any of these.
o Weight gain of 2 lbs in 2 days.
o Shortness of breath that is worth than usual.
o Swelling is worse in your hands, feet, or ankles.
o New tiredness that is not made better by rest.
o Fever of 38 Celsius (100.4 Fahrenheit) or higher.
o New or increased shortness of breath when lying
down.
o New dizziness or feeling light headed.
o Wheezing that is worse than usual.

26. TEACH-BACK “YELLOW ZONE”
• I want to make sure I did a good job explaining
this to you because it can be very confusing.
Can you tell me ....
• What symptoms should you immediately
report to your doctor?
• What weight gain you should report to your
doctor