Heart Failure and Clinic Care Plan: A Discharge Education Plan

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heart failure care plan

Heart failure is a widespread problem. Those patients with heart failure, who have undergone medical treatment, usually describe hospital discharge as a sudden, unexpected occurrence that is ill-prepared, which contributes to the high rates of re-hospitalizations during the transition period (Riley & Masters, 2016). As a result, the following discharge education plan will focus on reducing these problems by empowering patients to perform self-care activities after discharge using the available resources to prevent the recurrence of heart failure manifestations and the associated complications.

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Plan Objectives, Resources, and Tools

The plan will focus on achieving the objectives in the table below, as patients continue using different resources and tools to monitor their condition.

Table 1: Objectives of the Education Plan

Number Objective
1 To improve the knowledge levels on self-care concerning heart failure after discharge
2 To improve compliance with self-care activities in patients with heart failure after discharge
3 To reduce readmissions in heart failure patients during the transition period

To achieve these objectives, the following will be performed:

  • Nurses will organize educational sessions with patients before and during discharge at the group and individual levels to discuss self-care issues concerning heart failure.
  • Nurses will also inform patients on where and how to access the required resources to enhance self-care management after discharge, such as buying stopwatches and heart rate monitors.
  • Through educational sessions, nurses will teach patients how to use weighing machines, heart rate monitors, self-care management guidelines, and so forth. This strategy helps patients to take daily weight measures using weighing machines to note any signs of weight gain on a weight monitoring chart (David, Howard, Dalton, & Britting, 2018). Further, for improved compliance, patients will be advised to use reminders such as stopwatches to notify the exact time when to perform self-care activities that comprise taking medications.
  • Patients will be informed on how to determine any abnormalities based on the symptoms of the disease and the recorded parameters of weight. Patients can also use heart rate monitors to measure their actual heart rates and compare them with normal values to detect any deviances (David et al., 2018).
  • Nurses will teach patients what actions to undertake whenever there are problems including phone communication with the caregivers or visiting the clinic.
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Delivery Modalities and Knowing Patients’ Understanding

Verbal and written modalities will be used. According to Riley (2015), verbal messages can be delivered through counseling and active discussion sessions before and during the time of discharge. Moreover, nurses will use feedback to determine whether or not patients will have understood what is required of them as self-care providers. The teach-back technique that involves patients repeating and confirming their understanding of various aspects of heart failure and its management is necessary to verify their knowledge (Riley, 2015). Through this strategy, nurses will address issues of anxiety by asking and answering questions to patients and their families. Additionally, nurses will give out written material in the form of brochures with diagrammatic and narrative information for patients to read.

Meeting Language and Cultural Diversities

This plan will work successfully for patients from diverse multicultural backgrounds. For example, Velasco-Mondragon, Jimenez, Palladino-Davis, Davis, and Escamilla-Cejudo (2016) explain that Spanish, Caribbean, and Latin America Hispanics may fail to comprehend English-delivered messages. As such, nurses will convey messages in different languages to eliminate potential language barriers. Besides, offering transcultural nursing care that respects spiritual, religious, and traditional beliefs will be part of the health promotion plan (Rosa, 2017). More so, the aspect of complementary and alternative medicine will be considered for patients who value this option more than the conventional modern medicine (Dinallo, Allison, & Juarez, 2017). Therefore, patient beliefs and ways of seeking care will not be rebuked to avoid any resistance to treatment compliance.

Applying Legal and Professional Standards

Fundamentally, the educational plan is supported by the legal and professional standards of nursing practice. For instance, based on the legal and professional scope of practice, nurses in the United States have the responsibility of providing care coordination services when patients move across settings, including the time of discharge, with the aim of reducing hospitalizations, costs of care, and improving patient and provider satisfaction of care (Parker & Hill, 2017). Similarly, nurses should provide health education and counseling services before, during, and after discharge (Parker & Hill, 2017). This plan is embroiled in the legal and professional role of nurses offering health education to patients from diverse backgrounds with different healthcare needs.

Alignment to Recent Guidelines and Professional Standards

This discharge education plan aligns with the recent heart failure guidelines and professional standards in many ways. For instance, the American Heart Association Taskforce introduced the 2017 guidelines for managing heart failure by recommending patients and caregivers to collaborate in treating this condition and preventing its recurrence as well as the associated complications (Yancy et al., 2017). Further, professional standards of nursing for heart failure management stipulate that nurses should provide different types of care to patients with heart failure during and after discharge to promote independence following a dependent-hospitalization period (Jurgens et al., 2015). These standards align with the plan the primary intention of which is for patients to independently perform self-care activities to recover through the help of nurses’ educational services.

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Effectiveness and Successfulness of the Discharge Plan

There will be a need to determine whether or not the objectives of the discharge plan are met in order to understand its success. For instance, an evaluation will be done to see whether patients comply with self-management care in addition to determining the possible reduction in readmissions. Mainly, the accountability tools will comprise records, such as charts for measuring weight, discharge sheets revealing the frequency and nature of delivered educational services, and hospital records to determine discharge and readmission rates of patients with heart failure (David et al., 2018). This plan will focus on success indicators, such as reduced complications of heart failure during the discharge period that result in readmissions or death (Riley & Masters, 2016). In addition, the plan will focus on measuring the patient levels of knowledge on self-care and the actual performance of self-care activities to evaluate the effectiveness of the plan.


Overall, the discharge education plan will significantly reduce readmissions associated with heart failure, since it will improve patients’ knowledge and commitment to self-care management. The primary objective is improving self-care abilities to promote recovery and prevent the recurrence of heart failure symptoms that increase the likelihood of readmission. The effectiveness of the plan will rely on potential outcomes such as routine measuring of weight among others.

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