Heart Failure Home Health Protocol

My Home Nurses || NM
Clinical Intervention & Patient Teaching Guide

Reviewed and approved 06/30/2026
Annie Tchinjo RN, MSN  |  Terri Lorenz, RN  |  Felix Leshey MRes

CLINICAL PATHWAY ADVISORY: This template provides a standardized mechanism for identifying clinical shifts, trending daily baseline metrics, and delivering self-care training to patients transitioning under the Northwestern Medicine Bluhm Cardiovascular Institute guidelines.

1. MANDATORY PROGRAM SCHEDULING & FOLLOW-UP

• Post-Discharge Evaluation: The initial home health nursing assessment must be scheduled according to transition parameters. A follow-up phone call by a nurse must occur within 72 hours of discharge to review symptom metrics, weight, and medication compliance.
• Clinic Follow-Up: Verify an outpatient appointment is scheduled within 7 to 14 days of discharge with a cardiologist or primary care physician. Patients must bring their updated Personal Health Tracker booklet to every follow-up appointment.

2. CORE METRICS: DAILY WEIGHTS & SYMPTOMS

• Weighing Protocol: Weights must be taken every morning after waking, before food or liquids, and after voiding. Use the same scale on a hard, flat surface and wear a comparable amount of clothing. Record values immediately in the Personal Health Tracker.
• Home Safety Screening: At every visit, audit the following: significant windedness climbing stairs; difficulty tying shoes or tight footwear; tight clothing or need to loosen belt; and orthopnea (need for extra pillows or sleeping in a recliner). Affirmative responses confirm fluid accumulation.

3. DIETARY & FLUID COMPLIANCE

• Sodium Restriction: Enforce < 2,000 mg/day, with no more than 500–600 mg per meal. Select foods with < 300 mg per serving. Exclude table salt, processed foods, and seasonings ending in ‘salt’. Use lemon, vinegar, and salt-free herbs to boost flavor.
• Fluid Protocol: When fluid retention is present, limit intake to 32–64 ounces daily. This includes any substance liquid at room temperature (e.g., ice, soup, gelatin). Track volumes immediately.
• Thirst Mitigation: Use frequent tooth brushing, alcohol-free mouthwash, lemon wedges, hard sour candy, sugar-free gum, or frozen fruit/vegetables to manage thirst.

4. PHARMACOLOGICAL COMPLIANCE

• Management: Enforce adherence to prescribed doses and times using weekly pillboxes and alarms. Keep a detailed, updated medication list.
• Interventions: Monitor potassium/kidney function for diuretics and aldosterone inhibitors. Monitor for persistent dry cough with ACE inhibitors; avoid potassium-rich foods and salt substitutes. Screen for genital infections with SGLT2 inhibitors. Ensure ARNIs are not co-administered with ACE inhibitors or ARBs.

5. EXERCISE & LIFESTYLE

• Activity: Progress toward 30 minutes of aerobic activity daily (e.g., walking, yoga), avoiding heavy lifting or straining. Do not exercise in extreme heat or cold.
• Lifestyle: Stop smoking/vaping and eliminate illegal drugs. Limit alcohol and caffeine; encourage water or decaffeinated alternatives.

6. RN VISIT NOTE INSERT

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MHN/NM HOME HEALTH - DAILY HF VISIT NOTE
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[ ] CORE SCHEDULING: Initial assessment [ ] | 72h phone call [ ] 
    | Follow-up 7-14 days [ ] | Personal Tracker booklet [ ]
[ ] DAILY WEIGHTS/TRENDS: Today: ____ lbs | Baseline: ____ lbs
    - Daily morning fasting weigh-in compliance [ ]
    - Screened: Windedness [ ] | Tie shoes/tight shoes [ ] 
      | Tight clothing [ ] | Orthopnea [ ]
[ ] DIET/FLUIDS: Sodium < 2000mg [ ] | Label check (<300mg) [ ] 
    | Fluid cap 32-64oz [ ] | Thirst strategies used [ ]
[ ] PHARMACOLOGICAL: Pillbox/Alarm compliance [ ] 
    | Diuretic/lab monitor [ ] | SGLT2 screen [ ] 
    | No NSAIDs/salt substitutes [ ]
[ ] EXERCISE/ESCORT: Exercise progress [ ] | Smoke/Vape/Caffeine/Alc limits [ ]
[ ] DETERMINED COLOR ZONE: 
    [ ] GREEN (Stable) [ ] YELLOW (Caution) [ ] RED (Emergency)
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